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Original Investigation
January 19, 2016

Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries

Author Affiliations
  • 1Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 2Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 3Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 4Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 5Hamburg Center for Health Economics, University of Hamburg, Hamburg, Germany
  • 6Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, Rhode Island
  • 7Dartmouth Institute for Health Policy and Clinical Research, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
  • 8End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
  • 9Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  • 10Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  • 11Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
  • 12Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
  • 13Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
  • 14Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
  • 15Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Cancer Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
  • 16National End of Life Care Intelligence Network, Public Health England, London
JAMA. 2016;315(3):272-283. doi:10.1001/jama.2015.18603
Abstract

Importance  Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest.

Objective  To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.

Design, Setting, and Participants  Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012.

Main Outcomes and Measures  Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services.

Results  The United States (cohort of decedents aged >65 years, N = 211 816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21 054; 51.2%), Canada (N = 20 818; 52.1%), England (N = 97 099; 41.7%), Germany (N = 24 434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21 840), Norway (US $19 783), and the United States (US $18 500), intermediate in Germany (US $16 221) and Belgium (US $15 699), and lower in the Netherlands (US $10 936) and England (US $9342). Secondary analyses showed similar results.

Conclusions and Relevance  Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.

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