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Background: Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer., Methods: Data from Taiwan's National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups., Results: From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs., Conclusion: Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier., Competing Interests: The authors have declared that no competing interests exist.

Background: Spending on cancer patients is substantial and has increased in recent years. Accountable care organizations (ACOs) are arguably the most important national experiment to control health-care spending. How ACOs are managing patients with cancer at the end of life (EOL) is largely unknown. We conducted this study with the objective of determining whether becoming an ACO is associated with subsequent changes in EOL spending or utilization among patients with cancer., Methods: Using national Medicare claims from 2011 to 2015, we identified patients who died in 2012 (pre-ACO, n = 12 248) and 2015 (post-ACO, n = 12 248), assigning each decedent to a practice. ACOs were matched to non-ACOs within the same geographic region. We used a difference-in-difference model to examine changes in EOL spending and utilization associated with becoming an ACO in the Medicare Shared Savings Program for beneficiaries with cancer., Results: We found that the introduction of ACOs had no meaningful impact on overall EOL spending in cancer patients (change in overall spending in ACOs = -$1687 vs -$1434 in non-ACOs, difference = $253, 95% confidence interval = -$1809 to $1304, P= .75). We found no changes in total patient spending by cancer type examined or by spending categories, including cancer-specific categories of radiation, therapy, and hospice services. Finally, emergency department visits, inpatient hospitalization, intensive care unit admissions, radiation therapy, chemotherapy, and hospice use did not meaningfully differ between ACO and non-ACO patients., Conclusions: The introduction of ACOs does not appear to have had any meaningful effect on EOL spending or utilization for patients with a cancer diagnosis., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Context: The Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014., Objectives: This study examined whether this requirement has increased hospice total costs, general costs, and visiting services costs., Methods: We conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD, and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage index, care volume, case-mix, and hospice and market characteristics, stratified by hospice ownership type., Results: Both for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 than 2012. Nonprofit hospices also reported higher general costs PPD in 2014 than 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for nonprofit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and nonprofit hospices showed lower costs PPD for all types associated with more patients and longer length of stay., Conclusion: Hospice costs increased after the Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Malignant melanoma accounts for the vast majority of skin cancer deaths. Primary prevention is used to increase knowledge about skin cancer and set incentives for a change in behaviour, which leads to a decrease in cases. Primary prevention may be cost-effective or even cost saving. Cost-of-illness (COI) studies provide information on such potential savings. The purpose of this study is to give an overview on COI studies in European countries and to compare the COI in total and by cost categories. The results can be used to model potential cost savings from prevention. We conducted a systematic literature research in PubMed using the PRISMA checklist. All costs were converted into Euro and adjusted for the reference year 2012. For the ranking of countries according to their COI, all costs were adjusted for the purchasing power parity. All studies focusing on stage III-IV melanoma include information on hospital, hospice, and outpatient treatment. Costs for the treatment of advanced melanoma range between € 2972 in Italy and € 17 408 in Sweden after adjusting for purchasing power parity. Most studies on stage I-IV melanoma include costs of hospitalization, outpatient treatment and general practitioner consultation. Direct costs range from € 923 in Sweden to € 9829 in Denmark. Three articles also include information on indirect costs. Mortality costs vary between € 3511 in Sweden and € 20 408 in England, morbidity costs between € 103 in Sweden and € 4550 in England. We showed that costs for the treatment of skin cancer are moderately high in the included countries. Since after publication of the articles new costly drugs were approved in Europe, treatment costs of melanoma in Europe may be expected to have risen in the last few years, which means that there is a high expectable potential for prevention programmes to become cost-effective or even cost saving., (© 2018 European Academy of Dermatology and Venereology.)

Background: Cancer imposes substantial burdens on cancer suffers, their families and the health system, especially in the end of life (EOL) of care patients. There are few developing country studies of EOL health care costs and no specialist studies of the disparities in cancer treatment and care costs by geographical location in China. We sought to examine geographical disparities in the types of cancer treatments and care costs during the last 3 months of life for Chinese cancer patients., Methods: Using snowball sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between July 2013 and June 2016 in China. Total EOL health care costs were modeled using generalized linear models (GLMs) with log link and gamma distribution., Results: Total health care costs were highest for urban (US$12,501) and western region (US$9808) patients and lowest for rural (US$5996) and central region (US$5814) patients. Our study revealed about 40% of the health care expenses occur in the last three months of life, and was mainly driven by hospital costs that accounted for about 70% of EOL expenditures. Patients faced out-of-pocket expenses for health care, with the ability to borrow from family and friends also impacting the type of treatment and health facility. Life-extending treatments per cancer patient was about two times that of patients receiving conservative treatments.Urban patients were more likely to receive life-extending treatments, financed by higher incomes and a greater capacity to borrow from family and friends to bridge the gap between health insurance reimbursements and out-of-pocket expenditures. Cancer patients in western region and urban area were significantly more likely to access hospice care., Conclusions: We found significant urban-rural and regional disparities in EOL types of cancer treatment, utilization of medical care and the health care expenditures. The EOL cancer care costs imposed heavy economic burdens in China.We recommend better clinical guidelines, improved EOL conversations and fuller information on treatment regimes among patients, family caregivers and doctors. Policies and information should pay more attention to palliative care options and the socio-cultural context of cancer care decision-making by family.

Infrequent and late referral to hospice among patients on dialysis likely reflects the impact of a Medicare payment policy that discourages the concurrent receipt of these services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, we identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9 percent had escalating spending and 13 percent had persistently high spending throughout the last year of life, while 41 percent had relatively low spending with late escalation, and 37 percent had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low ranging from only 19 percent of those with persistently high costs to 21 percent of those with moderate costs and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). These findings signal the need for greater flexibility in the provision of end-of-life care in this population.

Although there are 3 hospice care programs for terminal cancer patients in Taiwan, the medical utilization and expenses for these patients by programs have not been well-explored. The aim of this study was to examine the medical utilization and expenses of terminal cancer patients under different programs of hospice care in the last 90, 30, and 14 days of life.This was a retrospective observational study by secondary data analysis. By using the National Health Insurance claim database and Hospice Shared Care Databases. We identified cancer descents from these databases and classified them into nonhospice care and hospice care groups based on different combination of hospice care received. We then analyzed medical utilization including inpatient care, outpatient care, emergency room visits, and medical expenses by patient groups in the last 90, 30, and 14 days of life.Among 118,376 cancer descents, 46.9% ever received hospice care. Patients had ever received hospice care had significantly lower average medical utilization and expenses in their last 90, 30, and 14 days of life (all P < 0.001) compared to nonhospice care group. Each hospice care group had significantly less medical utilization and expenses in the last 90, 30, and 14 days of life (all P < 0.01).Different kinds of hospice care program have different effects on medical care utilization reduction and cost-saving at different stage of the end of life of terminal cancer patients.

Context: In 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy., Objectives: We assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay)., Methods: A pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data., Results: The average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program., Conclusion: Through the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end., Methods: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes., Results: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life., Conclusions: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery.

Background: The healthcare costs of cancer care are highest in the last month of life. The effect of hospice care on end-of-life (EOL) healthcare costs is not clearly understood., Purpose: The purpose of this study was to evaluate the effect of hospice care on survival and healthcare costs for lung cancer patients in their final month of life., Methods: We adopted Taiwan's National Health Insurance Research Claims Database to analyze data for 3399 adult lung cancer patients who died in 1997-2011. A logistic regression analysis was performed to determine the predictors of high healthcare cost, defined as costs falling above the 90th percentile. Patients who received hospice cares were assigned to a hospice (H) group and those who did not were assigned to a non-hospice (non-H) group., Results: The patients in the H group had a longer mean (median) survival time than those in the non-H group did (1.40 ± 1.61 y (0.86) vs. 1.10 ± 1.47 (0.61), p<0.001). The non-H group had a lower mean healthcare cost than the H group (US $1,821 ± 2,441 vs. US $1,839 ± 1,638, p<0.001). And, there were a total of 340 patients (10%) with the healthcare costs exceeding the 90th percentile (US $4,721) as the cutoff value of high cost. The non-H group had a higher risk of high cost than the H group because many more cases in the non-H group had lower costs. Moreover, the risk of high health care costs were predicted for patients who did not receive hospice care (odds ratio [OR]: 3.68, 95% confidence interval [CI]: 2.44-5.79), received chemotherapy (OR: 1.51, 95% CI: 1.18-1.96) and intubation (OR: 2.63, 95% CI: 1.64-4.16), and those who had more emergency department visits (OR: 1.78, 95% CI: 1.24-2.52), longer hospital admission in days (OR: 1.08, 95% CI: 1.07-1.09), and received radiotherapy (OR: 1.33, 95% CI: 1.00-1.78). Lower risks of high health care costs were observed in patients with low socioeconomic status (OR: 0.58, 95% CI: 0.40-0.83), or previous employment (OR: 0.66, 95% CI: 0.47-0.92). After propensity-score matching, the patients of the non-H group had a higher mean cost and a higher risk of high cost. Similar results were obtained from logistic regression analysis in propensity score-matched patients., Conclusions: The survival of the hospice group was longer than non-H group, and patients in the non-H group were 3.74 times more likely to have high healthcare costs at EOL. The positive predictors for high health care costs were patients who did not receive hospice care, who received chemotherapy and intubation, who had more emergency department visits and longer hospital admission, and who received radiotherapy. Negative predictors were patients who had a low socioeconomic status or previous employment. The issue of how to reduce the high health care costs for patients with lung cancer in the last month of life is a challenge for policy makers and health care providers.

Purpose: The aim of this study was to compare health-care expenditures and survival of these terminally ill patients receiving or not receiving hospice care in their last month of life., Methods: Using Taiwan's National Health Insurance Claims Database, we analyzed hospitalizations, OPD visits, associated costs, and survival. Logistic regression was used to identify predictors of high cost., Results: We identified 3850 liver cancer patients who died during the 1997-2011 study period, 644 (16.6 %) of whom were hospice care patients. No significant difference was found in mean survival time between the hospice and non-hospice groups (1.77 ± 2.44 vs. 1.84 ± 2.37 years, p = 0.217). The mean health-care expenditures per person were US$2370 ± 3421 and US$2072 ± 1900 (p = 0.130). A total of 385 patients (10 %) received high-cost care (above US$5422) using 38.6 % of the total health-care expenditures spent on the entire population. The significant predictors of high costs were non-hospice care [odds ratio (OR) = 3.06, 95 % confidence interval (CI) 2.09-4.60], days of admission [risk increase per admission day being (OR = 1.19, 95 % CI 1.17-1.21)], admission into an intensive care unit (OR = 3.17, 95 % CI 1.94 to 5.15), use of ventilator (OR = 3.54, 95 % CI 1.91-6.52), cancer therapy (OR = 1.82, 95 % CI 1.33-2.48), hemodialysis (OR = 2.62, 95 % CI 1.07-6.02), and higher socioeconomic status (OR = 1.65, 95 % CI 1.10-2.45)., Conclusion: Hospice care did not significantly affect survival, and hospice patients had lower per-patient expenditures and were less likely to require high-cost medical care than their non-hospice counterparts.

Background: Limited data exist regarding real-world treatment patterns, resource utilization, and costs of extensive-stage small cell lung cancer (esSCLC) among elderly patients in the United States. While abundant data are available on treatment patterns in metastatic non-small cell lung cancer (mNSCLC), to our knowledge no data exist comparing costs and resource use between patients with esSCLC or mNSCLC., Methods: We retrospectively analyzed administrative claims data (2000-2008) of patients aged ≥65 years from the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Patients were selected on the basis of having newly diagnosed esSCLC (n=5,855) or mNSCLC (n=24,090) during 1/1/2000-12/31/2005, and were required to have received cancer-directed therapy. Survival and other measures were compared between esSCLC and mNSCLC patients using Kaplan-Meier log-rank and univariate chi-square and t-tests. Study measures were followed from first diagnosis date of either esSCLC or mNSCLC until the earlier of death or end of the database., Results: Survival between the cohorts did not differ significantly: mean of 10.4 months for esSCLC patients versus 11.1 months for mNSCLC; median survival was 7.4 months versus 5.9 months. A higher percentage of mNSCLC patients (vs. esSCLC) received radiation therapy (75.6% vs. 65.4%; P < 0.001) and surgery (13.6% vs. 7.8%; P < 0.001) during the metastatic disease period. Conversely, a higher percentage of esSCLC patients than mNSCLC patients received chemotherapy (85.5% vs. 60.3%; P < 0.001), red blood-cell transfusion (20.7% vs. 10.9%; P < 0.001), platelet transfusion (5.6% vs. 1.8%; P < 0.001), and growth-factor support (59.0% vs. 39.5%; P < 0.001). esSCLC patients incurred higher lifetime disease-related costs ($44,167 vs. $37,932; P < 0.001) and all-cause costs ($70,549 vs. $67,176; P < 0.001) than mNSCLC patients., Conclusions: Lifetime total and disease-related costs per patient were high. Increased use of chemotherapy, supportive care therapies (including growth factors), and disease-related hospitalizations were observed in esSCLC patients as compared with mNSCLC patients. Disease-related and all-cause costs for esSCLC also exceeded those of mNSCLC, except for hospice and skilled nursing services. Survival and per-patient costs for both groups underscore the unmet medical need for more effective therapies in patients with esSCLC or mNSCLC.

Importance: More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it., Objective: To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care., Design, Setting, and Participants: Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care., Exposures: Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients., Main Outcomes and Measures: Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life., Results: Among 86,851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3-34), and 51,924 patients (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18,165 patients in the hospice group and 18,165 in the nonhospice group. After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71,517 (95% CI, $70,543-72,490) for nonhospice and $62,819 (95% CI, $62,082-63,557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835)., Conclusions and Relevance: In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

This study examined the utilization and cost of all health services consumed during the last six months of life by cancer patients, and compared those with and without home-hospice care. Detailed information was extracted from the health care electronic administrative data files on 193 deceased cancer patients that their family approved the study (out of 429, 45%). About 88% had been hospitalized for 19 days on average and 53% visited the ER. One quarter received home-hospice care. Their average cost was $13,648 compared to $18,503 for patients without home-hospice care. Hospitalization contributed 32% to the total cost of patients with home-hospice care and 64% for those with it. The findings support the justification for significant expansion of home-hospice care., (© The Author(s) 2013.)

The cost of hospice care is rising. Although providing care for children at end of life may be costly for hospices, it is unclear whether or not gaining pediatric knowledge and even establishing a pediatric program may be done cost effectively. The purpose of our study was to examine the effect of possessing pediatric knowledge (i.e., pediatric program, pediatric experience) on core hospice care costs. Using 2002 to 2008 California hospice data, the findings of the regression analysis suggest that having pediatric knowledge does not significantly increase nursing, physician, and medical social service costs. Having a pediatric program was related to increased counseling costs. Our findings shed important light on the minimal costs incurred when hospices decide to develop pediatric knowledge.

Purpose: With rising health care costs in the United States, clearly defined end-of-life (EOL) cancer costs are needed to help health administrators proactively manage this important care. Our objective was to examine EOL health care resource costs among oncology patients in a US commercial insurance population., Methods: A retrospective claims database affiliated with OptumInsight was analyzed. Included patients had: a medical claim with cancer diagnosis between July 1, 2002, and December 31, 2009; death on or before December 31, 2009; continuous enrollment with medical/pharmacy benefits from diagnosis until death; ≥ 180 follow-up days; and active cancer in the last 6 months before death (MBD). Death was captured from facility discharge codes or Social Security Administration death files. Costs were determined by summing paid amounts on all services utilized within the last 6 MBD: cancer-related inpatient (IP) stays, cancer- related hospice care, and cancer-related outpatient (OP) services (ie, chemotherapy, erythropoiesis-stimulating agents, granulocyte colony-stimulating factors, radiation, cancer-related office or emergency room visits, cancer-related hospital OP procedures, and other services with cancer diagnosis)., Results: A total of 28,530 patients met inclusion criteria. Mean total cancer-related costs in the last 6 MBD were $74,212 (standard deviation, $112,740), comprising IP costs of $40,702 (55%), OP costs of $30,254 (41%), and hospice costs of $3,256 (4%). OP costs decreased from $6,021 in the sixth MBD to $2,238 in the last MBD, whereas IP care costs increased from $1,785 to $20,559. Hospice utilization increased from 0.7% in the sixth MBD to 35.6% in the last MBD., Conclusion: Oncology costs increase in the last 6 MBD largely because of increased IP costs, whereas OP costs decrease.

Background: Patients with severe, symptomatic aortic stenosis, who do not undergo valve replacement surgery have a poor long-term prognosis. Limited data exist on the medical resource utilization and costs during the final stages of the disease., Methods and Results: We used data from the 2003 Medicare 5% standard analytic files to identify patients with aortic stenosis and a recent hospitalization for heart failure, who did not undergo valve replacement surgery within the ensuing 2 calendar quarters. These patients (n=2150) were considered to have medically managed severe aortic stenosis and were tracked over 5 years to measure clinical outcomes, medical resource use, and costs (from the perspective of the Medicare Program). The mean age of the cohort was 82 years, 64% were female, and the estimated logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (a measure of predicted mortality with cardiac surgery) was 17%. During 5 years of follow-up, overall mortality was 88.4% with a mean survival duration of 1.8 years. During this time period, patients experienced an average of 4.4 hospital admissions, 52% were admitted to skilled nursing care, and 28% were admitted to hospice care. The total 5-year costs were $63 844 per patient, whereas mean annual follow-up costs (excluding the index quarter) per year alive were $29 278., Conclusions: Elderly patients with severe aortic stenosis undergoing medical management have limited long-term survival and incur substantial costs to the Medicare Program. These results have important implications for policy makers interested in better understanding the cost-effectiveness of emerging treatment options such as transcatheter aortic valve replacement.

Objective: To describe patterns of healthcare resource utilisation and associated costs for patients with advanced melanoma in the United Kingdom (UK), Italy, and France., Methods: For patients receiving systemic treatment, or supportive care, data describing hospitalisations, hospice care, and outpatient visits were retrieved retrospectively from advanced disease diagnosis as part of a multicountry observational study. Costs were estimated by multiplying utilisation level by unit cost. In an exploratory analysis, costs were compared between individuals who died within one year of initiating first-line treatment (short-term survivors) and those with ≥ 1 year follow-up (long-term survivors)., Results: Hospitalisation costs were highest in France (€6262 per-person compared with €3225 in the UK and €2486 in Italy), reflecting higher rates of hospitalisation. In contrast, outpatient costs were highest in the UK (€782 per-person, compared with €115 in France and €72 in Italy), reflecting the highest rate and frequency of outpatient visits and the highest cost per visit. Hospitalisation rates were consistently higher during supportive care compared with systemic therapy. Roughly one-third of patients entered clinical trials and were not included in the analysis. In exploratory analysis, total costs were generally higher for long-term survivors, but monthly per-patient costs were generally lower for long-term survivors, consistent with a hypothesis that resource utilisation and costs do not necessarily increase proportionally with extended survival., Conclusion: Total costs associated with resource utilisation for advanced melanoma patients varied across countries. Overall cost differences were due to differences in frequency and intensity of utilisation patterns and variation in unit costs of health resources., (Copyright © 2012. Published by Elsevier Ltd.)

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Hospice is a major expansion area within the Veterans Health Administration (VHA). The objective of this retrospective study was to explore trends in hospice utilization among older veterans receiving services at the end of life over a 4-year (2006-2009) time period. Reviewing trends, the number of veterans receiving hospice services increased annually, with 5779 veterans receiving services during 2009, up from 1742 veterans in 2006. The total cost of providing hospice rose dramatically, increasing from $1.98 million in 2006 to $5.91 million in 2009. More funds were spent on younger veterans, with an average of $1.5 million spent on veterans aged 55 to 64 and less than $400,000 spent on veterans aged 85 and older. Findings highlight the growing need and demand for hospice within the VHA to provide end-of-life services.

Objectives: This study explores the financial consequences of decreased acute care utilization and expanded community-based care for patients at the end of life in England., Method: A Markov model based on cost and utilization data was used to estimate the costs of care for cancer and organ failure in the last year of life and to simulate reduced acute care utilization., Results: We estimated at pounds 1.8 billion the cost to the taxpayer of care for the 127,000 patients dying from cancer in 2006. The equivalent cost for the 30,000 people dying from organ failure was pounds 553 million. Resources of pounds 16 to pounds 171 million could be released for cancer., Conclusion: People generally prefer to die outside hospital. Our results suggest that reducing reliance on acute care could release resources and better meet peoples' preferences. Better data on the cost-effectiveness of interventions are required. Similar models would be useful to decision-makers evaluating changes in service provision.

Congenital and acquired neurodegradative diseases are always the reason for prolonged stay in hospital, at the beginning of the establishment of diagnosis and treatment and afterwards for stabilizing all functional adaptation to an existence with the severe disability. Also infections of the lower respiratory tract accompanying the later course of the disease are usually directed to hospital treatment. The aim of the study was to delineate the role of hospice care of patients staying at home, in economical approach to the medical care of severly and incurably ill children. The study group consisted of 29 children with neurodegradative diseases, aged 6 months to 18 years, admitted to the home care of Priest Józef Tischner Cracovian Children' Hospice. The costs of yearly treatment (based on 2008 data) of the infections of the lower airways in the studied group, performed at home under the hospice care and in hospital, were compared. The actual expenses of home treatment were counted. Considering the hospital therapy costs, the simulation was performed following median expenses of a 10-day-treatment of a 20 kg-in-weight child with uncomplicated lower respiratory tract infection in pediatric department with the use of the first line therapy antibiotic. Three parameters were taken to calculations: the medical care costs, the expenses of laboratory tests and X-ray pictures and the costs of antibiotics. In studied children 61 cases of lower respiratory tract infections were diagnosed in 2008 (the median incidence was 2,1 per year; ranged 0-7), of which 48 cases were treated at home. The median time of antibiotics administration in home treatment was 13 days. In 31% of infections more than one antibiotic was used. In 19% of cases in home therapy parenteral medicine was necessary. The median summarized cost of treat- ment at home was calculated as 2657 zl. The need for hospital care in our group concerned 13 incidences. The median estimated cost of treatment of the lower airways infection in hospital for one child equaled 4942 zl. The expenses of home treatment of the lower airways infections under the hospice care were twice lower than the costs of the therapy in hospital. Apart from the obvious psychological and social benefits, also economic aspect contributes to the promotion of the hospice care of staying-at-home patient in the improvement of medical care for children with severe neurodegradative diseases.

The remarkable growth of palliative care in the United States in the last 25 years has been fueled by the expansion of Medicare to include a hospice benefit. Medicare provides health insurance for qualified elderly individuals and Medicaid covers the poor. Hospice benefits are the same for both Medicare and Medicaid. Over one million elderly Americans make use of this benefit annually. Private insurers often mirror the Medicare benefit. Increasingly, hospice patients in the United States are patients with diagnoses other than cancer. Although national average length of service has increased to over two months, median length of service has declined to 20 days, with both more long- and short-term periods of service. U.S. hospice care is predominantly care delivered in the place the patient calls home (95.6%). Although the hospice benefit has provided palliative care for more patients and families than any other country, the requirements for use have been found to be self-limiting.

This article overviews current funding and financing issues in the Australian hospice and palliative care sector. Within Australia, the major responsibilities for managing the health care system are shared between two levels of government. Funding arrangements vary according to the type of care. The delivery of palliative care services is a State/Territory responsibility. Recently, almost all States/Territories have developed overarching frameworks to guide the development of palliative care policies, including funding and service delivery structures. Palliative care services in Australia comprise a mix of specialist providers, generalist providers, and support services in the public, nongovernment, and private sectors. The National Palliative Care Strategy is a joint strategy of the Commonwealth and States that commenced in 2002 and includes a number of major issues. Following a national study in 1996, the Australian National Subacute and Nonacute Patient (AN-SNAP) system was endorsed as the national casemix classification for subacute and nonacute care. Funding for palliative care services varies depending on the type of service and the setting in which it is provided. There is no national model for funding inpatient or community services, which is a State/Territory responsibility. A summary of funding arrangements is provided in this article. Palliative care continues to evolve at a rapid rate in Australia. Increasingly flexible evidence-based models of care delivery are emerging. This article argues that it will be critical for equally flexible funding and financing models to be developed. Furthermore, it is critical that palliative care patients can be identified, classified, and costed. Casemix classifications such as AN-SNAP represent an important starting point but further work is required.

Background: Racial and ethnic minorities generally receive fewer medical interventions than whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end., Methods: Based on a random, stratified sample of Medicare decedents (N = 158 780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (eg, ventilators), and hospice to racial and ethnic differences in Medicare expenditures in the last 6 months of life., Results: In the final 6 months of life, costs for whites average $20,166; blacks, $26,704 (32% more); and Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice use account for 53% and 63% of the higher costs for blacks and Hispanics, respectively. While whites use hospice most frequently (whites, 26%; blacks, 20%; and Hispanics, 23%), racial and ethnic differences in end-of-life expenditures are affected only minimally. However, fully 85% of the observed higher costs for nonwhites are accounted for after additionally modeling their greater end-of-life use of the intensive care unit and various intensive procedures (such as, gastrostomies, used by 10.5% of blacks, 9.1% of Hispanics, and 4.1% of whites)., Conclusions: At life's end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

We obtained patient-level cost data from one hospice to explore variation in hospice costs across patients. We found that average per day costs decreased as duration of hospice stay increased. Costs per day were lower for nursing home residents than nonresidents. We identify possible alterations to the Medicare per diem payment system that could address these issues, including higher per diems for the first and last days and an adjuster for nursing home residence. However, replicating these results using data from a broader, more representative sample of hospices is needed before making changes to the per diem system.

This study examined and compared the cost of care provided to terminal metastatic cancer patients by home hospices and by conventional health services. The study population included 146 patients with metastatic cancer. Half received home hospice services, and the other half received conventional services. The average overall per-patient cost of care was, respectively, $4761 (operating costs included) and $12 434. On average, the costs were lower for older patients. A multiple regression analysis revealed that treatment units per patient, care framework, and patient age significantly contributed to explaining the cost variance. The findings suggest a financial advantage for home hospice care for terminal patients. This should be investigated further, as should the cost of informal caregivers and patient and caregiver satisfaction with the quality of care in both frameworks.

Hospice care is perceived as enhancing life quality for patients with advanced, incurable illness, but cost comparisons to non-hospice patients are difficult to make. The very large Medicare expenditures for care given during the end of life, combined with the pressure on Medicare spending, make this information important. We sought to identify cost differences between patients who do and do not elect to receive Medicare-paid hospice benefits. We introduce an innovative prospective/retrospective case-control method that we used to study 8,700 patients from a sample of 5% of the entire Medicare beneficiary population for 1999-2000 associated with 16 narrowly defined indicative markers. For the majority of cohorts, mean and median Medicare costs were lower for patients enrolled in hospice care. The lower costs were not associated with shorter duration until death. For important terminal medical conditions, including non-cancers, costs are lower for patients receiving hospice care. The lower cost is not associated with shorter time until death, and appears to be associated with longer mean time until death.

The aim of this work was to carry out a cost evaluation of the home care programme for terminally ill cancer patients run by the Istituto Oncologico Romagnolo (I.O.R.) in the areas of Forlì, Cesena, Ravenna and Rimini (Romagna, Italy). To determine effective home care direct costs, we first selected 1 week of care as an observation unit. We then proceeded to assess the medical and nursing care units together with the clinical protocols administered for each patient. The Karnofsky Performance Status (KPS) was also assessed weekly. In this way, we calculated care costs for each patient and for each week as the sum of medical costs, nursing costs, treatment costs and other costs. A consecutive series of 574 patients were involved in the study from 1 April 1994 to 31 March 1995. A total of 5164 patient-weeks of care was provided, with an average cost per week of 177.6 Ecu. This weekly cost increased in the last 100 days of life (week -15 = 179.5 Ecu; week -8 = 188.3 Ecu; week -2 = 221.0 Ecu; P < 0.001). When single components were analysed in relation to total cost (treatment protocols, physician and nursing care) the increased global cost was found to be mainly attributable to the intensification in nursing care (21.8% of costs in week -15 vs 27.3% of costs in week -2). Examination of the relation between the cost of 1 week of care and KPS values clearly shows that healthcare costs increased as KPS decreased (from 152.2 Ecu with KPS > or = 60 to 292.6 Ecu with KPS < or = 20; P < 0.001). Home care costs were also seen to vary with some clinical characteristics and symptoms present when patients entered the study: asthenia, anorexia, nausea/vomiting, bedsores. Given the good results of home care for cancer patients in terms of quality of life, this method of cost accounting for home-care providers can help to monitor the rising cost of assistance and confirm the cost effectiveness of this type of care.

This review of the literature of the past decade on medical care costs at the end of life finds that the data do not support the often-voiced hypothesis that the rise in medical care costs is due largely to the disproportionate use of high-technology medical care by persons who die. It also shows that although the intensity of care, as indicated by hospital expenditures, declines with age, any savings on hospital costs of very old decedents are offset by nursing-home costs. Studies of hospice care and advance directives are reviewed for their effectiveness in reducing end-of-life costs, but these strategies are not promising at this time, largely because of the difficulty of predicting when an individual patient will die. It is suggested that curbing the rise in medical care costs will require basic changes in the physician-patient relationship and in our attitude to death.

This article explores the organizational barriers that have limited the number of persons with AIDS cared for by hospice programs throughout the United States. The financial implications of caring for persons with AIDS are discussed and data from a survey of 15 hospice providers is presented. Examples of creative and cooperative coalitions among hospice programs and other community organizations that maximize scarce resources and share the financial burden of caring for those infected with HIV are presented as models. The diverse funding sources and individual hospice program decisions about palliative treatments and drugs and admission criteria highlight the difficulty of generalizing from the survey.