Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month’s costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL.
Method
Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance.
Results
Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000.
Discussion
ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs.
Conclusion
Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.
SmithSBrickAO'HaraSNormandC. Evidence on the cost and cost-effectiveness of palliative care: A literature review. Palliat Med. 2014;28(2):130-150.
2.
RileyGFLubitzJD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45(2):565-576.
3.
AldridgeMDKelleyAS. The myth regarding the high cost of end-of-life care. Am J Public Health. 2015;105(12):2411-2415.
4.
LiLHuLJiJ, et al.Determinants of total end-of-life healthcare costs of Medicare beneficiaries: A quantile regression forests analysis. J Gerontol A Biol Sci Med Sci. 2021.
5.
Fleischmann-StruzekCMikolajetzAReinhartK, et al.Hospitalization and intensive therapy at the end of life. Dtsch Arztebl Int. 2019;116(39):653-660.
6.
MarikPE. The cost of inappropriate care at the end of life: Implications for an aging population. Am J Hosp Palliat Care. 2015;32(7):703-708.
7.
Cardona-MorrellMKimJTurnerRMAnsteyMMitchellIAHillmanK. Non-beneficial treatments in hospital at the end of life: A systematic review on extent of the problem. Int J Qual Health Care. 2016;28(4):456-469.
8.
BekelmanJEHalpernSDBlankartCR, et al.Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries. JAMA. 2016;315(3):272-283.
9.
ChastekBHarleyCKallichJNewcomerLPaoliCJTeitelbaumAH. Health care costs for patients with cancer at the end of life. J Oncol Pract. 2012;8(6):75s-80s.
10.
DuncanIAhmedTDoveHMaxwellTL. Medicare Cost at End of Life. Am J Hosp Palliat Care. 2019;36(8):705-710.
11.
Tanguy-MelacAVerbouxDPestelLFagot-CampagnaATuppinPGastaldi-MenagerC. Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study. Eur J Health Econ. 2021;22(7):1039-1052.
12.
EarleCCLandrumMBSouzaJMNevilleBAWeeksJCAyanianJZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol. 2008;26(23):3860-3866.
13.
EarleCCNevilleBALandrumMB, et al.Evaluating claims-based indicators of the intensity of end-of-life cancer care. Int J Qual Health Care. 2005;17(6):505-509.
14.
EarleCCNevilleBALandrumMBAyanianJZBlockSDWeeksJC. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004;22(2):315-321.
15.
GardinerCIngletonCRyanTWardSGottM. What cost components are relevant for economic evaluations of palliative care, and what approaches are used to measure these costs? A systematic review. Palliat Med. 2017;31(4):323-337.
16.
ZhangBWrightAAHuskampHA, et al.Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med. 2009;169(5):480-488.
17.
ChambersCVDiamondJJPerkelRLLaschLA. Relationship of advance directives to hospital charges in a Medicare population. Arch Intern Med. 1994;154(5):541-547.
18.
EdesTELindbloomEJDealJLMadsenRW. Improving care at lower cost for end-stage heart and lung disease: Integrating end of life planning with home care. Mo Med. 2006;103(2):146-151.
19.
EngelhardtJBMcClive-ReedKPToselandRWSmithTLLarsonDGTobinDR. Effects of a program for coordinated care of advanced illness on patients, surrogates, and healthcare costs: A randomized trial. Am J Manag Care. 2006;12(2):93-100.
20.
HamletKSHobgoodAHamarGBDobbsACRulaEYPopeJE. Impact of predictive model-directed end-of-life counseling for Medicare beneficiaries. Am J Manag Care. 2010;16(5):379-384.
21.
MolloyDWGuyattGHRussoR, et al.Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA. 2000;283(11):1437-1444.
22.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274(20):1591-1598.
23.
MosoiuDDumitrescuMConnorSR. Developing a costing framework for palliative care services. J Pain Symptom Manage. 2014;48(4):719-729.
24.
SedhomRMacNabbLSmithTJYabroffKR. How palliative care teams can mitigate financial toxicity in cancer care. Support Care Cancer. 2021.
25.
GivenBAGivenCWStommelM. Family and out-of-pocket costs for women with breast cancer. Cancer Pract. 1994;2(3):187-193.
26.
LongoCJFitchMILoreeJM, et al.Patient and family financial burden associated with cancer treatment in Canada: A national study. Support Care Cancer. 2021;29(6):3377-3386.
27.
GadeGVenohrIConnerD, et al.Impact of an inpatient palliative care team: A randomized control trial. J Palliat Med. 2008;11(2):180-190.
28.
BrumleyREnguidanosSJamisonP, et al.Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.
29.
BrumleyRDEnguidanosSCherinDA. Effectiveness of a home-based palliative care program for end-of-life. J Palliat Med. 2003;6(5):715-724.
30.
HigginsonIJMcCronePHartSRBurmanRSilberEEdmondsPM. Is short-term palliative care cost-effective in multiple sclerosis? A randomized phase II trial. J Pain Symptom Manage. 2009;38(6):816-826.
31.
RabowMWPetersenJSchancheKDibbleSLMcPheeSJ. The comprehensive care team: a description of a controlled trial of care at the beginning of the end of life. J Palliat Med. 2003;6(3):489-499.
32.
CasselJBWebb-WrightJHolmesJLyckholmLSmithTJ. Clinical and financial impact of a palliative care program at a small rural hospital. J Palliat Med. 2010;13(11):1339-1343.
33.
DavisMPWalshDLeGrandSBLagmanRLHarrisonBRybickiL. The financial benefits of acute inpatient palliative medicine: An inter-institutional comparative analysis by all patient refined-diagnosis related group and case mix index. J Support Oncol. 2005;3(4):313-316.
34.
MayPGarridoMMCasselJB, et al.Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
35.
BainbridgeDSeowHSussmanJ. Common components of efficacious in-home end-of-life care programs: A review of systematic reviews. J Am Geriatr Soc. 2016;64(3):632-639.
36.
EnguidanosSPortanovaJ. The provision of home-based palliative care for those with advanced heart failure. Curr Opin Support Palliat Care. 2014;8(1):4-8.
37.
MayPNormandCDel FabbroE, et al.Economic analysis of hospital palliative care: Investigating heterogeneity by noncancer diagnoses. MDM Policy Pract. 2019;4(2):2381468319866451.
38.
MayPGarridoMMCasselJB, et al.Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from?. Palliat Med. 2017;31(4):378-386.
39.
MorrisonJPalumboMVRamburB. Reducing preventable hospitalizations with two models of transitional care. J Nurs Scholarsh. 2016;48(3):322-329.
40.
MayPGarridoMMCasselJB, et al.Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff. 2016;35(1):44-53.
41.
PenrodJDDebPDellenbaughC, et al.Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
42.
MorrisonRS. Better care, better bottom line for hospitals. Medscape J Med. 2008;10(12):274.
43.
MorrisonRSPenrodJDCasselJB, et al.Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
44.
PenrodJDDebPLuhrsC, et al.Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855-860.
45.
GomesBCalanzaniNCurialeVMcCronePHigginsonIJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013(6):CD007760.
46.
GrayNAHortonJRDionne-OdomJNSmithCBJohnsonKS. Update in Hospice and Palliative Care. J Palliat Med. 2016;19(5):559-565.
47.
MaetensABeernaertKDe SchreyeR, et al.Impact of palliative home care support on the quality and costs of care at the end of life: A population-level matched cohort study. BMJ Open. 2019;9(1):e025180.
48.
EnguidanosSRahmanAFieldsT, et al.Expanding access to home-based palliative care: A randomized controlled trial protocol. J Palliat Med. 2019;22(S1):58-65.
49.
EnguidanosSMCherinDBrumleyR. Home-based palliative care study: Site of death, and costs of medical care for patients with congestive heart failure, chronic obstructive pulmonary disease, and cancer. J Soc Work End Life Palliat Care. 2005;1(3):37-56.
50.
YouensDMoorinR. The impact of community-based palliative care on utilization and cost of acute care hospital services in the last year of life. J Palliat Med. 2017;20(7):736-744.
51.
DalalSBrueraE. End-of-life care matters: Palliative cancer care results in better care and lower costs. Oncologist. 2017;22(4):361-368.
52.
GreerJATramontanoACMcMahonPM, et al.Cost Analysis of a Randomized Trial of Early Palliative Care in Patients with Metastatic Nonsmall-Cell Lung Cancer. J Palliat Med. 2016;19(8):842-848.
53.
BhulaniNGuptaAGaoA, et al.Palliative care and end-of-life health care utilization in elderly patients with pancreatic cancer. J Gastrointest Oncol. 2018;9(3):495-502.
54.
TownsendJFrankAOFermontD, et al.Terminal cancer care and patients' preference for place of death: A prospective study. BMJ. 1990;301(6749):415-417.
55.
HoergerMGreerJAJacksonVA, et al.Defining the elements of early palliative care that are associated with patient-reported outcomes and the delivery of end-of-life care. J Clin Oncol. 2018;36(11):1096-1102.
56.
ApostolCCWaldfogelJMPfohER, et al.Association of goals of care meetings for hospitalized cancer patients at risk for critical care with patient outcomes. Palliat Med. 2015;29(4):386-390.
57.
BarnatoAEMohanDLaneRK, et al.Advance care planning norms may contribute to hospital variation in end-of-life ICU use: a simulation study. Med Decis Making. 2014;34(4):473-484.
58.
DavisMPVanenkevortEAElderA, et al.When does early palliative care influence aggressive care at the end of life? Support Care Cancer. 2022.
59.
PritchardRSFisherESTenoJM, et al.Influence of patient preferences and local health system characteristics on the place of death. SUPPORT investigators. Study to understand prognoses and preferences for risks and outcomes of treatment. J Am Geriatr Soc. 1998;46(10):1242-1250.
60.
MackJWCroninAKeatingNL, et al.Associations between end-of-life discussion characteristics and care received near death: A prospective cohort study. J Clin Oncol. 2012;30(35):4387-4395.
61.
MackJWCroninATabackN, et al.End-of-life care discussions among patients with advanced cancer: A cohort study. Ann Intern Med. 2012;156(3):204-210.
62.
WrightAAMackJWKritekPA, et al.Influence of patients’ preferences and treatment site on cancer patients’ end-of-life care. Cancer. 2010;116(19):4656-4663.
63.
MackJWWeeksJCWrightAABlockSDPrigersonHG. End-of-life discussions, goal attainment, and distress at the end of life: Predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol. 2010;28(7):1203-1208.
64.
KlinglerCder SchmittenJMarckmannG. Does facilitated advance care planning reduce the costs of care near the end of life? Systematic review and ethical considerations. Palliat Med. 2016;30(5):423-433.
65.
PatelMISundaramVDesaiM, et al.Effect of a lay health worker intervention on goals-of-care documentation and on health care use, costs, and satisfaction among patients with cancer: A randomized clinical trial. JAMA Oncol. 2018;4(10):1359-1366.
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