Taking care of terminally-ill patients at home - the economic perspective revisited

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Taking care of terminally-ill patients at home -
the economic perspective revisited

• Oren Tamir, Yoram Singer, Pesach Shvartzman
• Palliat Med.2007 21 537-541

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Introduction

• End-of-life care can be delivered in a variety of
  settings
• Inpatient hospice care
• Inpatient ward within a general hospital
• Palliative homecare (home hospice)
• Homecare using the existing community-based
  medical services.

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Introduction

• The majority of both terminal cancer patients and
  their family caregivers prefer to die at home
  (Tang et al.)
• Caregivers of patients who were cared for at home
  were more likely to report a favorable dying
  experience (Teno et al. )
• Similar findings were found among the Israeli
  population (Singer et al., Loven et al., Iecovich
  et al.).

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Introduction

• Home hospice care saves 31-64 of medical care
  costs
• The main difference in accounted for by the
  reduced use of hospital services.
• During the last six months of life, the mean
  medical costs for patients receiving hospice care
  at home are 27 less than for conventional care
• The saving with hospital-based hospice care are
  less than 15

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The aim of our study

• To evaluate health services utilization during
  the last year of life, in the Negev region and to
  compare terminally ill patients who have received
  home specialized palliative care services (HSPCS)
  compared to patients who died with no access to
  home specialized palliative care services
  (HNSPCS).

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The Negev palliative care program

• Home palliative care units (Beer-Sheva,
  Kiryat-Gat, and Rahat)
• A consultation service for the Oncology Institute
  at Soroka University Medical Center (SUMC)
• 28-35 patients on average at any given time, with
  about 120 patients per year.
• Referrals are received through the Oncology
  Institute, primary care physicians or directly by
  the families and patients.

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Study population

• 120 patients treated by the home specialized
  palliative care service (HSPCS) of Beer-Sheva and
  Kiryat-Gat who died between the years 1999-2000
• 515 patients who died in the same period, but had
  no access to the HSPCS (HNSPCS).
• The HNSPCS group included patients who lived
  mainly in Beer-Sheva vicinity.

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Data collection

• Health services utilization data were retrieved
  from the computerized database
• All patients belong to Clalit Health Services
  (CHS), thus all utilization costs of all medical
  services are recorded in the same computer
  mainframe using the same pricing methods.

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Results

• Age and gender distribution were similar in both
  groups.
• the older age group (65 years or older) accounted
  for 69.7 vs. 73.3 respectively (pgt0.05).
• The mean age was 67.913.3 in the HSPCS and
  69.113.1 in the HNSPCS. (pgt0.05)

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Results
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Results
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Results
Last Year of Life Last Year of Life Last Year of Life Last 3 Months of Life Last 3 Months of Life Last 3 Months of Life Last Month of Life Last Month of Life Last Month of Life
      HNSPCS HSPCS P value HNSPCS HSPCS P value HNSPCS HSPCS P value
Ambulatory procedures Ambulatory procedures Ambulatory procedures 9 10 NS 3 5 NS 0 1 Plt0.005
Imaging Imaging Imaging 813 623 NS 312 205 NS 121 91 NS
Laboratory Laboratory Laboratory 36 5 NS 23 2 NS 4 0 NS
Consultations Consultations Consultations 37 28 NS 7 5 NS 1 1 NS
Hospitalization Hospitalization Hospitalization 7,238 4,414 lt0.01 3,855 2,083 lt0.01 1,818 849 Plt0.001
Day Hospitalization Day Hospitalization Day Hospitalization 1,196 1,158 NS 331 297 NS 96 59 NS
ER ER ER 111 120 NS 47 50 NS 18 16 NS
Doctor visit Doctor visit Doctor visit 13 16 NS 4 7 NS 1 2 NS
Oncology treatment Oncology treatment Oncology treatment 775 614 lt0.05 338 235 NS 94 106 NS
other other other 163 146 NS 40 42 NS 13 7 NS
TOTAL TOTAL TOTAL 10,392 7,133 lt0.01 4,961 2,930 Plt0.005 2,179 1,134 Plt0.001
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Discussion

• 10-12 of the total health care budget being
  spent during the last year of life (Stooker et
  al., Emanuel et al.)
• One eighth of the health care providers total
  expenditure spent on patients in their last month
  of life (Lubitz et al., Riley et al.)
• Nearly 55 of the total medical expenses during
  the last year of life were spent over the last
  three months of life (Liu et al.)

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Discussion

• 27-30 of Medicare payments each year are for the
  5-6 of Medicare beneficiaries who die in that
  year (Lubitz et al., McCall et al.)
• In general, outcomes in a home palliative care
  setting showed improved satisfaction and better
  pain and symptom control (Finlay et al.)
• Case-control patients matched by diagnosis and
  age treated in an inpatient palliative care unit
  compared with conventional care showed direct
  costs were 56 lower and total costs 57 lower
  (Finlay et al.)

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Discussion

• In Israel, a study of Clalit Health Services
  (CHS) members, who died in 2001, showed that the
  average cost per capita during the last year of
  life was five times more than aged matched live
  patients (Bechar et al.)

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Discussion

• The results of our study provide evidence that,
  for terminally ill cancer patients, health
  services costs are lower for patients enrolled at
  the HSPCS compared with those who were not.
• Health services expenditures reduction is greater
  for periods closer to time of death, regardless
  of cancer type.
• The cost differences between the groups are
  largely due to fewer acute admissions to hospital
  and oncology treatments.

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Discussion

• In our previous work we found that death at home
  occurred for 80.3 of the patients with access to
  homecare and 20.5 of those without access.
• There was a greater overall satisfaction with the
  caring experience of those whose loved ones died
  at home and had access to the homecare program.

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Discussion

• In a prospective phase of our study (in process)
  preliminary data show a favorable experience and
  greater satisfaction amongst the HSPCS patients
  and their families.

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conclusion

• Given the large number of patients who die from
  cancer annually, the increasing strain on
  healthcare systems during the last year of life
  and the substantial cost reduction with home
  palliative care,
• we believe that home based palliative care has
  to be offered to all terminally ill cancer
  patients suitable for this service.