Impact of aggressive management and palliative care on cancer costs in the final month of life

Abstract

Background A significant share of the cost of cancer care is concentrated in the end-of-life period. Although quality measures of aggressive treatment may guide optimal care during this timeframe, little is known as to whether these metrics affect costs of care. Methods We used population data to identify a cohort of patients who died of cancer in Ontario, Canada (2005 to 2009). Individuals were categorized as having received aggressive end-of-life care or not, according to quality measures related to acute institutional care or chemotherapy administration in the end-of-life period. Costs (2009 $CAN) were collected over the last month of life by linking health system administrative databases. Multivariable quantile regression was used to identify predictors of increased costs. Results Among 107,253 patients, the mean per patient cost over the final month was $18,131 for patients receiving aggressive care and $12,678 for patients receiving non-aggressive care (p<0.0001). Patients who received chemotherapy in the last 2 weeks of life also sustained higher costs compared to those who did not (p<0.0001). For individuals receiving end-of-life care in the highest cost quintile, early and repeated palliative care consultation was associated with reduced mean per patient costs. On multivariable analysis, chemotherapy in the 2 weeks of life remained predictive of increased costs (median increase $536; p<0.0001) whereas access to palliation remained predictive for lower costs (median decrease $418; p<0.0001). Conclusions Cancer patients who receive aggressive end-of-life care incur 43% higher costs than those managed non-aggressively. Palliative consultation may partially offset these costs and offer resultant savings.

Population-Based Trends in Systemic Therapy Use and Cost for Cancer Patients in the Last Year of Life

“…Providing standard cancer care, including systemic therapy, together with early palliative care appears to provide both quantity and quality of life to patients with advanced disease. A recent population-based study of cancer decedents in Ontario reported that health care costs in the last month of life were reduced in patients who received palliative care services in the last year of life, even if those patients went on to receive aggressive end-of-life care 36 . On average, median costs were $536 higher in recipients of systemic therapy in the last 14 days of life than in patients who did not receive such aggressive care, and early palliative care was independently associated with a $418 decrease in median cost 36 .…”

“…A recent population-based study of cancer decedents in Ontario reported that health care costs in the last month of life were reduced in patients who received palliative care services in the last year of life, even if those patients went on to receive aggressive end-of-life care 36 . On average, median costs were $536 higher in recipients of systemic therapy in the last 14 days of life than in patients who did not receive such aggressive care, and early palliative care was independently associated with a $418 decrease in median cost 36 . Those results suggest that, even without changing the aggressiveness of care at end of life, early palliative services can to some extent offset the additional costs.…”

“…Finally, our analysis considered only the cost of systemic therapy; it did not take into account other health system costs, patient out-of-pocket costs, or indirect costs that might be affected by changes in systemic therapy use. Compared with patients who do not receive systemic therapy as they approach death, those receiving systemic therapy in the last 14 days of life have higher acute care costs and lower home and community care costs 36 , suggesting that the effect on health system costs extends beyond the systemic therapy budget.…”

Temporal Association between Home Nursing and Hospital Costs at End of Life in Three Provinces

“…Overall, 55% of Canadians die in hospital 1 , but research shows that most Canadians prefer to be cared for and to die at home 2 . Research has shown that, of provincial health care budgets, 10% is spent on patients in the last year of life 3 , with most of those costs being driven by hospital care 4 . Policymakers are investing in homecare nursing-and particularly palliative homecare nursing-because of its alignment with the preference of patients to be cared for and to die at home and its potential for cost savings by avoiding expensive acute hospitalizations.…”

What are the ethical aspects surrounding intensive care unit admission in patients with cancer?

“…One of the hypotheses proposed to explain this finding was that the expertise in specialist centres leads to earlier recognition of complications, leading to earlier treatment and avoidance of the need for ICU utilization, and as a result, better overall allocation of resources. It has been shown that cancer costs in the last month of life are higher in patients who receive aggressive end-of-life care, including ICU admission, than in those who are managed non-aggressively, with early initiation of palliative care consultations (19). It has also been reported that patients with metastatic non-small-cell lung cancer who had early palliative care integrated in their care plan survived longer and with better quality of life than patients who received standard management (20).…”