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Health care usage, costs in developed countries for patients dying with cancer

The JAMA Network Journals

The first international comparative study of end-of-life care practices finds that the United States actually has the lowest proportion of deaths in the hospital and the lowest number of days in the hospital in the last 6 months of life among seven developed countries. The study appears in the January 19 issue of JAMA.

Using data from 2010-2012, Ezekiel J. Emanuel, M.D., Ph.D., of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues examined patterns of care, health care utilization, and expenditures among patients dying in seven developed countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States. The researchers used administrative and registry data from 2010, and included decedents older than 65 years who died with cancer. In the U.S. 22.2 percent and in Netherlands 29.4 percent of cancer patients died in the hospital, which is in accordance with most patients' wishes. By comparison, in Belgium and Canada over 50 percent of patients died in the hospital, while in England, Norway, and Germany over 38 percent of patients died in the hospital.

Two decades ago, the majority of deaths due to terminal illness were reported to occur in the hospital. More than a quarter of the Medicare budget is devoted to the care of beneficiaries who die in that year. Other developed nations spend less than the United States on health care, a finding some attribute to lower-intensity care at the end of life.

The United States performs poorly in other aspects of end-of-life care, especially related to high technology interventions. Over 40 percent of patients who die with cancer are admitted to the intensive care unit (ICU) in the last 6 months of life, which is more than twice any other country in the study. Similarly, 38.7 percent of American patients dying with cancer received at least one chemotherapy episode in the last 6 months of life, more than any other country in the study.

In the last 180 days of life, average per capita hospital expenditures were higher in Canada (U.S. $21,840), Norway (U.S. $19,783), and the United States (U.S. $18,500), intermediate in Germany (U.S. $16,221) and Belgium (U.S. $15,699), and lower in the Netherlands (U.S. $10,936) and England (U.S. $9,342).

Analyses that included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012, showed similar results, suggesting that the differences observed were driven more by end-of-life care practices and organization rather than differences in cohort identification.

The authors write that the lower rates of acute care hospital admissions, length of stay, and in-hospital deaths in the United States and the Netherlands suggest that end-of-life care can evolve to reflect patient preferences and goals about site of death irrespective of health system. "In the early 1980s, more than 70 percent of U.S. cancer patients died in hospital. Over the last 30 years, recognition of preferences for home-based end-of-life care and patients' rights to refuse medical interventions and economic pressures to lower end-of-life costs and expand hospice use have all played an important role in advancing end-of-life care. Yet excessive utilization of high-intensity care near the end of life, particularly in the United States relative to other developed countries, underscores the need for continued progress to improve end-of-life care practices."


(doi:10.1001/jama.2015.18603; Available pre-embargo to the media at http:/

Editor's Note: This study was partially supported by the Commonwealth Fund and the National Institute on Aging and National Cancer Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

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