Costs of Cancer Care in the Last Five Days of Life in a Low-Resource Setting

doi:10.21203/rs.3.rs-2965955/v1

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Costs of Cancer Care in the Last Five Days of Life in a Low-Resource Setting

https://doi.org/10.21203/rs.3.rs-2965955/v1

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Background

End-of-life care for patients with advanced cancer is costly. The palliative care unit tend to reduce the healthcare costs of these patients. This study aimed to compare palliative care unit costs with non-palliative care unit costs in cancer patients admitted to a university hospital.

Methods

We calculated the cost and number of services the patients received in the last five days of life in this study. We adjusted all costs based on the 2018 US Dollar exchange rate. We evaluated the cost of hospitalization and care service delivery for 150 patients admitted to a university hospital; the participants were selected prospectively.

Results

A total of 150 patients were included in this study, 56 of whom (37%) were admitted to the palliative care unit. The average total cost of treatment in the last five days of life for each patient was three times higher in general, wards compared to palliative care unit. The total cost of cancer in the last five days of life was $2,873 in the non- palliative care unit setting and $909.63 in the palliative care unit setting.

Conclusions

Based on the results, establishing palliative care units in tertiary hospitals and providing palliative consultation to patients with advanced cancer can be profitable when resources are limited.

End-of-life cost

Palliative care

Cancer

Iran

Cancer is one of the costliest diseases around the world, accounting for a great share of economic burden in any country. According to the GLOBOCAN 2020 estimates, the incidence and mortality rates of all cancers were 19,292,789 and 9,958,133 worldwide and 131,191 and 79,136 in Iran, respectively (1). The total cost of some cancers has been estimated in Iran, including colorectal cancer ($298,148,718), oral cancer ($64,245,173), breast cancer ($947,374,468), and gynecological cancers ($51,000,000) (2–5). Approximately 13% of personal healthcare costs are attributed to the last years of life in cancer patients due to hospitalization and the need for intensive care unit (ICU) admission (6).

In China, data from 894 cancer patients revealed that the costs of treatment were US$18,234, US$13,043, US$6,349, and US$2,085 in the last six months, three months, and one month, and one week of life, respectively. In this regard, a study reported that the cost of healthcare increased dramatically as the patient’s death approached (7). Overall, cancer costs affect all family members and waste nearly all family savings, even when the patient is insured (8). As soon as physicians declare that there is no treatment for patients with advanced cancer, palliative care can be used to minimize both the patient's pain and the cost of treatment. It has been shown that palliative care improves the quality of life of patients with serious end-stage diseases at the end of life. Palliative care services reduce the patients’ symptoms and eliminate the need for medical interventions and non-beneficial imaging, which can increase the quality of life of patients, their families, and physicians compared to non-palliative care unit services (9, 10).

The palliative care units tend to reduce the healthcare costs of patients at the end of life (11–14). Therefore, increasing the number of palliative care units can lead to greater cost avoidance for the patients and the healthcare system (15). The total cost of care delivery in the last three days of life was estimated at $1,340.60 in the palliative care unit setting versus $9,467.78 in a tertiary hospital setting in Australia (16). Overall, palliative care units lead to cost savings by reducing the length of hospital stay (LOS) and the intensity of treatment (17). However, most of these examinations and cost-estimation studies have been conducted in high-income countries, and lack of evidence to support the cost-effectiveness of palliative care units in low- and middle-income countries is a potential barrier to their accessibility (18).

Since there are not many palliative care units in hospitals of Iran, economic evaluations conducted on cancer costs in Iran have not estimated the cost of palliative care (2–5). The present study aimed to determine whether implementing palliative care units in tertiary hospitals can reduce the cost and burden of cancer care and to evaluate and compare the cost of care in the last five days of life for cancer patients in these wards.

Study design, setting, and patient selection

We conducted a retrospective study at a university hospital during 2015–2018. Iran Cancer Institute is a multidisciplinary specialized hospital for cancer patients. It is the first hospital with a palliative care unit in the country, located in Imam Khomeini Hospital Complex (IKHC), which is a leading referral hospital in Iran. The palliative care unit was established in 2015 with six beds. Patients with cancer were either treated or diagnosed in the Cancer Institute or Imam Khomeini Hospital Complex. The cost data of patients admitted to the palliative care unit of Cancer Institute were abstracted and compared with the data of cancer patients admitted to Imam Khomeini Hospital Complex in any unit. We only selected cancer patients who died in the palliative care unit of Cancer Institute or the non- palliative care unit setting of IKHC, and we calculated the cost of cancer in the last five days of life. Most patients admitted to the palliative ward of Cancer Institute were in the last days of their lives. Patients who died within less than five days of admission were excluded from the study. Based on the inclusion criteria, we included a total of 56 patients in the palliative care unit setting and 94 patients in the non- palliative care unit setting in this study between 2015 and 2019.

Data extraction

We calculated the cost and number of services the patients received in the last five days of life in this study. The study variables included sex, age, cancer type, cancer morphology, file number, type of insurance, date of admission, date of death, hospitalization date, days of ICU stay, cost of hospitalization, frequency of hospitalization, consultation, imaging, laboratory tests, interventions, and prescribed medications.

Data analysis

We performed STATA 16 for windows for all statistical analyses. Data were not normally distributed, and we performed nonparametric tests to determine statistically significant differences between the groups concerning the variables under study. A P-value of 0.05 was considered statistically significant. We examined the differences in costs using Wilcoxon signed-rank test. Moreover, we performed a correlation analysis using Spearman’s rank correlation test to assess the relationship between care cost and type of ward. Moreover, we conducted Mann-Whitney test to examine the association between the sociodemographic variables and the type of wards. The median values are presented as interquartile range (IQR) between Q1–Q3. Since healthcare inflation was highly unstable between 2015 and 2018, we converted all costs based on the exchange rate from US Dollar (USD) to Iranian Rial in 2018 (one USD equaled 43,888 Rials in 2018).

In the present study, a total of 150 patients were included, 63 of whom (42%) were female. The total number of patients in the palliative care unit was 56. The mean age of female and male patients was 53.42 and 54.67 years, respectively. The majority of patients had social insurance (60%). The variables of sex, age, and type of insurance had no significant relationships with the type of ward. Table 1 presents the demographic status of the patients.

Table 1

The demographic characteristics of the participants stratified by the hospital unit
type of ward		Palliative care unit	Non- palliative care unit	total	P value
Age		53.42(18.5)	54.67(28)	54.2(22)	0,486
gender	Men	27	60	87	0.061
gender	Women	29	34	63	0.061
Type of Insurance	Armed Forces Medical Services	2	2	4	0.617
	National Health Insurance	18	37	55
	Social Insurance	36	55	91

Table 2

The mean value and IQR of variables stratified by the hospital unit
type of ward	Palliative care unit	Non- palliative care unit	ratio (Non-PCU to PCC)	P Value
type of ward	mean(IQR)	mean(IQR)	ratio (Non-PCU to PCC)	P Value
Number of visits	3.78(1)	2.18(5)	0.57	0.00003
Number of consults	0.46(0)	2.11(4)	4.58	0.00001
Number of lab test	4.01(5.3)	8.63(5.78)	2.15	0.00001
Number of medication	6.4(6.93)	18.61(17.74)	2.9	0.00001
Number of imaging	0.42(0)	1.03(2)	2.45	0.00001
Length of stay in ICU (median)	0	37(15)	37	0.00001

In this study as shown in Table 2, the average number of visits by physicians was 3.78 in the palliative care unit setting and 2.18 in the non- palliative care unit setting. The average number of laboratory tests in the non- palliative care unit setting was 2.15 times higher than that of the palliative care unit setting. The number of consultation visits, medications, and imaging procedures was lower in the palliative care unit compared to the non- palliative care unit setting. These results were statistically significant according to the type of hospital ward.

Table 3

The mean values of cancer cost (USD) and IQR in the last five days of life stratified by the hospital unit
type of unit	Palliative care unit	Non- palliative care unit	ratio (Non-PCU to PCU)	P value
	Mean	Mean
	(IQR)	(IQR)
cost of visit($)	68.25	45.87	0.67	0.00001
cost of visit($)	36.79	77.01	0.67	0.00001
cost of consult($)	8.44	45.58	5.4	0.00001
cost of consult($)	0	78.16	5.4	0.00001
cost of laboratory test($)	20.20	136.97	6.78	0.00001
cost of laboratory test($)	22.47	85.14	6.78	0.00001
cost of medication($)	73.22	667.61	9.11	0.00001
cost of medication($)	66.38	626.59	9.11	0.00001
cost of imaging($)	24.65	69.52	2.8	0.00001
cost of imaging($)	23.96	101.38	2.8	0.00001
cost of hoteling($)	713.18	1907.13	2.67	0.00001
cost of hoteling($)	442.03	1749.41	2.67	0.00001
total	909.63	2872.69	3.15	0.00001

According to Table 3, the average total cost of treatment in the last five days of life was $2872.69 for each patient in the non- palliative care unit setting and $909.63 in the palliative care unit setting (almost three times lower). The cost of medications was nine times higher in the non- palliative care units setting compared to the palliative care unit. The most significant difference in cost was related to hoteling expenses, with $1,907 in the non-palliative care unit setting and $713 in the palliative care unit; according to this comparison, all costs were significantly different. It should be noted that some patients were referred to the palliative care unit from the non-palliative care unit setting in the last days of their life.

Overall, 54 out of 94 patients (57%) in the non-palliative care unit setting were hospitalized in the ICU. The mean length of stay in the ICU was 37 days in the non-palliative care unit setting, while no patients in the palliative care units were admitted to the ICU. Evaluation of palliative consultation for patients admitted to the non- palliative care units setting showed that only three patients had an order of palliative consultation in their records.

The present results indicated cost-savings in the palliative care unit setting compared to the non-palliative care unit setting for patients with advanced cancers. Overall, hospitalization of patients in the last days of life to the palliative care unit can lead to lower costs for both hospitals and patients. The average cost of care in the last five days of life was 3.15 times lower in the palliative care unit compared to the non-palliative care unit setting. The total cost of care for patients admitted to the palliative care unit was $909.63 versus $2,872.69 for patients admitted to other hospital wards.

The most significant difference in cancer costs was related to hoteling expenses (7). In the present study, 57% of patients in the non-palliative care unit setting were hospitalized in the ICU, and the cost of ICU stay was the highest. The implementation of palliative care unit in the last month of life was beneficial; however, this setting caused no significant difference when established in the early stages of the disease. According to a previous study, in the last six months of life, patients were hospitalized several times. Procedures, such as chemotherapy and surgery, were the least frequently used interventions for advanced ovarian cancer in the last six months of life (19). In the current study, people who received palliative care services spent less money on care services compared to those who received other services. In a systematic review of 46 studies, the results showed that palliative care units were less costly than other approaches (20).

This study was performed in a public hospital, and most patients had public insurance (they were mostly insured). There were no significant differences between different types of insurance. On the other hand, patients with public insurance tended to use more expensive services and had extended ICU stays for recovery. However, private insurance reduced the LOS from 9.5 days to 8.5 days compared to public insurance (21). The costs of medication, laboratory tests, and ICU admission significantly reduced when patients died in palliative care units, compared to the non-palliative care unit setting. Overall, a net saving of $4,908 in direct costs per admission (P = 0.003), along with a saving of $374 in direct daily costs (P = 0.001), was reported in this study. Significant cost savings can be achieved by setting clear care goals, which can lead to the selection of an effective treatment by the patient's family and help achieve these goals and avoid unnecessary interventions (22).

Medication order costs in the non- palliative care unit setting were nine times higher than the palliative care unit setting. The cost of medication orders in the non- palliative care unit setting indicated that the used medications were costly, while their benefits were questionable. In previous research, 75.0% of patients in hospitals received three or more potentially ineffective medications in their last three days of life, whereas this percentage was about 42.6% in hospice care (23, 24). Since imaging for advanced patients has no diagnostic value, it can be only justified by the management of acute symptoms, assessment of disease progression, and evaluation of the effects of treatment; the latter can be helpful in assessing whether treatment should be discontinued or changed. Although there are currently available guidelines, diagnostic imaging remains controversial. In a previous study, in the last month of life, most patients had received at least one imaging procedure without improving their survival (25).

In the current study, palliative care units had a higher frequency and cost of daily visits compared to the non-palliative care unit setting. We only registered the cost of daily visits in the patient’s file when the corresponding physician made a visit, not the resident. During daily visits to the palliative care unit, the corresponding physician managed the patient, met the patient's family, and communicated with the patient; these visits were crucial in the last days of a patient's life (26, 27).

Generally, palliative care consultation affects the quality of life of patients. The present results revealed that few patients benefited from palliative care consultation during their hospital stay. The greatest share of costs in the non- palliative care unit setting was ICU admission. If there is no palliative care unit, palliative consultation can reduce the cost of patient management (28). It is known that improvement of the patients’ quality of life and their dignity and comfort is the main goal of palliative care. Besides reducing hospital costs, palliative care protects patients and their families against financial difficulties due to disease and disability (29).

To the best of our knowledge, this is the first study evaluating the economic benefits of palliative care unit implementation in Iran. This study, however, had some limitations. First, based on the inclusion criteria and the lack of palliative care units in Iran, the sample size was small. Second, only the cost of care for advanced cancer patients who died in the hospital was estimated, while the cost of care in the last five days of life in patients who died in their homes could not be calculated.

Palliative care does not refer to end-of-life care, but to care provided near the end of an individual’s life. It provides an alternative to disease-modifying and life-sustaining treatments of questionable value by assisting with the decision-making process, based on the patient's goals of care. The implementation of palliative care units can save money in the last days of life of cancer patients; therefore, it can be profitable in referral hospitals. In the absence of resources for establishing palliative care units, palliative consultation or adherence to palliative care guidelines, besides management of patients' symptoms, can be used to manage the cost burden of cancer.

Competing interests: The author(s) declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Availability of data and materials: The cost data of patients are available in the hospital information system

Funding: This work was supported by the Cancer Research Center of Cancer Institute, Tehran University of Medical Sciences (Grant No.: 97-01-51-37437).

Authors' contributions: All authors of this research paper have directly participated in the planning, execution, or analysis of the study. Dr A. Nahvijou and Dr M Tahmassebi and Dr K Zendehdel contributed to the design of the study A Darrudi and AH Poopak prepared the draft of paper. We used the consultation of R Daroudi and A G Motlagh for the design of the study and interpretation of the results. A Nahvijou and M Tahmassebi, as corresponding authors were both principle investigators and supervised the study. All authors of this paper have read and approved the final version submitted.

Ethics approval and consent to participate:

As the corresponding author, I confirm that all methods were carried out in accordance with relevant guidelines and regulations.

As the corresponding author, I confirm that all experimental protocols were approved by the research committee of the Cancer Institute of Tehran University of Medical Sciences (approval no 97-01-51-37437).

We used data from patient’s documents and our data were from deceased patients. All patients had signed their admission forms. The admission form contains informed consent in which patients allowed the hospital to use their data for research purposes. However, we had approval from the ethics committee (no: IR.TUMS.IKHC.REC.1397.007) and as the corresponding author, I comply with all confidential regulations for deceased patients.

Consent to publication:

Not applicable

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No competing interests reported.

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Version 1

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You are reading this latest preprint version

Costs of Cancer Care in the Last Five Days of Life in a Low-Resource Setting

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Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Study design, setting, and patient selection

Data extraction

Data analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1