Holly Prigerson, PhD
Few physicians are eager to discuss end-of-life care with their
patients. Yet such conversations may result in better quality of life
for patients and could lower national healthcare expenditures for cancer
care alone by tens of millions dollars each year, according to a study
led by researchers at Dana-Farber Cancer Institute.
As reported in the March 9 issue of the Archives of Internal Medicine,
investigators interviewed 603 advanced cancer patients about whether
they had an end-of-life (EOL) conversation with their physician. The
researchers calculated the final week health-care costs of patients who
reported such conversations and compared them to those of patients who
did not.
They found that patients who reported having an EOL conversation had
an estimated average of $1,876 in health-care expenses during their
final week of life, compared to $2,917 for those who didn't, a
difference of $1,041, or 36 percent. Higher costs — typically the
result of more intensive, life-prolonging care — were also associated
with a worse quality of death during patients' final week. In addition,
patients typically did not live longer if they received intensive care.
"We refer to the end-of-life discussion as the multi-million dollar
conversation because it is associated with shifting costs away from
expensive, burdensome, non-curative care, like being on a ventilator in
an ICU, to less costly comfort care provided at home or in hospice,
which most patients and their families say they would prefer," says the
study's senior author, Holly Prigerson, PhD, of Dana-Farber.
"As the nation looks to ways to improve patient care and reduce costs
of healthcare, end-of-life conversations should be considered. Policies
that promote increased communication, such as incentives for
end-of-life conversations, may be cost-effective ways to both improve
care and reduce some of the rising health care expenditures."
Previous studies have shown that a disproportionate share of
health-care spending in the United States is incurred at the end of life
and that patients who speak with their physicians about end-of-life
preferences have fewer life-sustaining procedures and lower rates of
intensive care admission. The study by Prigerson and her colleagues
suggests a direct link between communications at the end of life with
lower health care costs and better quality of life for patients with
advanced cancers.
The paper is part of a multi-institutional study called Coping with Cancer.
Funded by the National Institute of Mental Health and the National
Cancer Institute, the study tracks the health and psychological state of
627 patients nationwide with advanced cancer.
Although the study doesn't purport to show a cause-and-effect
relationship between EOL conversations and lower medical costs, it does
suggest a strategy for reducing such costs and for improving patients'
quality of life as death approaches, the authors state. If the national
proportion of patients reporting EOL discussions was increased to 50
percent, the annual cost savings could be more than $76 million dollars,
researchers estimate, based on the annual number of cancers deaths in
the U.S.
The study was supported by a grant from the National Institute of Mental Health, the National Cancer Institute, and Dana-Farber.
The study's lead author is Baohui Zhang, of Dana-Farber. Co-authors
are Susan Block, MD, of Dana-Farber and BWH; Alexi Wright, MD, Craig
Earle, MD, and Matthew Nilsson of Dana-Farber; Haiden Huskamp, PhD, of
Harvard Medical School; Matthew Maciejewski, PhD, of the University of
North Carolina and the Durham (N.C.) Veterans Affairs Medical Center;
and Paul Maciejewski, PhD, of Brigham and Women's Hospital.
Dana-Farber Cancer Institute (www.dana-farber.org)
is a principal teaching affiliate of the Harvard Medical School and is
among the leading cancer research and care centers in the United States.
It is a founding member of the Dana-Farber/Harvard Cancer Center
(DF/HCC), designated a comprehensive cancer center by the National
Cancer Institute.