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Studies probe health care costs at the end of life
Patients with advanced cancer who discuss end-of-life care with their physicians appear to have lower health care costs in the final week of life than those who do not, according to a report in the March 9, 2009, issue of Archives of Internal Medicine.
A second report in the same issue finds that black and Hispanic patients tend to have higher health care costs at the end of life than white patients, despite dying of similar causes.
A disproportionate share of medical costs occur at the end of life, according to the first article. Almost one-third of Medicare expenditures are attributable to the 5% of beneficiaries who die each year, and about one-third of expenses in the last year of life are spent in the final month. Previous studies suggest that most of those costs result from life-sustaining care, including resuscitation and mechanical ventilation.
Baohui Zhang, MS, center statistician at the Dana-Farber Cancer Institute, Boston, and colleagues studied 603 patients who were part of the Coping With Cancer study, funded by the National Institute of Mental Health and the National Cancer Institute. At the beginning of the study, between 2002 and 2007, 188 (31.2%) reported discussing their wishes about end-of-life care with their physicians. They then were followed up through death.
In the final week of life, patients who reported having end-of-life discussions with their physicians had average aggregate health care costs of $1,876, compared with $2,917 for patients who did not. Formal and informal caregivers who were interviewed after patients' deaths reported that those with higher costs also had a worse quality of death in their final week.
In the second article about end-of-life costs, Amresh Hanchate, PhD, of Boston University School of Medicine, and colleagues report on an analysis of data from 158,780 Medicare beneficiaries who died in 2001. In the last six months of life, costs varied significantly by racial and ethnic background. Costs for whites averaged $20,166, compared with $26,704 for blacks and $31,702 for Hispanics.
Between 40% and 60% of these excess differences are associated with geography, such as living in high medical expenditure areas. However, substantial differences remain, even after adjustment for many patient characteristics in addition to geographic variables, the authors wrote.
"Strikingly higher rates of use of intensive end-of-life treatments, such as ICU and ventilators, account for most of these residual differences," they wrote. "Therefore, at life's end, minorities often receive more expensive but not necessarily life-enhancing care. It is unclear how much of this was actively sought, or the extent to which racial and ethnic differences is principally driven by how choices are presented or how they are 'heard.'" The authors suggest additional research.