Utilisation and cost of health services in the last six months of life: a comparison of cohorts with and without cancer Rebecca Reeve, Preeyaporn Srasuebkul, Marion Haas, Sallie Pearson, Rosalie Viney on behalf of the EOL-CC team: J Langton 1, P Srasuebkul 1, R Reeve 2, B Parkinson 2, M Haas 2, R Viney 2, S Pearson 1 1: Faculty of Pharmacy, The University of Sydney; 2: CHERE, University of Technology Sydney
Background and motivation The last year of life is one of the most resource and cost intensive periods in cancer care Understanding patterns of care provides evidence to inform resource allocation and planning decisions There has been little research on end of life care in Australia (most existing research is in North America) Most existing Australian research focuses solely on hospital care or palliative care Few studies comparing cancer and non-cancer cohorts Observational studies using linked administrative datasets provide an approach to understanding patterns of care at the end of life 2
Existing literature* 78 studies of end-of-life cancer care 55 from North America 33 published since 2008 71 examined resource use alone (52) or in combination with costs (19) 30 focus on only one aspect of resource use 7 costs only 15 quality of care indicators none Australian and only 1 with non-cancer comparator 5 local studies Focused on use of palliative care services, hospital admissions and emergency department presentations All but one study conducted in the Western Australia Only one included data from the last decade Opportunities!!! * Langton J et al End-of-life resource utilization and costs: A systematic review of retrospective observational studies of cancer decedents using health administrative data (1990-2011) article forthcoming in Palliative Medicine 3
Langton J et al End-of-life resource utilization and costs: A systematic review of retrospective observational studies of cancer decedents using health administrative data (1990-2011) article forthcoming in Palliative Medicine 4
Aims and objectives To undertake a program of research using linked data to examine resource use, costs and quality of end of life care and to investigate the factors associated with these outcomes for cancer and non-cancer patients. In our first study within this program of research: To quantify resource use and costs in the last 6 months of life in a cohort of elderly decedents To compare resource use and costs for decedents with and without a cancer diagnosis To examine the distribution of resource use and costs across different types of medical services at the end of life To determine the predictors of resource use and costs at the end of life To examine trends in resource use and costs over the 6 months to death 5
Study population and data sources Department of Veterans Affairs (DVA) gold card holders who died between 2005 and 2009 and resided in NSW for the last 18 months of life - DVA clients include eligible veterans, war widows and widowers and their dependents - Gold card holders are funded by the DVA for treatment of all health conditions - PBS, RPBS, other sundry pharmaceutical items - MBS, dental and allied health services - Hospitalisations and emergency presentations 6
Study population and data sources Age >=65 at death, Last 6 months (180 days) of life Cancer cohort, N=9,862: identified by notifiable cancer diagnosis or cause of death (CCR and ABS) Non-cancer cohort, N=15,483: no notifiable cancer diagnosis (also excluded if received any cancer-related services) Datasets linked by the CHeReL (provided by the DVA and NSW ministry of health) DVA client database PBS and RPBS and additional DVA approved items MBS, dental and allied health NSW registry of births deaths and marriages NSW Central Cancer Registry Admitted patient data collection Emergency department data collection 7
Methods: utilisation Compare utilisation of services for cancer and non-cancer patients by service type and patient characteristics Report on utilisation of services in last 6 months of life and by proximity to death (months to death) Medicines (includes PBS, RPBS and sundry items) Health care services (MBS, dental, community nursing, allied health) Hospital admissions (episodes of care) Emergency department visits Negative binomial regression of predictors of resource utilisation * Detailed methods outlined in Langton et al Resource use, costs and quality of end of life care: Observations in a cohort of elderly Australian cancer decedents under review by the DVA, to be submitted as a protocol paper 8
Methods: costs Allocate costs to resource items and report by service type and overall for cancer and non-cancer patients. All costs expressed in common year (2009/10 reflecting most recently published NSW Cost of Care Standards Report) NSW Cost of Care Standards used to derive hospitalisations and ED costs in last 6 months of life.* Medications and health care services costs inflated to 2009/10 using inflation rates derived from AIHW published price indices. Report on utilisation of services in last 6 months of life and by proximity to death (months to death) Negative binomial regression of predictors of total resource cost * See Reeve and Haas, 2014, Estimating the cost of Emergency Department presentations in NSW. CHERE Working Paper 2014/01'. 9
Cohort characteristics 10 Cancer (n=9862) Non Cancer (n=15,483) Sex, F% : M% 31.6 : 68.4 48.9 : 51.4 Median age at death (range), years 86 (65-107) 87 (65-111) Age 85+ at death, % 55.7 65.9 SEIFA decile, % 1-2 Most disadvantaged 11.8 12.0 3-4 28.7 28.9 5-6 20.6 19.9 7-8 14.4 14.5 9-10 Least disadvantaged 20.5 20.6 Unknown 4.1 4.1 Remoteness area, % Major cities 62.3 61.6 Inner Regional 28.2 28.4 Outer Regional 8.8 9.1 Remote 0.4 0.5 Very Remote 0.1 0.0 Unknown 0.2 0.4 Co-morbidity burden % 0 4.9 5.5 1-2 13.4 13.8 3-5 39.9 39.5 > 6 41.8 41.2
Resource utilisation in the last 6 months of life Utilisation Emergency visits Hospital episodes Health care services, OOH Health care services, OOH + in hospital Non-Cancer Cancer Prescribed medicines 0 10 20 30 40 50 60 70 80 90 100 Mean resources utilised Health care services include MBS, dental, community nursing and allied health items 11
Resource costs in the last 6 months of life Cost Emergency visits Hospital episodes Health care services, OOH Health care services, OOH + in hospital Non-Cancer Cancer Prescribed medicines Mean resource cost Health care services include MBS, dental, community nursing and allied health items 12
Mean ED cost per person per month Mean ED visits per person per month 0.6 0.5 0.4 0.3 0.2 0.1 0 Resource utilisation and costs by month to death: ED visits Utilisation 6 5 4 3 2 1 Month to death Cancer Non-Cancer 300 250 200 150 100 50 0 Cost 6 5 4 3 2 1 Month to death Cancer Non-Cancer 13
Mean hospital episodes per person per month Mean hospital cost per person per month Resource utilisation and costs by month to death: Hospital episodes Utilisation 1.2 1 0.8 0.6 0.4 0.2 0 6 5 4 3 2 1 Month to death Cancer Non-Cancer 12000 10000 8000 6000 4000 2000 0 Cost 6 5 4 3 2 1 Month to death Cancer Non-Cancer 14
Mean health care services cost per person per month Mean health care services per person per month Resource utilisation and costs by month to death: Health care services* 30 25 20 15 10 5 0 Utilisation 6 5 4 3 2 1 Month to death Cancer Non-Cancer 2,500 2,000 1,500 1,000 500 0 Cost 6 5 4 3 2 1 Month to death Cancer Non-Cancer * Includes MBS, dental, community nursing and allied health items (in and out of hospital) 15
Mean prescribed medicine cost per person per month Mean prescribed medicines per person per month Resource utilisation and costs by month to death: prescribed medicines 10 8 6 Utilisation 4 2 Cancer Non-Cancer 0 6 5 4 3 2 1 Month to death Cost 400 300 200 100 0 6 5 4 3 2 1 Month to death Cancer Non-Cancer 16
Total resource costs by month to death: Cancer cohort 17
Total resource costs by month to death: Non-Cancer cohort 18
Regression results: ED presentations Results expressed as incident rate ratios (IRR) base category IRR = 1 Also controlled for sex, year of death, comorbidities (Charlson and Rx risk) 19
Regression results: Hospital episodes Results expressed as incident rate ratios (IRR) base category IRR = 1 Also controlled for sex, year of death, comorbidities (Charlson and Rx risk) 20
Regression results: Health care services Results expressed as incident rate ratios (IRR) base category IRR = 1 Also controlled for sex, year of death, comorbidities (Charlson and Rx risk) 21
Regression results: Prescription medicines Results expressed as incident rate ratios (IRR) base category IRR = 1 Also controlled for sex, year of death, comorbidities (Charlson and Rx risk) 22
Regression results: Total cost of EoL care Results expressed as incident rate ratios (IRR) base category IRR = 1 Also controlled for sex, year of death, comorbidities (Charlson and Rx risk) 23
Discussion Previous local research has focused on hospitalisations, ED and palliative care (in NSW only hospitalisations) We have extended this to provide a more complete picture over multiple resource types People with cancer have higher total EoL health care costs and use more of all resource types Our findings with respect to decreased EoL costs for hospitalisations in older age groups is consistent with NSW general population research Our findings also suggest that overall recourse use and costs of care to the health system are lower for older age cohorts This has implications for planning in the context of an ageing population whilst more people are aged >65 more will be dying at older ages 24
Future analyses Detailed investigation of utilisation and costs by subcategories of resource types Subgroup analyses by patient characteristics Disaggregate cancer cohort by whether cancer was the cause of death (58.9% of cancer cohort died of cancer) Investigate specific cancer types Develop indicators of quality of care for our data based on international validated indicators identified in the literature and report on these (examples to follow) Expand our approach to a general population Inform data collections by CINSW and CCNSW collecting and making better use of data 25
Aggressiveness of Care Indicators Rate (%)* Previous Studies Chemotherapy Last 14 days 1-19 7 Last 30 days 10-38 3 Emergency Department Visits Last 14 days 27-37 3 >1 visit last 30 days 7-19 6 Hospital Admissions Last 7 days 16 1 Last 30 days 45-64 2 >1 admission last 30 days 8-33 4 >14 days of last 30 days in hospital 11-58 3 Intensive Care Unit Admissions Last 14 days 5-6 2 Last 30 days 3-19 6 Life Sustaining Treatments CPR last 30 days 7-12 2 Intubation last 30 days 17-27 2 Mechanical ventilation last 30 days 19-33 2 * Rate = average rate of use in cancer cohort (if reported) in previous studies Langton J et al End-of-life resource utilization and costs: A systematic review of retrospective observational studies of cancer decedents using health administrative data (1990-2011) article forthcoming in Palliative Medicine 26
Palliative Care Indicators Rate (%)* Previous Studies Hospice Enrolment 3 days before death (late enrolment) 11-36 6 7 days before death (late enrolment) 19-23 2 No enrolment last 30 days 66 1 Enrolment duration 2 months (appropriate enrolment) 6-29 2 Prior to death 51-57 2 >180 days before death (inappropriate enrolment) 6-8 1 Opioids Outpatient prescription short- or long-acting last 30 days 25 1 Outpatient prescription short- or long-acting last 60 days 46 1 Other Physician house call last 14 days 25-28 1 Community follow-up last 6 months 16 1 Home care last 6 months 21-78 2 * Rate = average rate of use in cancer cohort (if reported) in previous studies Langton J et al End-of-life resource utilization and costs: A systematic review of retrospective observational studies of cancer decedents using health administrative data (1990-2011) article forthcoming in Palliative Medicine 27
Acknowledgements This research is supported by a NHMRC Capacity Building Grant (571926) and a Cancer Australia Grant (568773). S Pearson is also supported by a Cancer Institute NSW Career Development Fellowship (09/CDF/2-37) Special thanks to the Department of Veterans Affairs and their clients 28