From the Journals

Use and costs of CRC end-of-life care differ sharply between U.S., Canada



Patterns of health care use and costs at the end of life among colorectal cancer (CRC) patients differ considerably between the United States and Canada and offer learning opportunities for both countries, suggests a cross-sectional cohort study.

Total costs were one-fourth higher for U.S. patients, who more often received chemotherapy and imaging in the month leading up to death. Canadian patients in the province of Ontario were more likely to be hospitalized and to die in the hospital.

“Our findings add to the growing body of research describing health care utilization and costs among patients in different systems to inform efforts to improve organization and delivery of care,” write the investigators, led by Karen E. Bremner, BSc, a research associate with the Toronto General Hospital Research Institute, University Health Network, and the Toronto Health Economics and Technology Assessment (THETA) Collaborative. “These findings suggest opportunities for reducing chemotherapy and ICU use in the U.S. and hospitalizations in Ontario.”

The investigators used registries to identify patients who received a diagnosis of CRC of any stage during 2007-2013 and died of any cancer during that period at the age of 66 years or older.

Analyses compared health care use and costs between 16,565 patients from the U.S. Surveillance, Epidemiology, and End Results (SEER) cancer registries linked to Medicare claims and 6,587 patients from the Ontario Cancer Registry linked to administrative health data.

Across months, but especially in the month before death, the SEER-Medicare group was more likely than the Ontario group to receive chemotherapy (15.7% vs. 8.0% in the last month of life) and have imaging tests (39.4% vs. 31.1% in the last month of life), according to results reported in the Journal of Oncology Practice.

Ontario patients more often visited the emergency department (14.7% vs. 6.7%) and were hospitalized (62.5% vs. 51.0%) in the month before death; had longer stays (14.1 vs. 10.9 days); and were more likely to die in the hospital (42.0% vs. 24.3%). But once hospitalized, they were less often admitted to the ICU (17.9% vs. 43.2%).

Mean total costs for all health care resources in the last month of life were 25% higher for the SEER-Medicare group compared with the Ontario group ($17,284 vs. $13,849), with the gap widening by stage at diagnosis. Costs were 12% higher for those with stage 0 to II disease, 27% higher for those with stage III disease, and 32% higher for those with stage IV disease.

The SEER-Medicare group had higher hospitalization costs ($11,180 vs. $9,434) with daily hospital costs that were about twice those of Ontario counterparts ($2,004 vs. $1,067).

“[O]ur descriptive study of health care utilization and costs at the end of life in similar groups of older CRC patients, although not supporting a direct comparison of two health systems, generated hypotheses concerning areas for improvement in service delivery and lower costs in both settings,” Ms. Bremner and coinvestigators maintained.

“In Ontario, improving coordination of end-of-life care and reducing hospitalizations and in-hospital deaths could provide savings,” they noted. “Reducing daily hospital costs and intensity of health care services for SEER-Medicare patients, especially those with stage IV disease at diagnosis, could reduce costs to the Medicare program and decrease the financial burden on patients and families.”

Ms. Bremner disclosed that she had no conflicts of interest. The Ontario arm of the study was funded by the Canadian Centre for Applied Research in Cancer Control, which receives core funding from the Canadian Cancer Society Research Institute.

SOURCE: Bremner KE et al. J Oncol Pract. 2019 Oct 24. doi: 10.1200/JOP.19.00061.

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