Influence of Hospices on Health Care Expenditures and the Aggressiveness of Medical Care for Terminal Cancer Patients in Taiwan

Abstract

Rationale: Cancer has been the leading cause of death in Taiwan since 1982. The high medical cost spent in the acute care hospital for terminal cancer patients does not improve their well-being. It's believed that hospice care is a standard of care for patients with life-threatening illness to improve patients' quality of end of life. However, the assumption that hospice care can save money and decrease the aggressiveness of medical care prior to death has not been fully supported.

Objectives: To examine health care expenditures and the aggressiveness of medical care between conventional care and hospice care for terminal patients with lung, liver, and colorectal cancer in the last month of life.

Methodology: We first identified all National Health Insurance (NHI) beneficiaries who died of cancer and aged more than 20 years old in 2004 from the Death Certificate data file, and then linked to the inpatient and outpatient claims files to obtain a complete record of the NHI utilization experience. The total health care expenditures were limited only to the NHI payment, out-of-plan use and out-of-pocket payment were not included. Those beneficiaries were divided into the hospice care group and the conventional care group. The indicators pf possible misuse of aggressive interventions were measured: receiving chemotherapy in the last month of life, more than one emergency room visit in the last month of life, more than one hospital surgery in the last month of life, an intensive care unit (ICU) admission in the last month of life, and death in an acute care hospital. Logistic regression and multiple-regression were used to examine the difference of aggressive care use and health care expenditures of end-of-life care between conventional care and hospice care by controlling patient age, sex, marital status, place of death, type of cancer, comorbidity, and living area.

Results: Of the 14,884 patients analyzed, 12,622 (84.8%) were in the conventional care group and 2,262 (15.2%) were in the hospice care group. The mean total health care expenditures per patient in the conventional care group was 39.0% higher than that of the hospice care group in the last month of life (EUR 1,971.7 and EUR 1,203.0, respectively). Regression result shows that the total health care expenditures and the inpatient-care expenditures for hospice care patients were significantly less than that in conventional care after adjusting for other factors. The aggressiveness of medical care in conventional care were significant more than that in hospice care was noted for receiving chemotherapy in the last month of life (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.8-2.4), more than one emergency room visit in the last month of life (adjusted OR, 1.1; 95% CI, 1.1-1.2), an ICU admission in the last month of life (adjusted OR, 2.7; 95% CI, 2.4-2.9), and more than one hospital surgery in the last month of life (adjusted OR, 1.3; 95% CI , 1.3-1.5).

Conclusions: Hospice care had large savings and decreased the utilization of aggressive interventions of chemotherapy, emergency room visit, ICU admission, and hospital surgery over conventional care for cancer patients in the last month of life.

Keywords: Hospice care, Health care expenditure, National health insurance

JEL Classification: A00