The DOI matches its Crossref record; 21 of the 21 references it cites were found in a registry or an index; none of the 12 sources its claims cite is checked for support yet.
Health Care Costs in the Last Week of Life: Associations With End-of-Life Conversations
Open accessAbstract
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.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Association between medical costs, patients' quality of death and survival in the final week of life
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Discussion · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Results
Strength:plain· not yet calibratedn = 188Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes- Also stated in: § Patient characteristics · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- 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.
- Also stated in: § Association between medical costs, patients' quality of death and survival in the final week of life · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Association between medical costs, patients' quality of death and survival in the final week of life
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- 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.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Medical care at EOL, location of death, quality of death and survival
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- 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.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Propensity score matching was used to reduce selection biases.”
- Also stated in: § Statistical analysis · plain
“Propensity score matching15 was used to remove the observed differences between the two groups.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Methods
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Statistical analysis · plain
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These findings suggest that EOL discussions might reduce health care expenditures by reducing cancer patients' utilization of intensive care.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Introduction
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our findings demonstrate that advanced cancer patients who reported EOL conversations with physicians had lower medical costs in their final week of life compared to those who did not, which is largely a function of their more limited use of intensive interventions.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Because this is an observational study we cannot conclude that there is a causal relationship between EOL conversations and cost differences in the last week of life.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesNone of the sources cited for this claim have been checked yet.
In the paper
“Like most studies of medical expenditures 2,3, 23,24 which rely heavily on costs covered by insurers or Medicare, this study likely underestimates the total cost of care given that it does not include out-patient services or out-of-pocket expenditures or opportunity costs incurred by patients and their caregivers for additional pharmaceutical and home care payments.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
What the sources say
- Not checked yetcites [2]
- Not checked yetcites [3]
- Not checked yetcites [23]
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
- It may state two separate claims as one. 13
- Probably not a substantial claim. 5
- The quote only partly states this claim. 1
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Medical care at EOL, location of death, quality of death and survival
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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].”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“but the two groups did not differ in psychological distress, quality of death or survival.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Medical care at EOL, location of death, quality of death and survival
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They were more likely to receive outpatient hospice care and stay longer in hospice.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Results > Medical care at EOL, location of death, quality of death and survival
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: Patients' self-report of having had an end-of-life discussion accurately indicates whether such a discussion took place.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Background
What the sources say
- Not checked yetcites [5]
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Also stated in: § Introduction · plain
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Methods > Protocol and measures
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Nevertheless, our study suggests that increasing communication between patients and their physicians is associated with better outcomes and less expensive medical care.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one. The quote only partly states this 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.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“In addition, exclusion of unmatched subjects from the study may limit generalizability of the results to general population.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Abstract > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Also stated in: § Medical care at EOL, location of death, quality of death and survival · plain
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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,”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Load-bearingStrength:boosted· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Although propensity score matching is one of the most robust methods to correct for selection bias in observables, it cannot account for hidden biases.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- 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.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Methods > Statistical analysis
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
What the sources say
- Not checked yetcites [27]
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
What the sources say
- Not checked yetcites [23]
- Not checked yetcites [24]
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Discussion
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- 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.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Health Care Costs in the Last Week of Life: Associations with End of Life Conversations > Methods > Statistical analysis
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may state two separate claims as one.
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.”
Claims other papers make about this one
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In the citing paper
“it is underutilized by the ESRD population, even among patients who withdraw from dialysis.”
From Should there be an expanded role for palliative care in end-stage renal disease? (2010) · cites this paper as [11]
In the citing paper
“Rates of hospice use before death among patients with ESRD are less than half of those seen among patients dying of cancer, even among patients with ESRD who choose to withdraw from dialysis before death [11].”
From Should there be an expanded role for palliative care in end-stage renal disease? (2010) · cites this paper as [11]
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
MinorThe 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.
“Patient's self-reported health status was measured with the physical health and symptom burden subscales of the McGill Quality of Life Questionnaire [scale 0-10, where 0=desirable and 10=undesirable)].11”
“They had more co-morbid conditions [8.5(2.7) vs. 7.9(2.7), p=0.007) but lower symptom burden [McGill symptoms subscale score [10.4(4.3) vs. 12.0(4.4), p<0.0001)].”
Overall symptom scores disagree across two partitions of the sample
MinorThe 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.
“Among them, 188 (31.2%) reported having discussed their EOL wishes with physicians.”
“They had more co-morbid conditions [8.5(2.7) vs. 7.9(2.7), p=0.007) but lower symptom burden [McGill symptoms subscale score [10.4(4.3) vs. 12.0(4.4), p<0.0001)].”
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The development and validation of a questionnaire to audit advance care planning (ACP)
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Integrating Palliative Medicine into Comprehensive Breast Cancer Therapy – a Pilot Project
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Narrative review of prognosis related communication in advanced cancer patients
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Talking It Out: Helping Our Patients Live Better While Dying
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Improving Communication and Cost-effectiveness in the Intensive Care Unit Through Palliative Care
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The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit
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Quality Versus Quantity of Life: Beyond the Dichotomy
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Metadata
- 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)
- 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
- green
- www.ncbi.nlm.nih.gov
- 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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