AIM: End-of-life discussions drive down treatment costs, improve quality of life

Moral of the story: If you have a terminal illness discuss end-of-life decisions with your physician. You will be thankful in many ways as you will be on the same page as your doctor and painful, intensive treatments may be forgone for more comfortable arrangements.

AIM: End-of-life discussions drive down treatment costs Daily Briefing - The Advisory Board Company 03/11/2009

Terminally ill patients who discussed end-of-life (EOL) care with their physicians had significantly lower health care costs and were more likely to have a better quality of life (QOL) in their final week of life compared with patients who did not have these conversations, according to a study published this week in the Archives of Internal Medicine (AIM). For the study, researchers from the Boston-based Dana-Farber Cancer Institute and colleagues followed a cohort of 627 patients with advanced cancer who were recruited for the longitudinal, multi-institutional Coping With Cancer Study between September 2002 and December 2007. At baseline—on average, six months before death—188 of 603 participants reported they had EOL discussions with their physicians. According to the findings, patients who had these discussions were more likely than their counterparts to acknowledge that they were terminally ill and report a desire to avoid dying in an ICU; patients who had EOL discussions were also less likely to prefer that their physicians take aggressive measures to extend life for a few days. As a result, the cost of care in the final week of life for patients who had discussed EOL goals with physicians averaged 35.7% lower (at an average of $1,876) than the cost of care for patients who did not have an EOL dialogue with their physicians, whose care during their final weeks of life averaged $2,917, according to aggregate costs of care determined using data from the 2004 Nationwide Inpatient Sample. Additionally, higher costs of treatment in the final week of life were not associated with better outcomes; rather, high-cost patients experienced a worse quality of death, as reported by their caregivers. Noting that 30% of annual Medicare expenditures are attributed to the 5% of beneficiaries who die, and that about one-third of the expenditures in the last year of life are spent in the last month—mostly on life-sustaining care—the study’s authors suggest that EOL discussions between patients and providers may be an effective approach to curtailing medical care expenditures while improving patients’ quality of life and death. Specifically, the authors assert that if the “national proportion of individuals reporting EOL discussions” with health care providers increased to 50%, the cost difference between EOL and non-EOL patients could top $76 million nationally, based on the total number of U.S. cancer deaths annually. To that end, the authors support the adoption of strategies to “promote increased communication,” including direct reimbursement for EOL discussions, improved physician education regarding EOL communication, and expansion of hospital palliative care programs. Additionally, the authors suggest that oncologists and palliative care physicians co-manage care of patients with late-stage cancer.

STUDY FINDS END-OF-LIFE COSTS HIGHER AMONG BLACK, HISPANIC PATIENTS

In another study published in AIM, researchers from the Boston University School of Medicine and colleagues analyzed records of of more than 158,000 Medicare beneficiaries who died in 2001, finding that black and Hispanic patients have substantially higher EOL costs than white patients. Specifically, the mean cost of care for white patients averaged $20,166 across the last six months of life, compared with $26,704 for black patients and $31,702 for Hispanic patients. Although the study did not examine the direct cause of treatment cost disparities, the researchers attributed nearly 85% of the higher costs for non-white patients to greater use of ICU care and intensive procedures. According to the CMO of the American Cancer Society, higher utilization of life-extending procedures among minority patients may stem in part from the fact that minority populations are less likely to receive preventive care and establish long-term relationships with physicians (Zhang et al., AIM, 3/9 [subscription required]; Hanchate et al., AIM, 3/9 [subscription required]; Tanner, Associated Press/Los Angeles Times, 3/9; Stern, Reuters, 3/9; Smith, MedPage Today, 3/9).