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Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review
Open accessAbstract
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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“Advance care planning has been associated with earlier and increased use of hospice care [12–15], reduced intensive treatment and hospitalizations at the end of life [13, 15–18], and better quality of life in patients with cancer and caregivers [12, 19].”
From Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers. (2024) · cites this paper as [13]
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Financial toxicity in cancer care: origins, impact, and solutions
Abrams, H. R., Durbin, S., Huang, C. X., Johnson, S. F., Nayak, R., Zahner, G. J., & Peppercorn, J. M. (2021) · Translational Behavioral Medicine · doi:10.1093/tbm/ibab091 · Cited by 252
“survivorship needs [28]; and palliative or end-of-life care, conveying particularly high costs in the last days or weeks of a patient’s life [29].”
Bazargan, M., & Bazargan‐Hejazi, S. (2020) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909120966585 · Cited by 161
“Finally, reviews of research manuscripts published between January 2012 and January 2019 show that end-of-life discussions with patients with advanced cancer are associated with greater use of hospice care, greater likelihood of death outside the hospital, as well as less costly end-of-life care.(21)”
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Living with Metastatic Cancer: A Roadmap for Future Research
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“In fact, discussions between patients and providers regarding goals of care were associated with fewer hospital admissions and less aggressive treatment near end-of-life [183,184], which may improve quality of life and reduce financial toxicity [185].”
Background
Metadata
- 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.
- 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
- 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
- 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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