Cited by 132Palliative Care and End-of-Life IssuesPalliative and Oncologic CarePain Management and Opioid Use

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Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

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Starr, Lauren T., Ulrich, Connie M., Corey, Kristin L., Meghani, Salimah H.·2019·American Journal of Hospice and Palliative Medicine®

DOI 10.1177/1049909119848148PMC PMC6711813

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Abstract

Background: Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations (“EOL discussions”) may influence EOL health-care utilization and costs among persons with cancer. Objective: To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures. Methods: A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included. Results: End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death. Conclusions: End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.

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Chan, S.-Y., Lai, Y., Chen, Y., Chiang, S.-J., Tsai, Y.-F., Hsu, L., Chuang, P., Chen, C.-C., & Yen, Y. (2022) · Scientific Reports · doi:10.1038/s41598-022-11586-x · Cited by 6
Health care utilization among patients with oesophageal and gastric cancer: the impact of initial treatment strategy and assignment of a contact nurse
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Characteristics of critically ill patients with cancer associated with intensivist's perception of inappropriateness of ICU admission: A retrospective cohort study
da Silva, C. M. D., Besen, B. A. M. P., & Nassar, A. P. (2023) · Journal of Critical Care · doi:10.1016/j.jcrc.2023.154468 · Cited by 5
Intensity of end-of-life care for gynecologic cancer patients by primary oncologist specialty
Hicks-Courant, K., Kanter, G. P., Schapira, M. M., Brensinger, C. M., Liu, Q., & Ko, E. M. (2022) · International Journal of Gynecological Cancer · doi:10.1136/ijgc-2021-003285 · Cited by 5
End-of-life care discussions with healthcare providers and dying experiences: A latent class analysis using the health and retirement study
Lou, Y. (2023) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2023.105319 · Cited by 4
End-of-life in Hepatocellular Carcinoma
Goble, S. R., Sultan, A., & Debes, J. D. (2024) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000002091 · Cited by 4
Nurse Educators Establish and Evaluate Community Coalition to Promote Statewide Advance Care Planning Through RE-AIM
Kupershmidt, S., Fischbach, C., Hegge, H., AbouSamra, H., Penisten, L., & Dieter, C. (2020) · Journal of Hospice and Palliative Nursing · doi:10.1097/njh.0000000000000662 · Cited by 4
Goals of care discussions: perceptions of radiation and medical oncologists
Hong, D. Y., Das, L. C., Daily, E., Levine, S. K., Hahn, O. M., Liauw, S. L., Golden, D. W., & Son, C. H. (2021) · Supportive Care in Cancer · doi:10.1007/s00520-021-06258-x · Cited by 4
Disparities in the medical expenditures of patients with cancer and concomitant mental disorder: analyzing the effects of diagnosis sequence order
Ma, K.-J., Su, S.-Y., Nie, D., Chung, W., Yao, C.-Y., & Wang, J. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-09056-9 · Cited by 4
“57); lower odds of emergency department use and shorter length of hospital stay [41].”
Background
Interventions Performed in Children With Immunocompromised Conditions in the Pediatric Intensive Care Unit Within 48 Hours of Death
Kegel, A., Espinoza, J., Rahrig, A., Willis, T. S., & Rowan, C. M. (2024) · Journal of Palliative Medicine · doi:10.1089/jpm.2023.0400 · Cited by 4
Question prompt list intervention for patients with advanced cancer: a systematic review and meta-analysis
Wang, S., Hu, W., & Chang, Y. (2024) · Supportive Care in Cancer · doi:10.1007/s00520-024-08432-3 · Cited by 5
“…before death had lower health-care costs, received acute care (OR, 0.43–0.69), ICU treatment (OR, 0.26–0.68), lower likelihood of active treatment, and had a higher proportion of hospice use (OR, 1.79– 6.88) [6], reducing negative effects of unnecessary treatment in patients with advanced cancer.”
Influential
Expectations in the Communication About Death and Dying: Development and Initial Validation of the End-of-Life Conversations – Expectations Scale
Bendel, Y., Pinquart, M., Schulz-Quach, C., & von Blanckenburg, P. (2022) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228221110726 · Cited by 5
“Open communication about death and dying is associated with less aggressive medical treatment at the end of life, reduced risk of complicated grief (Wright et al., 2008; Yamaguchi et al., 2017) and overall lower costs for the healthcare system (Starr et al., 2019).”
Background
Elements of End-of-Life Discussions Associated With Patients’ Reported Outcomes and Actual End-of-Life Care in Patients With Pretreated Lung Cancer
Hasegawa, T., Okuyama, T., Uemura, T., Matsuda, Y., Otani, H., Shimizu, J., Horio, Y., Watanabe, N., Yamaguchi, T., Fukuda, S., et al. (2023) · The Oncologist · doi:10.1093/oncolo/oyad245 · Cited by 4
Association Between Systemic Anticancer Therapy Administration Near the End of Life With Health Care and Hospice Utilization in Older Adults: A SEER Medicare Analysis of End-of-Life Care Quality
Canavan, M., Cheng, L., Xiang, J. J., Lin, J. K., Hui, D., Zhao, H., Nortjé, N., Ratan, R., Cherny, N. I., Pham, T. H.-T., et al. (2025) · Journal of Clinical Oncology · doi:10.1200/jco-25-00530 · Cited by 4
Best practices for communication of prognosis and end-of-life discussions with patients with advanced breast cancer: A report from the advanced breast cancer global alliance
Fallowfield, L. J., Kiely, B. E., Travado, L., Ventura, R., Dullehan, J., & Cardoso, F. (2025) · The Breast · doi:10.1016/j.breast.2025.104595 · Cited by 3
“Providing people with ABC the opportunity to participate in conversations about EoL is essential to ensure autonomy and improve consistency of care aligned with patients ’ goals [7].”
Guidelines for goals of care discussions in patients with gynecologic cancer
Peters, P., Havrilesky, L. J., & Davidson, B. A. (2023) · Gynecologic Oncology · doi:10.1016/j.ygyno.2023.05.016 · Cited by 3
Evaluation of Direct Medical Costs and Associated Factors Within the Last 30 days of Life of Hospitalized Cancer Patients
Süffert, S. C. I., Motke, B. B., Linhares, A. B., Vargens, A. F., Alano, T. S., Lutz, A. T., Borges, R. B., Bica, C. G., & Alves, R. J. V. (2022) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091221147906 · Cited by 3
“9%) Age at diagnosis** 67 (60-75) Hospitalization days** 11 (6-16) Waiting for the hospital bed in the ward (days)** 3 (2-4) Overall survival, months** 4.”
Background
Better than expected? Predictors of coping with expectation violations in the communication about death and dying
Bendel, Y., Gesualdo, C., Pinquart, M., & von Blanckenburg, P. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1256202 · Cited by 2
The Current Status of Palliative Care, Hospice, and End-of-Life Health Care Utilization in Patients With Malignant Ureteral Obstruction
Felice, M. D., Koehne, E. L., Patel, H. D., Elliott, N., Hekman, L., Lewer, O., Rahman, F., Petix, S., Ellis, J. L., & Santos, G. D. (2023) · Urology Practice · doi:10.1097/upj.0000000000000472 · Cited by 3
“23 Unlike prior reports, PC utilization did not impact end-of-life HU in this study, as the time spent on nonhospice PC was likely too short to affect patient outcomes.”
Background
Effects of hospice-shared care on terminal cancer patients in Taiwan: A hospital-based observational study
Huang, H.-W., Liu, C., Tung, T., & Liu, L. (2024) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2024.102525 · Cited by 3
Perceptions and experiences of onco-haematology professionals in relation to advance care planning: a qualitative study
Lasmarías, C., Aradilla‐Herrero, A., Silva, N., & Trelis, J. (2024) · Supportive Care in Cancer · doi:10.1007/s00520-024-08371-z · Cited by 3
“Starr et al. found that ACP processes performed 30 days or more before death were associated with less aggressive treatments and lower costs than processes performed in the final days of life [18].”
Patient‐Reported Goals of Care in the Preoperative Clinic: Barriers to and Facilitators of Patient Values Elicitation and Documentation
Rosen, R. Y., Bartsch, C., Thompson, E., Letica‐Kriegel, A. S., Kaur, Y., Ng, S., Vaynrub, M., Rosa, W. E., Broach, V. A., Epstein, A. S., et al. (2024) · Journal of Surgical Oncology · doi:10.1002/jso.27974 · Cited by 3
Changing Rates of Goals of Care Designations in Patients With Advanced Pancreatic Cancer During a Multifactorial Advanced Care Planning Initiative: A Real-World Evidence Study
Anaka, M., Lee, M., Lim, E., Ghosh, S., Cheung, W. Y., & Spratlin, J. (2022) · JCO Oncology Practice · doi:10.1200/op.21.00649 · Cited by 3
“In addition, appropriate ACP is associated with reduced health care costs.(9,11-13)”
Background
End-of-life interventions in patients with cancer
Webber, C., Hafid, S., Gayowsky, A., Howard, M., Tanuseputro, P., Jones, A., Scott, M., Hsu, A. T., Downar, J., Manuel, D. G., et al. (2023) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2023-004222 · Cited by 2
Are specialist-provided end-of-life scenarios key to initiation of advance care planning in primary care? A mixed-methods study
Poelman, S. W., Ermers, D. J. M., Schers, H., Vissers, K. C. P., Veldhoven, C. M. M., Kuip, E. J. M., & Perry, M. (2024) · Palliative & Supportive Care · doi:10.1017/s1478951523002055 · Cited by 2
“In addition, end-of-life discussions are associated with more appropriate care and lower healthcare costs (Mack et al. 2012; Starr et al. 2019; Wright et al. 2008).”
Improving End-of-Life Care through AI-Based Clinical Decision Support
Saleska, J. L., Moore, N. H., Pitzer, K., Foraker, R. E., & White, P. (2025) · NEJM Catalyst · doi:10.1056/cat.24.0392 · Cited by 2
Using Human-Centered Design to Improve Serious Illness Care for Older Adults With Advanced Dementia
Chehab, L. Z., Goitiandia, S. W., Pereira, L. M., Jung, K., Chen, A., Patel, D., Axelrod, J. K., Li, L., Williams, I., Dohan, D. P., et al. (2024) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2024.11.015 · Cited by 2
Advance Care Planning Billing Codes Associated With Decreased Healthcare Utilization in Neurological Disease
Brown, G. M., Jesus, S. D., Leboffe, E., Esch, A., & Newport, K. B. (2024) · Journal of Healthcare Management · doi:10.1097/jhm-d-23-00234 · Cited by 2
“…goals does not always lead to less care utilization, studies have consistently found that older individuals have a preference for choosing less aggressive interventions at the end of life (Kirchhoff et al., 2012), and these discussions result in less healthcare utilization (Starr et al., 2019).”
The Impact of Advanced Care Planning on Hospice Utilization in Patients with Cancer: A Nationwide Analysis in Korea
Kim, W., Kim, B., Kim, M., & Choi, J. (2025) · Cancers · doi:10.3390/cancers17091471 · Cited by 2
“This approach addresses the limitations of previous studies that relied on hospital-based or regional data [19,20,24], which often lacked a comprehensive inclusion of patients with various types of cancer or had a limited number of study participants.”
Relevance and consequence of economic and social resources of severely ill persons and their informal caregivers at the end-of-life: a systematic review of qualitative studies
Matzinger, M., Baum, E., Bernhardsgrütter, D., Kesseli, M., Michelak, G., Orosaj, F., Kobleder, A., & Vetsch, J. (2025) · BMC Palliative Care · doi:10.1186/s12904-025-01961-6 · Cited by 2
Do-Not-Resuscitate Orders and Outcomes for Patients with Pancreatic Cancer
Hao, Q., Segel, J. E., Gusani, N. J., & Hollenbeak, C. S. (2022) · Journal of Pancreatic Cancer · doi:10.1089/pancan.2022.0006 · Cited by 2
“Even though previous studies have shown that DNR orders appear to lower hospitalization costs in the last week of life among patients with advanced cancer, there may be differences in cost savings across cancer sites.(9,21,22) Furthermore, high health care costs accompany advanced cancer throughout the entire inpatien…”
BackgroundMethodResultInfluential
Increase in hospital care at the end of life: Retrospective analysis of the last 20 years of life of a cohort of patients
Jiménez-Puente, A., Escalante, M. D. M., Martos, F., & García‐Alegría, J. (2024) · Revista Española de Geriatría y Gerontología · doi:10.1016/j.regg.2024.101484 · Cited by 1
Existenzielle Kommunikation – Schlagwort oder wichtiges Werkzeug?
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Implantable cardioverter defibrillators in people dying with cancer: A SEER‐Medicare analysis of ICD prevalence and association with aggressive end‐of‐life care
Mullins, M. A., Wang, T., Shahan, K. L., Zaha, V. G., Goswami, R., Sulistio, M. S., Gerber, D. E., & Pruitt, S. L. (2024) · Cancer · doi:10.1002/cncr.35640 · Cited by 1
Factors and Considerations in No‐Treatment Decisions in Patients With Key Hematological Malignancies: A Nationwide, Population‐Based Study in the Netherlands
Zijlstra, M., Snijders, R. A. H., de Boer, F., Chamuleau, M. E. D., Fransen, H. P., Oerlemans, S., van der Padt‐Pruijsten, A., Posthuma, E. F. M., Visser, O. J., Zweegman, S., et al. (2025) · European Journal Of Haematology · doi:10.1111/ejh.14390 · Cited by 1
Patients' Experiences With Advance Care Planning and Decision‐Making: An Interview Study in Finnish Hospital Palliative Care Wards
Kuusisto, A. M., Saranto, K., Lähteenmäki, K., Soikkeli‐Jalonen, A., & Haavisto, E. (2025) · Nursing Open · doi:10.1002/nop2.70158 · Cited by 1
Advanced Care Planning Conversations: A Scoping Review of Nurse Practitioners’ Approach
Hussein, M. T. E., & Favell, D. (2025) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2025.105421 · Cited by 1
Casemanagers Positioned as Key Advance Care Planning Conversationalists in Oncology Care: A Qualitative Interview Study on the Perspectives of Healthcare Professionals and Patients
Putker, A. E., Perry, M., Chalkiopoulos, J., Piek, A., Engels, Y., & Kuip, E. J. M. (2025) · Cancer Medicine · doi:10.1002/cam4.71195 · Cited by 1
Temporal trends and determinants of inpatient palliative care utilization among hospitalized patients with acute myeloid leukemia: a retrospective cross-sectional study
Amaeshi, L. C., & Imeh, M. (2025) · BMC Palliative Care · doi:10.1186/s12904-025-01949-2 · Cited by 1
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End-of-Life Care Terminology
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Muehlensiepen, F., Stanze, H., May, S., Stahlhut, K., Helm, C., Hakam, H. T., Bała, M. M., Peričić, T. P., Vrbová, T., Klugarová, J., et al. (2024) · International Journal of Evidence-Based Healthcare · doi:10.1097/xeb.0000000000000445 · Cited by 1
Increasing resuscitation status-related goals of care discussions for older adults with severe mental illness in a Canadian mental health setting: a retrospective study
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Optimal Contract Design for End-of-Life Care Payments
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End-of-Life Care Among Patients With Metastatic Renal Cell Carcinoma: Importance of a Patient-Centric Focus in Clinical Decision Making
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Authors: Starr, L. T., Ulrich, C. M., Corey, K. L., & Meghani, S. H.
Affiliations: Leonard Davis Institute of Health Economics (US)
University of Pennsylvania (US)
Corresponding author: Starr, Lauren T.
ORCID: Starr, Lauren T.
Ulrich, Connie M.
Meghani, Salimah H.
Venue: American Journal of Hospice and Palliative Medicine®
Publisher: SAGE Publications
Published: 2019-05-09
Volume: 36
Issue: 10
Pages: 913-926
ISSN: 1049-9091 (ISSN-L)
1938-2715
DOI: 10.1177/1049909119848148
PMC: PMC6711813
OpenAlex: W2944707386
Cited by: 132
References: 54
Citations by year: 2026: 13 · 2025: 22 · 2024: 26 · 2023: 22 · 2022: 23 · 2021: 12 · 2020: 14
FWCI: 2.00
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations: American Journal of Hospice and Palliative Medicine® (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: Leonard Davis Institute of Health Economics at the University of Pennsylvania (Jonas Nurse Leaders Scholars program)
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
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
Keywords: end-of-life discussions, advance care planning, goals of care discussions, advanced cancer, health care utilization, end-of-life care costs, place of death, hospice use, chemotherapy near death, quality of end-of-life care
MeSH terms: Communication, Health Expenditures, Health Resources, Health Services, Humans, Neoplasms, Patient Acceptance of Health Care, Patient Care Planning, Quality of Life, Severity of Illness Index, Terminal Care, Advance Care Planning

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Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

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