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Cited by 898Palliative Care and End-of-Life IssuesPalliative and Oncologic CareEconomic and Financial Impacts of Cancer

Health Care Costs in the Last Week of Life: Associations With End-of-Life Conversations

Open access
Zhang, Baohui, Wright, Alexi A., Huskamp, Haiden A., Nilsson, Matthew E., Maciejewski, Matthew L., Earle, Craig C., Block, Susan D., Maciejewski, Paul K. +1 more·2009·Archives of Internal Medicine
DOI 10.1001/archinternmed.2008.587PMC PMC2862687
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Abstract

BACKGROUND: Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. METHODS: Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. RESULTS: Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). CONCLUSIONS: Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Integrity signals

Registry

Crossref · 10.1001/archinternmed.2008.587

Cites

21 of 21 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 12 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    No survival difference was linked to higher health care spending at the end of life.

    “There was no survival difference associated with higher health care expenditures at the EOL.”
    • Also stated in: § Discussion · plain
      “there was no survival difference associated with health care expenditures”
    Quote in the paperSubstantial claim
  • Findingown data

    At baseline, 188 patients (31.2%) reported having had an end-of-life discussion.

    “188 patients (31.2%) reported EOL discussions at baseline.”
    • Also stated in: § Patient characteristics · plain
      “Among them, 188 (31.2%) reported having discussed their EOL wishes with physicians.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Greater spending on care in the last week of life correlated with poorer overall quality of death as rated by caregivers (Pearson partial r=-0.17, p=0.006), after adjustment for age, race, gender, education, survival, and source of report.

    “Patients with higher costs had worse quality of death (Pearson partial r=-0.17, p=0.006) in their final week.”
    • Also stated in: § Association between medical costs, patients' quality of death and survival in the final week of life · plain
      “Additional analyses using deceased patients in the study sample (N=316) showed that higher medical costs in the final week of life were associated with more physical distress in the last week of life (Pearson partial r=0.18, p=0.003) and worse overall quality of death as reported by the caregiver (Pearson partial r=-0.17, p=0.006) after controlling for age, race, gender, education, survival and”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.
  • Findingown data

    Greater spending on care in the last week of life correlated with more physical distress during that week (Pearson partial r=0.18, p=0.003), after adjustment for age, race, gender, education, survival, and source of report.

    “Additional analyses using deceased patients in the study sample (N=316) showed that higher medical costs in the final week of life were associated with more physical distress in the last week of life (Pearson partial r=0.18, p=0.003) and worse overall quality of death as reported by the caregiver (Pearson partial r=-0.17, p=0.006) after controlling for age, race, gender, education, survival and”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.
  • Findingown data

    Patients reporting end-of-life discussions experienced less physical distress in the last week of life (3.6 vs 4.5, p=0.04) than those who did not.

    “Patients who reported EOL discussions had less physical distress in the last week of life [3.6 (3.2) vs. 4.5 (3.7), p=0.04] than those who did not”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.
  • May combine two claims. 13
  • Classified as probably not a substantial claim. 5
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    Patients who reported having end-of-life conversations with doctors at baseline were less likely to receive ventilation or resuscitation, or to be admitted to or die in an intensive care unit during the final week of life.

    “Patients who reported EOL conversations with their physicians at baseline were less likely to undergo ventilation, resuscitation, be admitted to or die in an ICU in the final week of life.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.

  • May combine two claims.

    Findingown data

    In the propensity-score matched cohort, adjusted aggregate costs in the last week of life were $1876 (SE=177) for patients reporting end-of-life discussions and $2917 (SE=285) for those not reporting them, a difference of $1041 (35.7% lower), p=0.002.

    “Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the aggregate costs of care were $1876 (SE=177) for patients who reported EOL discussions compared with $2917 (SE=285) for patients who did not (in 2008 US dollars), a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) [p=0.002].”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.

  • May combine two claims.

    Findingown data

    The two groups showed no differences in psychological distress, quality of death, or survival.

    “but the two groups did not differ in psychological distress, quality of death or survival.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Those who reported end-of-life discussions were more likely to use outpatient hospice services and to have longer hospice stays.

    “They were more likely to receive outpatient hospice care and stay longer in hospice.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.

  • May combine two claims.

    Premisecitation

    Patients who discuss end-of-life wishes with their doctors tend to receive fewer life-sustaining treatments and are less often admitted to intensive care.

    “Patient-physician discussions about EOL wishes were found to be associated with lower rates of intensive interventions.”
    • Also stated in: § Introduction · plain
      “A recent study, using data from a longitudinal, multi-institutional cohort study, Coping with Cancer (CWC), showed that EOL conversations between patients and physicians are associated with fewer life-sustaining procedures and lower rates of ICU admission.5”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Interviewers were trained to achieve a high level of accuracy in SCID diagnoses, with a kappa greater than 0.85.

    “Interviewers were trained by research staff at Yale University School of Medicine and were required to achieve a level of accuracy based on concordance with the Yale training director's rating of the Structured Clinical Interview for the DSM-IV (SCID) diagnoses (κ>0.85).”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Interpretationown data

    More communication between patients and physicians is linked to better outcomes and lower medical care costs.

    “Nevertheless, our study suggests that increasing communication between patients and their physicians is associated with better outcomes and less expensive medical care.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Dropping unmatched subjects may reduce how well the results generalize to the general population.

    “In addition, exclusion of unmatched subjects from the study may limit generalizability of the results to general population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    After propensity score matching, the 145 remaining patients did not differ in socio-demographic characteristics, recruitment sites, illness acknowledgement, or treatment preferences.

    “After propensity score matching, the remaining 145 patients did not differ in socio-demographic characteristics, recruitment sites, illness acknowledgement or treatment preferences.”
    • Also stated in: § Medical care at EOL, location of death, quality of death and survival · plain
      “The deceased patients in the propensity-score matched cohort (N=145) did not differ by the variables shown in Table 2.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The matched subjects were similar on observed variables, and potential confounders were controlled for, producing a well-balanced and adjusted sample.

    “One strength of this study is that the matched subjects did not differ in observed variables, including patients' socio-demographic characteristics, cancer type, recruitment sites, treatment preferences, or illness acknowledgment. Additionally, these variables were also examined as potential confounders and were controlled for if they remained significant in the multivariate analyses. Therefore,”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Propensity score matching cannot address unobserved biases.

    “Although propensity score matching is one of the most robust methods to correct for selection bias in observables, it cannot account for hidden biases.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Higher health care spending was not linked to better outcomes at the end of life; no survival difference was found, and patients with higher spending had worse quality of life in their final week.

    “In this study, higher health care costs were not associated with better outcomes at the EOL: there was no survival difference associated with health care expenditures, and patients who spent more in insured health care had worse quality of life in their final week of life.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    A wide set of covariates was included in the propensity score model predicting the likelihood of having an end-of-life discussion.

    “Covariates, including age, gender, race, education, marriage status, health insurance, religion, Karnofsky score, Charlson Comorbidity Index, MQOL physical and symptom subscales, recruitment sites (Yale, Parkland, NHOH), treatment preferences and desire to know life expectancy, were included in predicting the conditional likelihood of having an EOL discussion.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    The study does not cover all US geographic areas, which may matter given documented regional variation in the intensity of end-of-life care.

    “Although propensity-score matching balanced differences among the recruitment sites, our study does not include all geographic areas in the United States which may be particularly important since there are documented regional differences in the intensity of EOL care. 27”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27]

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    Cost estimates relied on aggregated national averages instead of medical claims data, yet they are comparable to estimates from studies using claims data.

    “Another limitation is that cost estimates were based upon aggregated costs from national averages for hospitalizations, life-sustaining procedures and hospice care instead of medical claims data. Although this method may be viewed as less accurate, our cost estimates are comparable to other studies that used medical claims data.23,24”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [23]

      Not checked in the free run.

    • cites [24]

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The cost reductions come with improved quality of life for advanced cancer patients at the end of life.

    “Our study is unique in that it also suggests that these cost deductions are accompanied by a better quality of life for advanced cancer patients at the EOL.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Potential confounders were examined and those that remained significant were controlled for in multivariate models.

    “Models examined potential confounders of socio-demographic characteristics, religion, cancer type, recruitment sites, Karnofsky score, illness acknowledgement, treatment preferences and survival time using the backward selection procedure and controlled for those remained significant in the multivariate models.”
    Quote in the paperSubstantial claim
17 of 17

  • The paper relies on this without support.

    The link between health care spending and patient-physician communication at the end of life has not been thoroughly studied.

    “To the best of our knowledge, the association between health care expenditures and patient-physician communication at the EOL has not been fully examined.”

  • The paper relies on this without support.

    Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.

    “EOL discussions were assessed at baseline by asking: “Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?””

  • The paper relies on this without support.

    Reports from caregivers or nurses about the patient's quality of death accurately capture the patient's quality of life in the final week.

    “After the patients' death, caregivers both formal (i.e., paid clinicians such as nurses) and informal (i.e., unpaid caretakers such as spouses) were asked to assess the patients' quality of life in the period immediately prior to death e.g. “In your opinion, how would you rate overall quality of the patient's death/last week of life?””

  • The authors state this as an assumption.

    Patients and caregivers may place different values on care.

    “Additionally, we acknowledge that patients and caregivers may value care differently. Patients may consider extra dollars spent and more life-sustaining care worth the added expense whereas caregivers may devalue life-sustaining care.”
4 of 4

Claims other papers make about this one

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Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Reported symptom scores exceed the stated scale maximum

    Minor

    The methods define the McGill symptom burden subscale as ranging from 0 to 10, but the results report group means of 10.4 and 12.0 on that subscale. A group mean cannot exceed the scale's maximum.

  • Overall symptom scores disagree across two partitions of the sample

    Minor

    The discussion groups partition the 603 patients into 188 and 415, giving an overall symptom mean of about 8.66 from the reported group means. The matched and unmatched groups also partition those 603 patients, but their reported means give an overall mean of about 11.34 for the same symptom subscale.

2 of 2

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Authors
Zhang, B., Wright, A. A., Huskamp, H. A., Nilsson, M. E., Maciejewski, M. L., Earle, C. C., Block, S. D., Maciejewski, P. K., & Prigerson, H. G.
Affiliations
  • Dana-Farber Cancer Institute (US)
  • Harvard University (US)
  • University of North Carolina at Chapel Hill (US)
  • Brigham and Women's Hospital (US)
  • Yale University (US)
ORCID
Venue
Archives of Internal Medicine
Publisher
American Medical Association (AMA)
Published
2009-03-09
Volume
169
Issue
5
Pages
480
ISSN
0003-9926 (ISSN-L)
DOI
10.1001/archinternmed.2008.587
PMC
PMC2862687
OpenAlex
W2169467289
Cited by
898
References
21
Citations by year
2026: 20 · 2025: 25 · 2024: 35 · 2023: 45 · 2022: 57 · 2021: 58 · 2020: 69 · 2019: 66 · 2018: 57 · 2017: 80 · 2016: 57 · 2015: 67 · 2014: 50 · 2013: 61 · 2012: 50
FWCI
49.41
Type
journal article
Language
en
Open access
Locations
  • Archives of Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institute of Mental Health (MH-63892, R01MH063892)
  • National Cancer Institute (R01CA106370, CA106370)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Economic and Financial Impacts of Cancer
Keywords
end-of-life care, advanced cancer, health care costs, advance care planning, quality of death, intensive care utilization, hospice care, mechanical ventilation, resuscitation, last week of life
MeSH terms
Adult, Aged, Attitude to Death, Female, Humans, Male, Middle Aged, Neoplasms, Physician-Patient Relations, Quality of Life, Terminal Care, Health Care Costs

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