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Objective: Hemodialysis (HD) is the most common renal replacement therapy for patients with end-stage renal disease in Taiwan. The use of HD in hospice care and its impact on terminal cancer patients remains unclear., Methods: Using claim data from the Taiwan National Health Insurance Research Database, all patients who died from cancer and claim data of their terminal admissions in hospice from 2007 to 2010. Those with a comorbid diagnosis of renal failure or who had health insurance claims data for HD were enrolled., Results: A total of 5482 subjects were identified, of whom 4484 received HD and 998 did not. The HD group was significantly correlated with a younger age and high costs of terminal hospice admission. After adjusting for age and gender, the HD group was positively associated with a long hospice stay, in-hospice death, bone/connective tissue/breast cancers, and secondary/metastatic cancers, but negatively associated with genitourinary cancer. Compared with Department of Health/municipal hospitals, patients at both national and private university-affiliated hospitals were less likely to undergo HD., Conclusions: For terminal cancer patients under hospice care, HD was associated with a younger age, long terminal hospice stay, and high medical costs. Some types of cancers were associated with HD. University-affiliated hospitals played significant roles in non-HD renal supportive care. In-hospice HD is still common in Taiwan. Dialysis withdrawal and alternative care have space to promoting in hospice care.

Background: Costs of medical care have been found to be highest at the end of life., Aim: To evaluate the effect of provider reimbursement for hospice care on end-of-life costs., Design: The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life., Setting/participants: A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan., Results: Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%., Conclusion: By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.

Context: Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months., Objective: The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated., Methods: In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001-2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations., Results: The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared., Conclusion: Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

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.

Inpatient hospice care can reduce futile treatment and medical costs. However, the cost trimming effect of home-based hospice care in hospital has yet not been explored. This study evaluates the impact of home-based hospice care on end-of-life expenditure in hospitals with different spending intensity. This is a population-based retrospective study in Taiwan. Cancer decedents were identified in the National Health Insurance Research Database (NHIRD) from 2009 to 2011. They are categorized by hospital spending intensity. A hierarchical linear regression model with a random-intercept model was used to analyze the relationship between end-of-life expenditure (dependent variable) with and without home-based hospice, and both patient-level and hospital-level characteristics. A total of 78,613 cancer decedents were identified in the NHIRD from 2009 to 2011. Of these decedents, 17,638, 43,286, and 17,689 were categorized by hospital spending intensity as high, moderate, and low, respectively. Decedents with home-based hospice care were associated with US$2452 less in expenditure per patient compared with those without home-based hospice care. The majority of savings occurred in the last 3 months of life. These savings with home-based hospice care were consistent in hospitals with different levels of spending intensity. Home-based hospice reduced one-fifth expenditure at the end of life of cancer decedents treated in hospitals with different spending intensity.

Background/purpose: As the number of terminal cancer patients increases, several care models have been adopted to provide better care quality and reduce medical expenditure. This study compared inpatient medical expenditure and family satisfaction in a hospice ward (HW) and general ward (GW) for terminal cancer patients in Taiwan., Methods: We enrolled terminal cancer patients who were admitted and died during the same admission period in a tertiary care hospital in Taiwan from January 2003 to December 2005. These patients were allocated into three groups: inpatient care in HW alone; inpatient care in GW alone; and inpatient care in mixed group (initially in GW, then transferred to HW). Inpatient medical expenditure and family satisfaction were compared between the three groups., Results: A total of 1942 patients were recruited and allocated into HW (n = 292), GW (n = 1511) and mixed (n = 139) groups. The average medical expenditure per person or per inpatient day was lower in the HW than the GW or mixed group. Subjects who had ever been admitted to the intensive care unit or received cardiopulmonary resuscitation in the GW or mixed groups required more expenditure on medical care than that in the HW group. Daily medical expenditure in the HW group also was much lower than that in the GW and mixed groups, based on length of stay and cancer type. The family satisfaction score was significantly higher in the mixed and/or HW group than the GW group., Conclusion: For terminal cancer patients, hospice care can improve family satisfaction while reducing medical expenditure in Taiwan.

Cancer has been the leading cause of death in Taiwan since 1982, with nearly one out of four deaths caused by malignant neoplasm. The huge amount of money being spent in the acute care setting for terminally ill cancer patients does not increase their wellbeing. In this study, we employ an Instrumental Variable (IV) model to correct for the self-selection problem and use population-based insurance claim data to test two null hypotheses: there is no difference in total expenditures between hospice care and conventional care, and that there is no difference in total expenditures between hospital-based hospice care and home hospice care. Both null hypotheses are rejected.