- Email: [email protected]
A comparative cost analysis of terminal cancer care in home hospice patients and controls
J Chron Dis Vol. 40, No. 8, pp. 801-810, 1987 Printed in Great Britain. All rights reserved
Copyright
Q
002l-9681/87 1987 Pergamon
$3.00 f0.00 Journals Ltd
A COMPARATIVE COST ANALYSIS OF TERMINAL CANCER CARE IN HOME HOSPICE PATIENTS AND CONTROLS DENNIS GRAY,’ DOUGLAS MACADAM’
and DUNCAN BOLDY’
‘Department of Community Practice, University of Western Australia, 328 Stirling Highway, WA 6010 and 2Centre for Advanced Studies in Health Sciences, Curtin University of Technology, Western Australia (Received in revised form 26 June 1986)
Abstract-A comparison is made between the expenditure during the last 90 days of life on 98 terminal cancer patients cared for by a home based hospice service and that on matched patients dying without the home hospice service. The control patients were matched for site of primary cancer, age and sex. The individual records of both groups of patients were analyzed and costed. It was found that the costs of providing 24 hour comprehensive medical and nursing care at home to those dying of cancer and support for their families was no more expensive than traditional institutional care. Hospice
Cancer
Terminal
Palliative
INTRODUCTION
In Perth, Western Australia, a home based hospice service, the Hospice Palliative Care Service (HPCS) was established in 1982 [l]. HPCS provides care for patients dying in their homes and support for family or friends, both during the terminal illness and in subsequent bereavement. The service is delivered by eight district teams caring for up to twenty patients at a time in distinct geographical areas of Perth. Each of these teams is headed by an HPCS general practitioner (GP). Medical care may be provided by the patient’s own GP, an HPCS GP, or a combination of both. The nursing staff work on a day, evening and night shift system. During the day nursing care is provided by the home care nurse (district sister) who may visit 2-3 times a day if necessary, and who may have attended to the patient for a long time in the pre-terminal phase of illness. The evening and night nursing sisters of the HPCS team visit to provide regular and emergency nursing care when the district sister is not on duty. The HPCS liason sister coordinates the work of all who care for the patient (i.e. the district, evening 801
Homecare
Cost-effective
and night sisters), liases with the doctors, is a key person at the regular clinical management meetings, organizes the volunteers when needed, and has a particular responsibility for supporting the family members during the final illness and subsequently. A night special nurse is employed occasionally to be with a patient throughout the night if the patient would otherwise have to go to hospital. Both nurses and doctors can be contacted at all times through a paging system by those in the patients’ homes. This ready availability of nursing and medical help enables appropriate hospice care to be given in the home to all but the most dependent patient. In 1985 HPCS was caring for more than 50% of all patients dying from cancer in Perth. Sixty percent of those cared for died at home. The care provided by HPCS is not exclusive and all HPCS patients receive some care and undergo some investigation in more conventional facilities at various stages of their illnesses. The aim of the present study was to use matched controls to compare the total costs incurred by HPCS patients with the costs of more conventional terminal care. Health services and expenditure during the last 90 days of
802
DENNISGRAYet al.
life were estimated and compared in respect of 98 patients under HPCS and a control group of 98 patients who died without HPCS. The period of 90 days was chosen to avoid the problem of deciding when terminal care begins. METHODS
and opposite sex. In 18 cases it was not possible to match HPCS patients on age and the person whose age was closest to that of the HPCS patient was selected as a control regardless of sex. Among these latter pairs, seven HPCS patients and controls were aged within 10 years of each other and 16 pairs were of the same sex.
Patient selection
Data collection
The factors which decide whether or not a patient is referred to HPCS for care at home are ill-defined and it was not possible to obtain a control group of patients which matched an HPCS group on the basis of selection for home care. Rather, a group of HPCS patients was matched with a group of patients who died in the same year on the basis of site of primary cancer, age and sex. The assumption was made that patients so matched would present similar clinical problems. All of the 98 HPCS patients listed on the Cancer Registry of the Health Department of Western Australia as dying of cancer in 1983 were included in the study, and the control group of patients was also drawn from the Registry. As statutory notification of cancer cases forms the basis of the Registry and do not begin in Western Australia until August 1981 [2], the study groups include only patients diagnosed after that date. There were 885 people on the Cancer Registry who died from malignant neoplasms (International Classification of Diseases, revision 9 codes 140.0-208.9 [3]) in 1983 and who lived in Perth (i.e. the Perth Statistical Division). This is a relatively small number which precluded exact matching on the lesser selection criteria or upon other criteria which might have been deemed desirable. All patients included in the study were Perth residents who died in 1983 and were matched on three digits of the respective ICD-9 codes (86 pairs were matched on four digits). Those potential control patients whose dates of birth were within +5 years of the HPCS patients were considered to be of equivalent age. HPCS patients were matched with the first person whose name appeared on the Cancer Registry who had the same diagnosis and who was of the same age and sex. Seventy-two HPCS patients were thus matched. Age was considered a more important variable on which to match than sex, since disability is related to aging and disability is likely to influence care needs. In six instances where no potential match was available on both age and sex, HPCS patients were matched with the first person of the same age
Data for the study were obtained from a number of sources. From the Cancer Registry, it was possible to obtain cause of death, place of death, survival time from diagnosis and basic demographic data such as age, sex, and place of residence. The Health Department of Western Australia provided information on all public and private hospital admissions and their duration. Similar data for public and private nursing homes was provided by the Commonwealth Health Department. HPCS provided access to records of duration of patient care under the Service. From these sources, complete data on admissions for all patients were available. When considering the settings in which care was provided, it is important to recognize that they are not exclusive and that, for example, a person might have received some care in both public and private hospitals as well as from HPCS. Data on investigations and procedures were similarly derived from various sources but were less complete than admission data and in some cases had to be estimated. Four of the five major metropolitan public teaching hospitals in Perth and all of the non teaching public hospitals in which study patients had been treated provided access to relevant medical records. Three nurse research assistants were employed to enter aggregated data from these patient medical records on to standardized recording sheets. Data recorded included number of admissions, hospitals and wards to which patients were admitted and days spent in each, medical and paramedical attendances, and the provision of various investigations, services and procedures. Where applicable, all investigations and procedures were recorded using the appropriate codes from the Commonwealth Department of Health’s Medical Benefits Schedule Book [4], which is a list of medical services and approved fees. The quality of the information in the medical records varied considerably. Whereas there appeared to be virtually complete documentation of investigative procedures, records of atten-
Cost Analysis of Terminal Cancer Care
dances by paramedical personnel were very uneven. For this reason, provision of this category of services is underestimated for both groups of patients. Nineteen HPCS patients and eight controls had been admitted to the nonparticipating public teaching hospital. For those patients, estimates were made of the number of procedures and investigations likely to have been undertaken based on those carried out for similar patients on the other public teaching hospitals. A total of 74 patients had received care in private hospitals. Direct access to the hospital records of these patients was not available. However, a major private health insurance fund agreed to participate in the study. The fund had insured 36 of the private hospital patients-24 HPCS patients and 12 controls. For these patients, the insurance fund provided a list of all services provided in the last 90 days of life for which a claim had been made. In the case of those patients who spent time in public hospitals, the health fund data provided a valuable independent check confirming the accuracy of the procedures employed to extract data from medical records. As direct access was not available to the records of 38 patients in private hospitals, insurance fund data on private hospital patients also provided a basis for estimating the medical services, and investigations and procedures carried out in such institutions. Costing procedure
Although the patients died in 1983 and the services provided relate to this time, the costs in this study were derived on the basis of those current in July-December 1984 in Australian dollars. The largest single group of patients (65 or 33.2%) had been in Perth’s major teaching hospital. The mean cost per occupied bed day by speciality of interest and for that hospital as a whole were derived (Table 1). These costs reflect, among other things, the intensity of nursing care provided in the different wards. The costs for this one hospital were used to
Table 1. Average cost per occupied bed day by speciality (July-December 1984) Specialty
A%
Oncology General medicine General surgery Neurosurgery Extended care
314 293 287 409 250
All specialties
A$316
803
calculate average bed day costs for all patients who had been in other public hospitals (except for a Veterans Affairs hospital which utilizes a different accounting system and which provided an average bed cost per patient day). To facilitate this, scaling factors reflecting the variation in costs among the public hospitals were provided by the Health Department of Western Australia. These scaling factors ranged from 0.82 to 1.34 for the teaching hospitals and 0.48 to 0.67 for the non-teaching public hospitals. The cost of items of service which could be and were attributed to particular individual patients, i.e. pharmaceutical and paramedical services, investigations, and operative procedures were excluded from the calculation of bed-day costs and separately measured. Allowance for the capital depreciation of public hospital buildings is specifically excluded from public hospital accounting and this is estimated by State Health Department personnel to understate the “true” cost per day by approximately 4-5%. Therefore the bed day costs within the public hospital were multiplied by a factor of 1.04. The result was a figure which included nursing, domestic, food, linen and engineering services, and an administrative component. In the case of the teaching hospitals, but not the non-teaching public hospitals, the result also included the cost of medical services. Records of medical attendances in the public non-teaching hospitals were generally incomplete and the best estimate of the cost of these came from insurance fund data. The mean cost of both general practitioner ($2.99/day) and specialistconsultant (%2.69/day) attendances were based on eight patients who spent time only in nonteaching public hospitals. These values, which are likely to be an underestimate, were added to the bed day costs derived for each non-teaching public hospital and applied to the number of days that the total 19 of the patients spent in these hospitals. Access to the running costs of each of the private hospitals was not available. Consequently, the amount per day charged to patients at one of the smaller private hospitals ($120) plus the Commonwealth Government’s daily bed subsidy ($30)-a total of $150/daywas applied to each of the 13 private hospitals in which study patients had been treated. Due to the small size of the hospital from which the basic cost was derived, this procedure probably underestimates total expenditure. As in the case of the non-teaching public hospitals, the mean
804
DENNISGRAYet al.
derived cost of $150/bed day includes nursing but not medical services. However, one health insurance fund provided data on the medical services provided to seven of its clients who had been in private hospitals and who were in the study group. For these patients, the mean daily cost of general practitioner visits was $7.43/day and for specialist-consultant attendances, $9.18/day. These amounts were added to the basic bed day cost to give a total of $166.81 per bed day in private hospitals. Data was not available from other insurance funds for the remaining 31 patients who had spent time in a private hospital. Therefore, the $166.81 per bed day was used to calculate the cost of private hospitalization for all 38 patients who had been in private hospitals. Fourteen patients-three HPCS patients and eleven controls-had been admitted to ten different nursing homes. Five of these were public homes and the Health Department of Western Australia provided average occupied bed day costs for each of them. No information was available to us on the bed day cost of the five private homes. It is assumed, however, that the operating cost of such institutions would not differ greatly from those of the public nursing homes. Thus, the mean occupied bed day cost of the public homes-$55.58-was used to estimate expenditure for the private nursing home patients. This figure is an underestimate, because it does not include the cost of medical services provided to nursing home patients. Medical costs could not be included as no medical record data was available from the nursing homes and too little was available from the health insurance data to make a confident estimate of such services. Control patients spent more than twice as many days in nursing homes as did HPCS patients. Therefore the exclusion of medical costs in nursing homes from the estimates of total expenditure underestimates control patient costs relative to HPCS patient costs. Hospital accounting systems do not allow the derivation of unit costs for each particular service provided. A small study was undertaken which indicated it would be appropriate to utilize the Medical Benefits Schedule fees as the best approximation of expenditure on such services. In costing, the numbers of each particular service provided were multiplied by the scheduled fees. In the case of the non-participating teaching hospital the mean cost of services per day provided in the other teaching hospitals to
study patients was derived and multiplied by patient days of hospitalization. Similarly, health insurance records were used to calculate a mean cost of services per day in private hospitals and these were applied to patients in those hospitals for whom medical records were not available. The mean cost of services per patient which were derived in this way have been grouped according to the broad categories utilized in the Medical Benefits Schedule Book and are presented in Table 7. As previously indicated medical care under HPCS may be provided by an HPCS doctor, a patient’s own general practitioner, or by a combination of both. Visits by private general practitioners are not recorded in HPCS nursing records which consequently understate the provision of medical care. To overcome this limitation the cost of medical care was calculated by taking the mean number of medical visits, both the HPCS and private practitioners (obtained from a previous study [SJ) and costing it at $22.53 per visit. This figure was derived by taking the ratio of home visits of varying duration both “in” and “after” hours provided to the insurance fund patients-this being the only source of information available to us on general practitioner visiting-and applying appropriate Medical Benefits Schedule fees. All home nursing in Perth is carried out by the one organization, of which HPCS is a part. It is possible that some patients in the control group received daytime nursing care at home. As this would have been a small part of a busy district home nurse’s case load it was not possible to identify it separately. Any cost would have only marginally increased the total cost of care of the controls. The costs for HPCS nursing services were calculated by taking the salary costs for each category of nurse and the total central costs which included administration, counselling, transport, education, and the organization of volunteers. These central costs were distributed equally between the categories of nurse. For each such category, the number of visits were totalled and a cost per type of visit derived (see Table 6). During the period July-December 1984, which was used as the basis for all costs in the study, the costs per type of HPCS nursing visit were exceptionally high. This was because at that time the work load per nurse employed was low due to the expansion of the service and the need to train nursing staff after employment had commenced. This bias inflates the cost of HPCS care. As a conse-
805
Cost Analysis of Terminal Cancer Care Table 2. Causes of death
Cancer causing death Lip, oral cavity, pharynx Digestive organs, peritoneum Respiratory and intrathoracic organs Bone, connective tissue, skin, breast Genitourinary organs Other and unspecified sites Lymphatic and haematopoietic tissue Totals
quence a corrected costing of HPCS services was undertaken based on nursing workloads after the service had been established for 12 months. The services provided to patients by general practitioners outside of hospitals, nursing homes or HPCS care are not included. The impossibility of locating all the general practitioners who provide care and then obtaining permission for access to their records precluded incorporating such costs into the study. Also excluded are hospital out-patient visits and the use of ambulance services. The data obtained on these was of varying quality. Drug costs were also excluded from the costing of both HPCS patients and controls. The decision to exclude drug costs was made because of the multitude of separate items, the lack of information on dispensing and packaging costs of the drugs, and the lack of completeness in the recording of drug use in both groups. Appendix A summarizes the costing procedures employed. RESULTS
The mean age of the study group was 63.3 years (range 3-92; SD 14.9) males outnumbered females by a ratio of 1.8 : 1. This reflects the fact that breast cancer is the commonest cancer in women and has a longer survival time than the period of 28 months covered by the study. This resulted in few women with breast cancer being in the study. There was no statistically significant difference in marital status between the HPCS and control patients. Fifty percent of each group were married or living in de facto relationships and roughly equal proportions within each group fell into the single, widowed and separated or divorced categories. While it was not possible to match patients in terms of suburb of residence, it was possible to compare the postal districts from which they were drawn
ED-9 code
Study patients n = 196 %
14&149 15cN59 16165 170-175 1799189 19c-199 20&208
3.1 37.7 25.5 4.1 14.3 10.2 5.1 100
in terms of the percentage of people aged over 15 who, at the 1981 census, had an annual income in excess of $15,000. According to Houghton [6] this provides an accurate guide to the social status of particular suburbs and this was used as a proxy measure of the socioeconomic status of individuals. Using this procedure, no statistically significant status differences between HPCS patients and controls were found. Table 2 indicates the major sites of cancer among patients within the study group. As is to be expected given the means of entry onto the Cancer Registry and the short period in which it has been operating, there is a high proportion of those suffering from more acute cancers or cancers in which survival time is relatively shorter. Since no cancers which had been diagnosed more than 28 months before death were included in this study and since the controls were matched by site of cancer and age it was to be expected that the mean survival time from diagnosis to death would be similar for the HPCS patients and their controls. However, the HPCS patients had a mean survival time nearly 100 days longer than the control group (292 vs 194 days). Between the time of diagnosis and death, people with cancer spend much time at home. However, although some die there, most are admitted to an institution to die. The 98 study patients receiving HPCS care were referred to the service at differing stages of their illnesses, with 59% of them dying at home; the others being transferred to a hospital or nursing home a variable number of days before death. This compares with only 16% of the control group who died at home. Although the HPCS patients survived significantly longer, they spent less time in hospital after the time of diagnosis. The ratio of days in hospital to days survival (Table 3) shows
806
DENNRGRAYet al. Table 3. Characteristics of institutional admissions Admissions Means length of admission (days) during which death occurred* Mean number of institutional days in last 21 days of life Mean number of institutional days in last 30 days of life Mean number of institutional days in last 90 days of life Total institutional days from diagnosis to death Mean number of days survival from diagnosis Ratio of institutional days to survival days
HPCS n =98
Control n =98
8.7
17.5
4.7
F
Sig.
9.8
20.803
0.000
6.5
12.3
15.166
0.000
18.8
28.4
8.265
0.005
49.8
57.1
0.696
0.405
291.6
193.7
13.565
0.000
1:5.9
1:3.4
*Refers only to the 40HPCS and 82 control patients dying in an institution.
this clearly. The most significant differences in days of institutionalization occurred in the last 30 and 21 days of life. It was also in these periods of time that greatest use was made of HPCS services. In Table 4 a comparison is presented of the total number of days spent in various institutions by HPCS patients and controls during the last 90 days of life. With the exception of time spent in private hospitals which was greater for the HPCS patients, the controls spent more time in all institutions and overall the controls spent an average of 9.6 days longer in institutional care. The total bed day cost of this care is shown in Table 5 which also shows that the mean cost per control was $1793 greater than that for the HPCS patients. The mean period of time patients spent under the care of HPCS was 38.8 days. The mean number of nursing and medical visits provided to each HPCS patient is presented in Table 6. It is important to note that these services are not distributed evenly over the whole of the period under HPCS care. The majority of services are provided during a period of intensive nursing care in the last days before death. The mean length of this period is 12 days. When this period of time is added to the number of days
of institutional care (18.8) received by HPCS patients, the mean number of days per patient under intensive nursing and medical care is 30.8. This is only slightly more than the 28.4 days spent under institutional care by the controls and the difference is not statistically significant. Two castings of HPCS care are presented in Table 6. As indicated in the discussion of costing procedures, the first of these is based on 1984 costs. However, for the reasons given, the mean cost per patient of $2958 is likely to be an overestimate of HPCS costs. The correct costing is based on nursing workload under established conditions in 1985. The mean cost per patient of $2080 calculated on this basis is believed to be a more accurate reflection of the “true” cost of HPCS care. The data presented in Table 7 indicate that the ratio of expenditure on procedures and investigations to the total cost of institutional care is similar in the two groups. This suggests that the extra time spent in hospital by the control group is not just for nursing care. Rather when dying patients are admitted they receive a similar number of investigations and procedures as they did in earlier stages of their disease. When the cost of HPCS care based on the
Table 4. Days of institutional care during the last 90 days
Table 5. Cost of days of institutional 90 days of life
care during last
HPCS patients Total
Control patients Total
266,722 9036 88,970 7281
445,226 20,261 66,644 15,618
A$372,009 AS3796
A%547,749 A$5589
of life Place of care
HPCS patients Total
Control patients Total
Place of care
Teaching hospital Other public hospital Private hospital Nursing home
1105 68 534 131
1872 229 400 281
Teaching hospital Other public hospital Private hospital Nursing home
Totals Mean/patient
1838 18.8
2782 28.4
Totals Mean/patient
Cost Analysis of Terminal Cancer Care
807
Table 6. Mean HPCS costs per patient during the last 90 days of life 1984 costing Type of visit
X Visit@?
Liason sister District sister Evening sister Night sister Night special sister Medical practitioner
16.3 12.7 15.0 13.0 1.9 12.0
Corrected costing
Cost/visit
x cost/Pt
Cost/visit
X Cost/Pt
66.82 8.81 43.25 42.94 149.50 22.53
1090 112 649 559 278 270
35.61 8.81 23.83 37.45 144.01 22.53
580 112 357 487 274 270
Total
A$2958
1984 figures is added to the cost of institutional care, the mean cost per patient for the HPCS group was $7355. This was $853 more than the mean cost per patient of $6502 among the controls. However, it is important to note that one way analysis of variance revealed that this difference was not statistically significant (F = 1.27 p = 0.26). If the corrected costing of HPCS care is employed, the mean total cost of care per HPCS patient totals $6477 and is slightly less than the mean of $6502 expended on care for the control group. Again, however, this difference is not statistically significant. These figures are summarized in Table 8.
DISCUSSION
Hospice studies in the United States have suggested that the costs of home based hospice care are lower than for conventional carealthough in some cases this is dependent upon the period over which care is given [7-91. However, there have been methodological problems with these studies which include lack of control
AS2080
Table 8. Mean cost of care per patient during last 90 days of life HPCS patients 1984 costing AS7355
HPCS patients adjusted costing
Control patients
A$6477
A$6502
for the medical care required and bias in patient selection [lO-121. The present study has compared the costs of a group of home care hospice patients with a control group matched on medical criteria, age and sex. Furthermore, the fact that there was no difference in either marital or socioeconomic status suggests that in broad terms there were no differences in the amount of home based support and that there were no financial constraints upon the selection of care by either group. Essentially, hospital costs can be broken down into two major components, bed day costs and services, procedures and investigations; with the former accounting for the greatest proportion of total costs. Given the availability of accurate data for all hospital and nursing home admissions, the detailed data on public
Table 7. Summary of mean institutional costs per patient during last 90 days of life Control
HPCS Service Institutional bed Paramedical Anaesthetics Miscellaneous Pathology* Radiology Radiotherapy Computerized axial tomography Operations Nuclear medicine
Item No.
%
401-564 770-998 10062174 2502-2859 2861-2941
3796 12 26 62 194 91 30
5589 19 42 115 304 128 19
85.9 0.3 0.6 1.8 4.7 2.0 0.3
2960-297 1 3004-8683 8700-8850
37 125 24
0.8 2.8 0.5
46 192 48
0.7 3.0 0.7
*Includes haematology, chemistry, pathology and cytology. w--E
AS
86.3 0.3 0.6 1.4 4.4 2.1 0.7
Total
CD
%
AS
AS4397 microbiology,
AS6502 immunology,
histo-
808
DENNISGRAYet al.
hospital costs provided by the Health Department of Western Australia, and the broad comparability of non-teaching public hospital and private hospital costs, we contend that the bed days costs presented have a high degree of accuracy. The same holds true for the cost of HPCS care. The accuracy of the costing of services, procedures and investigations varies. With one exception, those for teaching hospital patients and patients for whom medical insurance data were available are quite accurate. However, in the case of patients from the non-participating teaching hospital and some private hospital patients, costs of services, procedures and investigations had to be estimated from data available for other study patients. Furthermore, provision of paramedical services was underrecorded and no basis was available for estimating the cost of medical services provided in nursing homes. Some of these factors, including the absence of nursing home medical services, and the deliberate policy of undercosting rather than overcosting hospital care whenever there was a choice of costing assumptions, tend to result in an underestimation of control patient costs. However, due to the fact that services, procedures and investigations comprise a relatively small proportion of total costs we believe that on balance such gaps in the data are likely to have had only minor effect on the outcome of the study. Considerable discussion was undertaken with an independent advisory committee appointed by the Cancer Foundation of Western Australia and staff of the Health Departmnent of Western Australia to ensure that the costing procedures employed were appropriate. Under the circumstances, we believe that the results presented are the most reasonable available. Over the last 90 days of life the control group had a mean of about 10 days more in hospital than did the HPCS group-28.4 compared to 18.8. The mean number of days of intensive nursing care for HPCS patients at home, i.e. regular 24 hour nursing care, was 12 and it is reasonable to suggest that HPCS patients would have been in hospital for this care if HPCS had not existed. Within the 90 day period, the total expenditure on health care was similar for both the home care patients and the controls. That is, a mean cost per HPCS patient of either $7355 or $6477 (depending upon the assumptions made in costing HPCS care) vs a mean cost of $6502 per control patient.
It is not clear why the HPCS patients had a longer survival time than the controls. It is possible that patients are more often selected for referral to HPCS when the progression of the disease prior to the terminal phase has been slower. However, as indicated, there was no difference between the two groups in requirements for medical and nursing care in the last 90 days, so that it cannot be argued that the terminal phase of disease was more acute in one group of patients than in the other. Clearly, though, there was a difference between the two groups of patients which was not matched in the selection of the control group. Consideration was given to the hypothesis that, as a consequence of their shorter mean survival time, the controls might have undergone intensive forms of investigation and treatment during their last 90 days of life which the HPCS patients had received prior to that period. As it was not possible to test this hypothesis by comparing costs of care in the last 90 days with the total cost of care, the converse situation was considered. The 27 control patients who had survived for a period equal to or longer (R = 326) than their HPCS counterparts (x = 158) were selected and their costs during the last 90 days of life compared with those of the HPCS matches. This comparison revealed that there was no significant difference in total costs between the two groups. Furthermore, there was again no significant difference in the ratio of the cost of investigations and procedures to institutional bed day costs. These results support our contention that while survival time may have been a factor in the choice of terminal care it was not a factor which significantly influenced the cost of care among patients in the study. The clinical manifestations of cancer were essentially the same, they required similar treatment and resulted in similar expenditure on care. In 1983, 1624 people from the Perth Statistical Division died from cancer. However, because many of these had been diagnosed prior to its establishment, only 855 were listed on the Cancer Register. On the Register, there was an under-representation of people suffering from cancers in which survival time is relatively long such as female breast cancer and a greater proportion of people suffering from more acute cancers or cancers in which survival time is relatively short-such as, respiratory cancer, brain cancer, and disseminated unspecific cancers. The results of the present study are therefore strictly generalizable only to patients with
809
Cost Analysis of Terminal Cancer Care
patterns of illness clinically similar to those among this latter group. It has been shown that there is considerable variation in the services provided by hospices [ 121and that one of the determinants of hospice costs is the value of services utilized [9]. As indicated in Table 6, the level of services provided by HPCS is relatively high. Although the cost of HPCS would be reduced by decreasing the number and/or duration of home visits, those involved in HPCS believe that such levels of service are necessary to ensure quality of patient care. While there was little difference in the expenditure required to care for the HPCS and control patients, the real saving to third party expenditure made possible by HPCS is any decrease in the necessary provision of hospital beds for the expected future increase in the number of deaths from cancer. This is of major significance in Western Australia where the population is aging and where the proportion of all deaths due to cancer is expected to rise from 20% in 1984 to 25% within 10 years, thus increasing the demand for terminal cancer care. When comparing the costs of any new service with that of an established service two elements need to be identified; that of substitution or replacement of what previously existed and that which represents additional services not previously provided. A new service cannot be justified on replacement grounds alone. In the case of HPCS these elements are inseparably entwined. As compared to hospice care, the hospital in-patient care of dying persons, however devoted the clinical staff, puts no comparable emphasis on support for the family during terminal illness, nor in the subsequent bereavement period. Much of an HPCS sister’s work, especially that of the liason sister which is particularly expensive, is spent with the relatives of the patient for which there is no hospital equivalent. This is assumed to have a direct positive influence on the patient’s well-being. This assumption is supported by the strong consumer demand for hospice care from both patients and their familes. Furthermore, the great growth of the hospice movement suggests that the quality of life for patients dying under hospice care is as good or better than that available elsewhere. The controlled studies by Morris et al. [8] which showed no better quality of life for hospice patients has been criticized by Mount and Scott [lo] on the grounds that the quality indices used in the studies do not reflect
the real issues and perceptions of patients in the terminal phase of disease. Further doubt on the validity of the indices of quality used by Morris et al. is found in the study by MacAdam and Smith [13]. In seeking to evaluate the effectiveness of hospice care, this factor of quality is of equal if not greater importance than expenditure. No attempt was made in this study to cost or compare the role of family or friends. During their last illness those in the control group spent 3.4 days at home for every day in hospital, and those under HPCS spent 5.9 days. In both groups any calculation of the total cost as distinct from third party expenditure would have to include the time and energies spent by family and friends in the home and in daily visiting to hospital. A previous study of HPCS patients showed that 64% were cared for at home by their spouse and 18% by siblings [5]. A U.S. study reported a significant emotional burden on families of patients caring for a dying member at home, but also reported that these family members did not regret their decision to nurse their relative at home [8]. CONCLUSIONS
This study has shown that it can take as much professional effort and cost to provide terminal care in the home as to continue to pursue treatment in hospital. Hospice care is labour intensive and will never be cheap for that reason. It is not surprising that the costs will be high when such a service is taken to a patient’s home. This study examined the comparative costs to a third party when 24 hour availability of skilled nursing and medical care is provided at home to terminal cancer patients with clinical problems comparable to those managed in acute hospitals. It shows that the costs of the service are no greater than if the patient had gone to hospital. However, for the same money the general practitioner based HPCS is also able to provide the full benefits of a hospice service previously not available. Acknowledgements-Funding for this study was provided by the Cancer Foundation of Western Australia Inc. Vahrable assistance and advice was also provided by a scientific advisory committee appointed by the Cancer Foundation: Associate Professor B. K. Armstrong, Dr C. Bower, Mr C. Deverall, Associate-Professor MST. Hobbs, Dr C. D. J. Holman and Mr P. Schapper. Preliminary discussions with Dr Francis Cunningham and her colleagues in the Commonwealth Department of Health assisted in the design of the protocol for the study. The Health Department of Western Australia made available data from its Cancer
DENNISGRAYet al.
810
Registry and MS M. D. Clarke-Hundley provided a great deal of assistance in accessing those data. Mr La1 Perera of the Financial and Administrative Services Division of Sir Charles Gairdner Hospital provided help with the costing of services.
6.
I.
8.
REFERENCES 1. MacAdam DB: The Development of the Hospice Palliative Care Service in Western Australia. Cancer Foundation of Western Australia, Perth, 1985. 2. Hatton WM, ClarkeHundley MD Cancer in Western AustraIIa:An Analysis of Age and Sex Specific Rates. Perth: Health Department of Western Australia, 1984 3. World Health Organisation: International Clasaification of Procedurea in Medicine. Geneva: World Health Organisation, 1978 Department of Health: Medical 4. Commonwealth Benefits Schedule Book. Canberra: Government Printer, 1984 5. MacAdam DB: A review of 715 terminal patients
9. lo. 11.
12. 13.
APPENDIX
cared for at home by a hospice palliative care service. Cancer Fomm 9:3, 1985 Division of National Mapping & Australian Bureau of Statistics: Perth: A social Atlaa. 1981 Cenana. Canberra: DNP & ABS, 1984 Brooks CH, Smyth-Staruch K: Cost Saw of Hospice Home Care to T&I-Party Insurers. Cleveland: Case Western University, 1983 Morris JN, Suissa S, Sherwood S, Wright SM, Greer D: Last days: a study of the quality of life of terminally ill cancer patients. J Cbron Dis. 39: 4762, 1986 Bimbaum HG, Kidder D: What does hospice cost? Am J Public HeaIth 74: 689-697, 1984 Mount B, Scott JF: Whither hospice evaluation? J Chron Dis 36: 731-736, 1983 Mor V, Hiris J: Determinants of site of death among Hosnice Cancer Patients. J Health Sot Rehav 24: 375-385, 1983 Torens PR: Hospice care: what have we learned? Ann Rev Public Health 6: 65-85. 1985 MacAdam DB, Smith M: An mitial assessment of suffering in terminal illness. Palliative Medicine, 1: 31-47, 1987
A
Outline of Costing Approach
Service
Source of unit cost
Comments
Actual figures from major teaching hospital, with overall correction factor reflecting average cost/day variations.
Assumes cancer patient is typical of average patient by specialty.
Included in l(a) Insurance fund data.
Likely to be underestimates.
Scheduled fees.
Possible overestimate of cost.
(a) Average bed day costs (excluding items of service, and medical attendances).
Estimated from daily charge levied by one of the smaller private hospitals, plus daily bed subsidy.
Possible underestimate.
(b) Medical attendances. (c) Average cost of services per day.
Insurance fund data. Insurance fund data.
1. Public Hospitals (a) Bed day by specialty (excluding various items of service). (b) Medical attendances -teaching hospitals -non-teaching hospitals (c) Items of service excluded from l(a) (e.g. investigations, operative procedures, paramedical services). Private Hospitals
Nursing Homes
Average bed day cost.
Health Dept of W.A. (applicable to public nursing homes and assumed to be the same for private nursing homes).
Excludes the provision of medical services.
HPCS Nursing Services
Cost per visit
HPCS records and accounts, with a correction for changes in nursing workloads.
GP Visits
(a) Under HPCS. (b) Outside HPCS and hospitals.
Estimated from data from a previous study. Excluded.
Note: Excluded from the costing procedure were the following: general (non-HPCS) home nursing visits, use of ambulance services and drugs.
Copyright
Q
002l-9681/87 1987 Pergamon
$3.00 f0.00 Journals Ltd
A COMPARATIVE COST ANALYSIS OF TERMINAL CANCER CARE IN HOME HOSPICE PATIENTS AND CONTROLS DENNIS GRAY,’ DOUGLAS MACADAM’
and DUNCAN BOLDY’
‘Department of Community Practice, University of Western Australia, 328 Stirling Highway, WA 6010 and 2Centre for Advanced Studies in Health Sciences, Curtin University of Technology, Western Australia (Received in revised form 26 June 1986)
Abstract-A comparison is made between the expenditure during the last 90 days of life on 98 terminal cancer patients cared for by a home based hospice service and that on matched patients dying without the home hospice service. The control patients were matched for site of primary cancer, age and sex. The individual records of both groups of patients were analyzed and costed. It was found that the costs of providing 24 hour comprehensive medical and nursing care at home to those dying of cancer and support for their families was no more expensive than traditional institutional care. Hospice
Cancer
Terminal
Palliative
INTRODUCTION
In Perth, Western Australia, a home based hospice service, the Hospice Palliative Care Service (HPCS) was established in 1982 [l]. HPCS provides care for patients dying in their homes and support for family or friends, both during the terminal illness and in subsequent bereavement. The service is delivered by eight district teams caring for up to twenty patients at a time in distinct geographical areas of Perth. Each of these teams is headed by an HPCS general practitioner (GP). Medical care may be provided by the patient’s own GP, an HPCS GP, or a combination of both. The nursing staff work on a day, evening and night shift system. During the day nursing care is provided by the home care nurse (district sister) who may visit 2-3 times a day if necessary, and who may have attended to the patient for a long time in the pre-terminal phase of illness. The evening and night nursing sisters of the HPCS team visit to provide regular and emergency nursing care when the district sister is not on duty. The HPCS liason sister coordinates the work of all who care for the patient (i.e. the district, evening 801
Homecare
Cost-effective
and night sisters), liases with the doctors, is a key person at the regular clinical management meetings, organizes the volunteers when needed, and has a particular responsibility for supporting the family members during the final illness and subsequently. A night special nurse is employed occasionally to be with a patient throughout the night if the patient would otherwise have to go to hospital. Both nurses and doctors can be contacted at all times through a paging system by those in the patients’ homes. This ready availability of nursing and medical help enables appropriate hospice care to be given in the home to all but the most dependent patient. In 1985 HPCS was caring for more than 50% of all patients dying from cancer in Perth. Sixty percent of those cared for died at home. The care provided by HPCS is not exclusive and all HPCS patients receive some care and undergo some investigation in more conventional facilities at various stages of their illnesses. The aim of the present study was to use matched controls to compare the total costs incurred by HPCS patients with the costs of more conventional terminal care. Health services and expenditure during the last 90 days of
802
DENNISGRAYet al.
life were estimated and compared in respect of 98 patients under HPCS and a control group of 98 patients who died without HPCS. The period of 90 days was chosen to avoid the problem of deciding when terminal care begins. METHODS
and opposite sex. In 18 cases it was not possible to match HPCS patients on age and the person whose age was closest to that of the HPCS patient was selected as a control regardless of sex. Among these latter pairs, seven HPCS patients and controls were aged within 10 years of each other and 16 pairs were of the same sex.
Patient selection
Data collection
The factors which decide whether or not a patient is referred to HPCS for care at home are ill-defined and it was not possible to obtain a control group of patients which matched an HPCS group on the basis of selection for home care. Rather, a group of HPCS patients was matched with a group of patients who died in the same year on the basis of site of primary cancer, age and sex. The assumption was made that patients so matched would present similar clinical problems. All of the 98 HPCS patients listed on the Cancer Registry of the Health Department of Western Australia as dying of cancer in 1983 were included in the study, and the control group of patients was also drawn from the Registry. As statutory notification of cancer cases forms the basis of the Registry and do not begin in Western Australia until August 1981 [2], the study groups include only patients diagnosed after that date. There were 885 people on the Cancer Registry who died from malignant neoplasms (International Classification of Diseases, revision 9 codes 140.0-208.9 [3]) in 1983 and who lived in Perth (i.e. the Perth Statistical Division). This is a relatively small number which precluded exact matching on the lesser selection criteria or upon other criteria which might have been deemed desirable. All patients included in the study were Perth residents who died in 1983 and were matched on three digits of the respective ICD-9 codes (86 pairs were matched on four digits). Those potential control patients whose dates of birth were within +5 years of the HPCS patients were considered to be of equivalent age. HPCS patients were matched with the first person whose name appeared on the Cancer Registry who had the same diagnosis and who was of the same age and sex. Seventy-two HPCS patients were thus matched. Age was considered a more important variable on which to match than sex, since disability is related to aging and disability is likely to influence care needs. In six instances where no potential match was available on both age and sex, HPCS patients were matched with the first person of the same age
Data for the study were obtained from a number of sources. From the Cancer Registry, it was possible to obtain cause of death, place of death, survival time from diagnosis and basic demographic data such as age, sex, and place of residence. The Health Department of Western Australia provided information on all public and private hospital admissions and their duration. Similar data for public and private nursing homes was provided by the Commonwealth Health Department. HPCS provided access to records of duration of patient care under the Service. From these sources, complete data on admissions for all patients were available. When considering the settings in which care was provided, it is important to recognize that they are not exclusive and that, for example, a person might have received some care in both public and private hospitals as well as from HPCS. Data on investigations and procedures were similarly derived from various sources but were less complete than admission data and in some cases had to be estimated. Four of the five major metropolitan public teaching hospitals in Perth and all of the non teaching public hospitals in which study patients had been treated provided access to relevant medical records. Three nurse research assistants were employed to enter aggregated data from these patient medical records on to standardized recording sheets. Data recorded included number of admissions, hospitals and wards to which patients were admitted and days spent in each, medical and paramedical attendances, and the provision of various investigations, services and procedures. Where applicable, all investigations and procedures were recorded using the appropriate codes from the Commonwealth Department of Health’s Medical Benefits Schedule Book [4], which is a list of medical services and approved fees. The quality of the information in the medical records varied considerably. Whereas there appeared to be virtually complete documentation of investigative procedures, records of atten-
Cost Analysis of Terminal Cancer Care
dances by paramedical personnel were very uneven. For this reason, provision of this category of services is underestimated for both groups of patients. Nineteen HPCS patients and eight controls had been admitted to the nonparticipating public teaching hospital. For those patients, estimates were made of the number of procedures and investigations likely to have been undertaken based on those carried out for similar patients on the other public teaching hospitals. A total of 74 patients had received care in private hospitals. Direct access to the hospital records of these patients was not available. However, a major private health insurance fund agreed to participate in the study. The fund had insured 36 of the private hospital patients-24 HPCS patients and 12 controls. For these patients, the insurance fund provided a list of all services provided in the last 90 days of life for which a claim had been made. In the case of those patients who spent time in public hospitals, the health fund data provided a valuable independent check confirming the accuracy of the procedures employed to extract data from medical records. As direct access was not available to the records of 38 patients in private hospitals, insurance fund data on private hospital patients also provided a basis for estimating the medical services, and investigations and procedures carried out in such institutions. Costing procedure
Although the patients died in 1983 and the services provided relate to this time, the costs in this study were derived on the basis of those current in July-December 1984 in Australian dollars. The largest single group of patients (65 or 33.2%) had been in Perth’s major teaching hospital. The mean cost per occupied bed day by speciality of interest and for that hospital as a whole were derived (Table 1). These costs reflect, among other things, the intensity of nursing care provided in the different wards. The costs for this one hospital were used to
Table 1. Average cost per occupied bed day by speciality (July-December 1984) Specialty
A%
Oncology General medicine General surgery Neurosurgery Extended care
314 293 287 409 250
All specialties
A$316
803
calculate average bed day costs for all patients who had been in other public hospitals (except for a Veterans Affairs hospital which utilizes a different accounting system and which provided an average bed cost per patient day). To facilitate this, scaling factors reflecting the variation in costs among the public hospitals were provided by the Health Department of Western Australia. These scaling factors ranged from 0.82 to 1.34 for the teaching hospitals and 0.48 to 0.67 for the non-teaching public hospitals. The cost of items of service which could be and were attributed to particular individual patients, i.e. pharmaceutical and paramedical services, investigations, and operative procedures were excluded from the calculation of bed-day costs and separately measured. Allowance for the capital depreciation of public hospital buildings is specifically excluded from public hospital accounting and this is estimated by State Health Department personnel to understate the “true” cost per day by approximately 4-5%. Therefore the bed day costs within the public hospital were multiplied by a factor of 1.04. The result was a figure which included nursing, domestic, food, linen and engineering services, and an administrative component. In the case of the teaching hospitals, but not the non-teaching public hospitals, the result also included the cost of medical services. Records of medical attendances in the public non-teaching hospitals were generally incomplete and the best estimate of the cost of these came from insurance fund data. The mean cost of both general practitioner ($2.99/day) and specialistconsultant (%2.69/day) attendances were based on eight patients who spent time only in nonteaching public hospitals. These values, which are likely to be an underestimate, were added to the bed day costs derived for each non-teaching public hospital and applied to the number of days that the total 19 of the patients spent in these hospitals. Access to the running costs of each of the private hospitals was not available. Consequently, the amount per day charged to patients at one of the smaller private hospitals ($120) plus the Commonwealth Government’s daily bed subsidy ($30)-a total of $150/daywas applied to each of the 13 private hospitals in which study patients had been treated. Due to the small size of the hospital from which the basic cost was derived, this procedure probably underestimates total expenditure. As in the case of the non-teaching public hospitals, the mean
804
DENNISGRAYet al.
derived cost of $150/bed day includes nursing but not medical services. However, one health insurance fund provided data on the medical services provided to seven of its clients who had been in private hospitals and who were in the study group. For these patients, the mean daily cost of general practitioner visits was $7.43/day and for specialist-consultant attendances, $9.18/day. These amounts were added to the basic bed day cost to give a total of $166.81 per bed day in private hospitals. Data was not available from other insurance funds for the remaining 31 patients who had spent time in a private hospital. Therefore, the $166.81 per bed day was used to calculate the cost of private hospitalization for all 38 patients who had been in private hospitals. Fourteen patients-three HPCS patients and eleven controls-had been admitted to ten different nursing homes. Five of these were public homes and the Health Department of Western Australia provided average occupied bed day costs for each of them. No information was available to us on the bed day cost of the five private homes. It is assumed, however, that the operating cost of such institutions would not differ greatly from those of the public nursing homes. Thus, the mean occupied bed day cost of the public homes-$55.58-was used to estimate expenditure for the private nursing home patients. This figure is an underestimate, because it does not include the cost of medical services provided to nursing home patients. Medical costs could not be included as no medical record data was available from the nursing homes and too little was available from the health insurance data to make a confident estimate of such services. Control patients spent more than twice as many days in nursing homes as did HPCS patients. Therefore the exclusion of medical costs in nursing homes from the estimates of total expenditure underestimates control patient costs relative to HPCS patient costs. Hospital accounting systems do not allow the derivation of unit costs for each particular service provided. A small study was undertaken which indicated it would be appropriate to utilize the Medical Benefits Schedule fees as the best approximation of expenditure on such services. In costing, the numbers of each particular service provided were multiplied by the scheduled fees. In the case of the non-participating teaching hospital the mean cost of services per day provided in the other teaching hospitals to
study patients was derived and multiplied by patient days of hospitalization. Similarly, health insurance records were used to calculate a mean cost of services per day in private hospitals and these were applied to patients in those hospitals for whom medical records were not available. The mean cost of services per patient which were derived in this way have been grouped according to the broad categories utilized in the Medical Benefits Schedule Book and are presented in Table 7. As previously indicated medical care under HPCS may be provided by an HPCS doctor, a patient’s own general practitioner, or by a combination of both. Visits by private general practitioners are not recorded in HPCS nursing records which consequently understate the provision of medical care. To overcome this limitation the cost of medical care was calculated by taking the mean number of medical visits, both the HPCS and private practitioners (obtained from a previous study [SJ) and costing it at $22.53 per visit. This figure was derived by taking the ratio of home visits of varying duration both “in” and “after” hours provided to the insurance fund patients-this being the only source of information available to us on general practitioner visiting-and applying appropriate Medical Benefits Schedule fees. All home nursing in Perth is carried out by the one organization, of which HPCS is a part. It is possible that some patients in the control group received daytime nursing care at home. As this would have been a small part of a busy district home nurse’s case load it was not possible to identify it separately. Any cost would have only marginally increased the total cost of care of the controls. The costs for HPCS nursing services were calculated by taking the salary costs for each category of nurse and the total central costs which included administration, counselling, transport, education, and the organization of volunteers. These central costs were distributed equally between the categories of nurse. For each such category, the number of visits were totalled and a cost per type of visit derived (see Table 6). During the period July-December 1984, which was used as the basis for all costs in the study, the costs per type of HPCS nursing visit were exceptionally high. This was because at that time the work load per nurse employed was low due to the expansion of the service and the need to train nursing staff after employment had commenced. This bias inflates the cost of HPCS care. As a conse-
805
Cost Analysis of Terminal Cancer Care Table 2. Causes of death
Cancer causing death Lip, oral cavity, pharynx Digestive organs, peritoneum Respiratory and intrathoracic organs Bone, connective tissue, skin, breast Genitourinary organs Other and unspecified sites Lymphatic and haematopoietic tissue Totals
quence a corrected costing of HPCS services was undertaken based on nursing workloads after the service had been established for 12 months. The services provided to patients by general practitioners outside of hospitals, nursing homes or HPCS care are not included. The impossibility of locating all the general practitioners who provide care and then obtaining permission for access to their records precluded incorporating such costs into the study. Also excluded are hospital out-patient visits and the use of ambulance services. The data obtained on these was of varying quality. Drug costs were also excluded from the costing of both HPCS patients and controls. The decision to exclude drug costs was made because of the multitude of separate items, the lack of information on dispensing and packaging costs of the drugs, and the lack of completeness in the recording of drug use in both groups. Appendix A summarizes the costing procedures employed. RESULTS
The mean age of the study group was 63.3 years (range 3-92; SD 14.9) males outnumbered females by a ratio of 1.8 : 1. This reflects the fact that breast cancer is the commonest cancer in women and has a longer survival time than the period of 28 months covered by the study. This resulted in few women with breast cancer being in the study. There was no statistically significant difference in marital status between the HPCS and control patients. Fifty percent of each group were married or living in de facto relationships and roughly equal proportions within each group fell into the single, widowed and separated or divorced categories. While it was not possible to match patients in terms of suburb of residence, it was possible to compare the postal districts from which they were drawn
ED-9 code
Study patients n = 196 %
14&149 15cN59 16165 170-175 1799189 19c-199 20&208
3.1 37.7 25.5 4.1 14.3 10.2 5.1 100
in terms of the percentage of people aged over 15 who, at the 1981 census, had an annual income in excess of $15,000. According to Houghton [6] this provides an accurate guide to the social status of particular suburbs and this was used as a proxy measure of the socioeconomic status of individuals. Using this procedure, no statistically significant status differences between HPCS patients and controls were found. Table 2 indicates the major sites of cancer among patients within the study group. As is to be expected given the means of entry onto the Cancer Registry and the short period in which it has been operating, there is a high proportion of those suffering from more acute cancers or cancers in which survival time is relatively shorter. Since no cancers which had been diagnosed more than 28 months before death were included in this study and since the controls were matched by site of cancer and age it was to be expected that the mean survival time from diagnosis to death would be similar for the HPCS patients and their controls. However, the HPCS patients had a mean survival time nearly 100 days longer than the control group (292 vs 194 days). Between the time of diagnosis and death, people with cancer spend much time at home. However, although some die there, most are admitted to an institution to die. The 98 study patients receiving HPCS care were referred to the service at differing stages of their illnesses, with 59% of them dying at home; the others being transferred to a hospital or nursing home a variable number of days before death. This compares with only 16% of the control group who died at home. Although the HPCS patients survived significantly longer, they spent less time in hospital after the time of diagnosis. The ratio of days in hospital to days survival (Table 3) shows
806
DENNRGRAYet al. Table 3. Characteristics of institutional admissions Admissions Means length of admission (days) during which death occurred* Mean number of institutional days in last 21 days of life Mean number of institutional days in last 30 days of life Mean number of institutional days in last 90 days of life Total institutional days from diagnosis to death Mean number of days survival from diagnosis Ratio of institutional days to survival days
HPCS n =98
Control n =98
8.7
17.5
4.7
F
Sig.
9.8
20.803
0.000
6.5
12.3
15.166
0.000
18.8
28.4
8.265
0.005
49.8
57.1
0.696
0.405
291.6
193.7
13.565
0.000
1:5.9
1:3.4
*Refers only to the 40HPCS and 82 control patients dying in an institution.
this clearly. The most significant differences in days of institutionalization occurred in the last 30 and 21 days of life. It was also in these periods of time that greatest use was made of HPCS services. In Table 4 a comparison is presented of the total number of days spent in various institutions by HPCS patients and controls during the last 90 days of life. With the exception of time spent in private hospitals which was greater for the HPCS patients, the controls spent more time in all institutions and overall the controls spent an average of 9.6 days longer in institutional care. The total bed day cost of this care is shown in Table 5 which also shows that the mean cost per control was $1793 greater than that for the HPCS patients. The mean period of time patients spent under the care of HPCS was 38.8 days. The mean number of nursing and medical visits provided to each HPCS patient is presented in Table 6. It is important to note that these services are not distributed evenly over the whole of the period under HPCS care. The majority of services are provided during a period of intensive nursing care in the last days before death. The mean length of this period is 12 days. When this period of time is added to the number of days
of institutional care (18.8) received by HPCS patients, the mean number of days per patient under intensive nursing and medical care is 30.8. This is only slightly more than the 28.4 days spent under institutional care by the controls and the difference is not statistically significant. Two castings of HPCS care are presented in Table 6. As indicated in the discussion of costing procedures, the first of these is based on 1984 costs. However, for the reasons given, the mean cost per patient of $2958 is likely to be an overestimate of HPCS costs. The correct costing is based on nursing workload under established conditions in 1985. The mean cost per patient of $2080 calculated on this basis is believed to be a more accurate reflection of the “true” cost of HPCS care. The data presented in Table 7 indicate that the ratio of expenditure on procedures and investigations to the total cost of institutional care is similar in the two groups. This suggests that the extra time spent in hospital by the control group is not just for nursing care. Rather when dying patients are admitted they receive a similar number of investigations and procedures as they did in earlier stages of their disease. When the cost of HPCS care based on the
Table 4. Days of institutional care during the last 90 days
Table 5. Cost of days of institutional 90 days of life
care during last
HPCS patients Total
Control patients Total
266,722 9036 88,970 7281
445,226 20,261 66,644 15,618
A$372,009 AS3796
A%547,749 A$5589
of life Place of care
HPCS patients Total
Control patients Total
Place of care
Teaching hospital Other public hospital Private hospital Nursing home
1105 68 534 131
1872 229 400 281
Teaching hospital Other public hospital Private hospital Nursing home
Totals Mean/patient
1838 18.8
2782 28.4
Totals Mean/patient
Cost Analysis of Terminal Cancer Care
807
Table 6. Mean HPCS costs per patient during the last 90 days of life 1984 costing Type of visit
X Visit@?
Liason sister District sister Evening sister Night sister Night special sister Medical practitioner
16.3 12.7 15.0 13.0 1.9 12.0
Corrected costing
Cost/visit
x cost/Pt
Cost/visit
X Cost/Pt
66.82 8.81 43.25 42.94 149.50 22.53
1090 112 649 559 278 270
35.61 8.81 23.83 37.45 144.01 22.53
580 112 357 487 274 270
Total
A$2958
1984 figures is added to the cost of institutional care, the mean cost per patient for the HPCS group was $7355. This was $853 more than the mean cost per patient of $6502 among the controls. However, it is important to note that one way analysis of variance revealed that this difference was not statistically significant (F = 1.27 p = 0.26). If the corrected costing of HPCS care is employed, the mean total cost of care per HPCS patient totals $6477 and is slightly less than the mean of $6502 expended on care for the control group. Again, however, this difference is not statistically significant. These figures are summarized in Table 8.
DISCUSSION
Hospice studies in the United States have suggested that the costs of home based hospice care are lower than for conventional carealthough in some cases this is dependent upon the period over which care is given [7-91. However, there have been methodological problems with these studies which include lack of control
AS2080
Table 8. Mean cost of care per patient during last 90 days of life HPCS patients 1984 costing AS7355
HPCS patients adjusted costing
Control patients
A$6477
A$6502
for the medical care required and bias in patient selection [lO-121. The present study has compared the costs of a group of home care hospice patients with a control group matched on medical criteria, age and sex. Furthermore, the fact that there was no difference in either marital or socioeconomic status suggests that in broad terms there were no differences in the amount of home based support and that there were no financial constraints upon the selection of care by either group. Essentially, hospital costs can be broken down into two major components, bed day costs and services, procedures and investigations; with the former accounting for the greatest proportion of total costs. Given the availability of accurate data for all hospital and nursing home admissions, the detailed data on public
Table 7. Summary of mean institutional costs per patient during last 90 days of life Control
HPCS Service Institutional bed Paramedical Anaesthetics Miscellaneous Pathology* Radiology Radiotherapy Computerized axial tomography Operations Nuclear medicine
Item No.
%
401-564 770-998 10062174 2502-2859 2861-2941
3796 12 26 62 194 91 30
5589 19 42 115 304 128 19
85.9 0.3 0.6 1.8 4.7 2.0 0.3
2960-297 1 3004-8683 8700-8850
37 125 24
0.8 2.8 0.5
46 192 48
0.7 3.0 0.7
*Includes haematology, chemistry, pathology and cytology. w--E
AS
86.3 0.3 0.6 1.4 4.4 2.1 0.7
Total
CD
%
AS
AS4397 microbiology,
AS6502 immunology,
histo-
808
DENNISGRAYet al.
hospital costs provided by the Health Department of Western Australia, and the broad comparability of non-teaching public hospital and private hospital costs, we contend that the bed days costs presented have a high degree of accuracy. The same holds true for the cost of HPCS care. The accuracy of the costing of services, procedures and investigations varies. With one exception, those for teaching hospital patients and patients for whom medical insurance data were available are quite accurate. However, in the case of patients from the non-participating teaching hospital and some private hospital patients, costs of services, procedures and investigations had to be estimated from data available for other study patients. Furthermore, provision of paramedical services was underrecorded and no basis was available for estimating the cost of medical services provided in nursing homes. Some of these factors, including the absence of nursing home medical services, and the deliberate policy of undercosting rather than overcosting hospital care whenever there was a choice of costing assumptions, tend to result in an underestimation of control patient costs. However, due to the fact that services, procedures and investigations comprise a relatively small proportion of total costs we believe that on balance such gaps in the data are likely to have had only minor effect on the outcome of the study. Considerable discussion was undertaken with an independent advisory committee appointed by the Cancer Foundation of Western Australia and staff of the Health Departmnent of Western Australia to ensure that the costing procedures employed were appropriate. Under the circumstances, we believe that the results presented are the most reasonable available. Over the last 90 days of life the control group had a mean of about 10 days more in hospital than did the HPCS group-28.4 compared to 18.8. The mean number of days of intensive nursing care for HPCS patients at home, i.e. regular 24 hour nursing care, was 12 and it is reasonable to suggest that HPCS patients would have been in hospital for this care if HPCS had not existed. Within the 90 day period, the total expenditure on health care was similar for both the home care patients and the controls. That is, a mean cost per HPCS patient of either $7355 or $6477 (depending upon the assumptions made in costing HPCS care) vs a mean cost of $6502 per control patient.
It is not clear why the HPCS patients had a longer survival time than the controls. It is possible that patients are more often selected for referral to HPCS when the progression of the disease prior to the terminal phase has been slower. However, as indicated, there was no difference between the two groups in requirements for medical and nursing care in the last 90 days, so that it cannot be argued that the terminal phase of disease was more acute in one group of patients than in the other. Clearly, though, there was a difference between the two groups of patients which was not matched in the selection of the control group. Consideration was given to the hypothesis that, as a consequence of their shorter mean survival time, the controls might have undergone intensive forms of investigation and treatment during their last 90 days of life which the HPCS patients had received prior to that period. As it was not possible to test this hypothesis by comparing costs of care in the last 90 days with the total cost of care, the converse situation was considered. The 27 control patients who had survived for a period equal to or longer (R = 326) than their HPCS counterparts (x = 158) were selected and their costs during the last 90 days of life compared with those of the HPCS matches. This comparison revealed that there was no significant difference in total costs between the two groups. Furthermore, there was again no significant difference in the ratio of the cost of investigations and procedures to institutional bed day costs. These results support our contention that while survival time may have been a factor in the choice of terminal care it was not a factor which significantly influenced the cost of care among patients in the study. The clinical manifestations of cancer were essentially the same, they required similar treatment and resulted in similar expenditure on care. In 1983, 1624 people from the Perth Statistical Division died from cancer. However, because many of these had been diagnosed prior to its establishment, only 855 were listed on the Cancer Register. On the Register, there was an under-representation of people suffering from cancers in which survival time is relatively long such as female breast cancer and a greater proportion of people suffering from more acute cancers or cancers in which survival time is relatively short-such as, respiratory cancer, brain cancer, and disseminated unspecific cancers. The results of the present study are therefore strictly generalizable only to patients with
809
Cost Analysis of Terminal Cancer Care
patterns of illness clinically similar to those among this latter group. It has been shown that there is considerable variation in the services provided by hospices [ 121and that one of the determinants of hospice costs is the value of services utilized [9]. As indicated in Table 6, the level of services provided by HPCS is relatively high. Although the cost of HPCS would be reduced by decreasing the number and/or duration of home visits, those involved in HPCS believe that such levels of service are necessary to ensure quality of patient care. While there was little difference in the expenditure required to care for the HPCS and control patients, the real saving to third party expenditure made possible by HPCS is any decrease in the necessary provision of hospital beds for the expected future increase in the number of deaths from cancer. This is of major significance in Western Australia where the population is aging and where the proportion of all deaths due to cancer is expected to rise from 20% in 1984 to 25% within 10 years, thus increasing the demand for terminal cancer care. When comparing the costs of any new service with that of an established service two elements need to be identified; that of substitution or replacement of what previously existed and that which represents additional services not previously provided. A new service cannot be justified on replacement grounds alone. In the case of HPCS these elements are inseparably entwined. As compared to hospice care, the hospital in-patient care of dying persons, however devoted the clinical staff, puts no comparable emphasis on support for the family during terminal illness, nor in the subsequent bereavement period. Much of an HPCS sister’s work, especially that of the liason sister which is particularly expensive, is spent with the relatives of the patient for which there is no hospital equivalent. This is assumed to have a direct positive influence on the patient’s well-being. This assumption is supported by the strong consumer demand for hospice care from both patients and their familes. Furthermore, the great growth of the hospice movement suggests that the quality of life for patients dying under hospice care is as good or better than that available elsewhere. The controlled studies by Morris et al. [8] which showed no better quality of life for hospice patients has been criticized by Mount and Scott [lo] on the grounds that the quality indices used in the studies do not reflect
the real issues and perceptions of patients in the terminal phase of disease. Further doubt on the validity of the indices of quality used by Morris et al. is found in the study by MacAdam and Smith [13]. In seeking to evaluate the effectiveness of hospice care, this factor of quality is of equal if not greater importance than expenditure. No attempt was made in this study to cost or compare the role of family or friends. During their last illness those in the control group spent 3.4 days at home for every day in hospital, and those under HPCS spent 5.9 days. In both groups any calculation of the total cost as distinct from third party expenditure would have to include the time and energies spent by family and friends in the home and in daily visiting to hospital. A previous study of HPCS patients showed that 64% were cared for at home by their spouse and 18% by siblings [5]. A U.S. study reported a significant emotional burden on families of patients caring for a dying member at home, but also reported that these family members did not regret their decision to nurse their relative at home [8]. CONCLUSIONS
This study has shown that it can take as much professional effort and cost to provide terminal care in the home as to continue to pursue treatment in hospital. Hospice care is labour intensive and will never be cheap for that reason. It is not surprising that the costs will be high when such a service is taken to a patient’s home. This study examined the comparative costs to a third party when 24 hour availability of skilled nursing and medical care is provided at home to terminal cancer patients with clinical problems comparable to those managed in acute hospitals. It shows that the costs of the service are no greater than if the patient had gone to hospital. However, for the same money the general practitioner based HPCS is also able to provide the full benefits of a hospice service previously not available. Acknowledgements-Funding for this study was provided by the Cancer Foundation of Western Australia Inc. Vahrable assistance and advice was also provided by a scientific advisory committee appointed by the Cancer Foundation: Associate Professor B. K. Armstrong, Dr C. Bower, Mr C. Deverall, Associate-Professor MST. Hobbs, Dr C. D. J. Holman and Mr P. Schapper. Preliminary discussions with Dr Francis Cunningham and her colleagues in the Commonwealth Department of Health assisted in the design of the protocol for the study. The Health Department of Western Australia made available data from its Cancer
DENNISGRAYet al.
810
Registry and MS M. D. Clarke-Hundley provided a great deal of assistance in accessing those data. Mr La1 Perera of the Financial and Administrative Services Division of Sir Charles Gairdner Hospital provided help with the costing of services.
6.
I.
8.
REFERENCES 1. MacAdam DB: The Development of the Hospice Palliative Care Service in Western Australia. Cancer Foundation of Western Australia, Perth, 1985. 2. Hatton WM, ClarkeHundley MD Cancer in Western AustraIIa:An Analysis of Age and Sex Specific Rates. Perth: Health Department of Western Australia, 1984 3. World Health Organisation: International Clasaification of Procedurea in Medicine. Geneva: World Health Organisation, 1978 Department of Health: Medical 4. Commonwealth Benefits Schedule Book. Canberra: Government Printer, 1984 5. MacAdam DB: A review of 715 terminal patients
9. lo. 11.
12. 13.
APPENDIX
cared for at home by a hospice palliative care service. Cancer Fomm 9:3, 1985 Division of National Mapping & Australian Bureau of Statistics: Perth: A social Atlaa. 1981 Cenana. Canberra: DNP & ABS, 1984 Brooks CH, Smyth-Staruch K: Cost Saw of Hospice Home Care to T&I-Party Insurers. Cleveland: Case Western University, 1983 Morris JN, Suissa S, Sherwood S, Wright SM, Greer D: Last days: a study of the quality of life of terminally ill cancer patients. J Cbron Dis. 39: 4762, 1986 Bimbaum HG, Kidder D: What does hospice cost? Am J Public HeaIth 74: 689-697, 1984 Mount B, Scott JF: Whither hospice evaluation? J Chron Dis 36: 731-736, 1983 Mor V, Hiris J: Determinants of site of death among Hosnice Cancer Patients. J Health Sot Rehav 24: 375-385, 1983 Torens PR: Hospice care: what have we learned? Ann Rev Public Health 6: 65-85. 1985 MacAdam DB, Smith M: An mitial assessment of suffering in terminal illness. Palliative Medicine, 1: 31-47, 1987
A
Outline of Costing Approach
Service
Source of unit cost
Comments
Actual figures from major teaching hospital, with overall correction factor reflecting average cost/day variations.
Assumes cancer patient is typical of average patient by specialty.
Included in l(a) Insurance fund data.
Likely to be underestimates.
Scheduled fees.
Possible overestimate of cost.
(a) Average bed day costs (excluding items of service, and medical attendances).
Estimated from daily charge levied by one of the smaller private hospitals, plus daily bed subsidy.
Possible underestimate.
(b) Medical attendances. (c) Average cost of services per day.
Insurance fund data. Insurance fund data.
1. Public Hospitals (a) Bed day by specialty (excluding various items of service). (b) Medical attendances -teaching hospitals -non-teaching hospitals (c) Items of service excluded from l(a) (e.g. investigations, operative procedures, paramedical services). Private Hospitals
Nursing Homes
Average bed day cost.
Health Dept of W.A. (applicable to public nursing homes and assumed to be the same for private nursing homes).
Excludes the provision of medical services.
HPCS Nursing Services
Cost per visit
HPCS records and accounts, with a correction for changes in nursing workloads.
GP Visits
(a) Under HPCS. (b) Outside HPCS and hospitals.
Estimated from data from a previous study. Excluded.
Note: Excluded from the costing procedure were the following: general (non-HPCS) home nursing visits, use of ambulance services and drugs.