Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population‐Based Cohort Study in Taiwan

• Published in: The oncologist (Dayton, Ohio) Vol. 22; no. 4; pp. 460 - 469
• Main Authors: Hung, Yen‐Ni, Liu, Tsang‐Wu, Wen, Fur‐Hsing, Chou, Wen‐Chi, Tang, Siew Tzuh
• Format: Journal Article
• Language: English
• Published: United States AlphaMed Press 01.04.2017
• Subjects: Administrative data analysis; Age Factors; Cancer patients; Comorbidity; Cost-Benefit Analysis - economics; End‐of‐life care; Female; Health care expenditures; Health Expenditures; Health Outcomes and Economics of Cancer Care; Hospice Care - economics; Humans; Male; Neoplasms - economics; Neoplasms - epidemiology; Population‐based study; Taiwan; Terminal Care - economics; Administrative data analysis; Population‐based study; Cancer patients; Health care expenditures; End‐of‐life care
• ISSN: 1083-7159; 1549-490X
• DOI: 10.1634/theoncologist.2016-0283

Background No population‐based longitudinal studies on end‐of‐life (EOL) expenditures were found for cancer decedents. Methods This population‐based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient‐level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health‐specific purchasing power parity conversions to account for different health‐purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. Results Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic‐pancreatic cancers, and dying within 7–24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. Conclusion Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non‐U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high‐risk patients. Implications for Practice Cancer‐care costs are highest during the end‐of‐life (EOL) period for cancer decedents. This population‐based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL‐care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non‐U.S. countries surveyed in 2010. To slow the increasing cost of EOL‐cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high‐risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care. 摘要 背景. 尚未针对癌症死亡患者的临终（EOL）费用进行人群纵向研究。 方法. 本项回顾性人群队列研究考察了2001‐2010年间339 546例台湾癌症死亡患者在生命最后一年内的健康护理费用。个体患者水平的数据来自管理数据集。采用健康特异性购买力平价换算法将健康护理费用由台币换算为美元, 以评价健康购买力的差异。采用广义估计方程法, 通过多水平线性回归模型评价患者、医生、医院和区域因素与EOL护理费用之间的关系。 结果. 从2000年到2010年期间, 台湾癌症死亡患者的年均EOL护理费用由49 591美元增加至68 773美元, 其中三分之一的花费来源于患者生命的最后一个月。EOL护理费用增加与以下因素有关：男性, 低龄, 已婚, 诊断为肺癌、胃癌和肝脏‐胰腺癌以外的其他恶性血液疾病和血液系统癌症, 在诊断后7‐24个月内死亡。以下患者的EOL花费较少：共病和转移性疾病较多, 诊断后6个月内死亡, 由肿瘤科医师、胃肠科医师和重症监护医师进行护理, 在晚期癌症患者较多的教学医院接受护理。在基层医院和区域水平接受较高强度的EOL护理时, EOL护理费用有所增加。 结论. 台湾癌症死亡患者在EOL时的全民健康保险支出相当可观, 总体费用比2010年调查的6个发达国家（不包括美国）都要高。为了遏制花费的不断上涨并提高EOL癌症护理的质量, 应针对EOL护理经验较少和倾向于对高危患者进行高强度EOL护理的医院和临床医生进行干预, 以确保提供适当的EOL护理。 对临床实践的提示：癌症死亡患者在EOL阶段的癌症护理花费最高。本项人群研究纵向考察了癌症死亡患者的EOL费用。从2000年到2010年期间, 台湾癌症死亡患者的年均EOL护理费用由49 591美元增至68 733美元, 其中三分之一的花费来源于患者生命的最后一个月, 比2010年调查的6个发达国家（不包括美国）都要高。为了遏制不断上涨的EOL癌症护理费用, 应针对EOL护理经验较少和倾向于对高危患者进行高强度EOL护理的医院/临床医生进行干预, 以避免高强度EOL护理产生的肉体痛苦、精神负担和经济费用。 End‐of‐life care expenditures for cancer decedents are explored in this population‐based study. The accelerating costs of end‐of‐life cancer care are a quality concern not only for the unsustainability of health care systems but also for the negative impact of aggressive end‐of‐life care on terminally ill cancer patients and their family caregivers.