Prospective cohort study of hospitalized adults with advanced cancer: Associations between complications, comorbidity, and utilization
BACKGROUND
Inpatient hospital stays account for more than a third of direct medical cancer care costs. Evidence on factors driving these costs can inform planning of services, as well as consideration of equity in access.
OBJECTIVE
To measure the association between hospital costs, and demographic, clinical, and system factors, for a cohort of adults with advanced cancer.
DESIGN
Prospective multisite cohort study.
SETTING
Four medical and cancer centers.
PATIENTS
Adults with advanced cancer admitted to a participating hospital between 2007 and 2011, excluding those with dementia. Final analytic sample included 1020 patients.
METHODS
With receipt of palliative care controlled for, the associations between hospital cost and patient factors were estimated. Factors covered the domains of demographics (age, sex, race), socioeconomics and systems (education, insurance, living will, proxy), clinical care (diagnoses, complications deemed to pose a threat to life or bodily functions, comorbidities, symptom burden, activities of daily living), and prior healthcare utilization (home help, analgesic prescribing).
OUTCOME MEASURE
Direct hospital costs.
RESULTS
A major (markedly abnormal) complication (+$8267; P < 0.01), a minor but not a major complication (+$5289; P < 0.01), and number of comorbidities (+$852; P < 0.01) were associated with higher cost, and admitting diagnosis of electrolyte disorders (–$4759; P = 0.01) and increased age (–$53; P = 0.03) were associated with lower cost.
CONCLUSIONS
Complications and comorbidity burden drive inhospital utilization for adults with advanced cancer. There is little evidence of sociodemographic associations and no apparent impact of advance directives. Attempts to control growth of hospital cancer costs require consideration of how the most resource-intensive patients are identified promptly and prioritized for cost-effective care. Journal of Hospital Medicine 2017;12:407-413. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Of the major chronic conditions that affect adult patients in the United States, cancer accounts for the highest levels of per capita spending.1 Cost growth for cancer treatment has been substantial and persistent, from $72 billion in 2004 to $125 billion in 2010, and is projected to increase to $173 billion by 2020.2 Thirty-five percent of US direct medical cancer costs are attributable to inpatient hospital stays.3 Policy responses that can provide financially sustainable, high-quality models of care for patients with advanced cancer and other serious illness are urgently sought.4-7
Patterns and levels of resource utilization in providing healthcare to patients with serious illness reflect not only treatment choices but a complex set of relationships among demographic, clinical, and system factors.8-10 Patient-level factors previously identified as potentially significant drivers of resource utilization among cancer populations specifically include age,11 sex,12 primary diagnosis,13 and comorbidities.11 Among end-of-life populations, significant associations have been found between cost and ethnicity,14 socioeconomic status,15 advance directive status,16 insurance status,16 and functional status.17
Evidence on factors strongly associated with cost of hospital admission for patients with advanced cancer can therefore inform provision and planning of healthcare. For example, when a specific diagnosis or clinical condition is found to be associated with high cost, then improving coordination and provision of care for this patient group may reduce avoidable utilization. Determining associations between sociodemographics and hospital care cost can help in identifying possible disparities in care, such as those that might occur when care differs by race, class, or insurance status.
We conducted the Palliative Care for Cancer (PC4C) study, a prospective multisite cohort study of the palliative care consultation team intervention for hospitalized adults with advanced cancer.18,19 In our primary analysis, we controlled for receipt of palliative care and analyzed a rich patient-reported dataset to examine associations between hospital care cost, and sociodemographic factors, clinical variables, and prior healthcare utilization. The results provide evidence regarding the factors most associated with the cost of hospital-based cancer care.
METHODS
Design, Setting, Participants, Data Sources
The PC4C study has been described in detail by authors who estimated the impact of specialist palliative care consultation teams on hospitalization cost.19-21 We prospectively collected sociodemographic, clinical, prior utilization, and cost data for adult patients with a primary diagnosis of advanced cancer admitted to 4 large US hospitals between 2007 and 2011.
