Resource utilization for ovarian cancer patients at the end of life: How much is too much?

Gynecologic Oncology 99 (2005) 261 – 266 www.elsevier.com/locate/ygyno

Resource utilization for ovarian cancer patients at the end of life: How much is too much? Sharyn N. Lewin a, Barbara M. Buttin a, Matthew A. Powell a, Randall K. Gibb a, Janet S. Rader a, David G. Mutch a, Thomas J. Herzog b,* b

a Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA Division of Gynecologic Oncology, Columbia University School of Physicians and Surgeons, 161 Ft Washington Avenue, New York, NY 10032, USA

Received 25 February 2005 Available online 2 September 2005

Abstract Objective. End-of-life (EOL) medical care consumes 10 – 12% of national health care expenditures and 27% of Medicare dollars annually. Studies suggest that hospice services decrease EOL expenditures by 25 – 40%. The goal of this study was to compare the total cost of hospital-based resources utilized in ovarian cancer patients during their last 60 days of life for those enrolled in hospice versus those not on hospice. Methods. Study eligibility included patients who expired from ovarian cancer from 1999 to 2003. Medical records were reviewed for demographic data as well as treatment, response and recurrence rates, histologic type, grade and stage. Billing records were analyzed for costs of inpatient and outpatients visits, including radiologic, laboratory and pharmacy charges. Total cost of hospital resources was compared between patients managed on hospice for >10 days (hospice group) versus <10 days (non-hospice group) using the following methods: Mann – Whitney U, Kruskal – Wallis and Student’s t tests. Overall survival was compared using Kaplan – Meier statistics. Results. Of the 84 patients analyzed, 67 (79.8%) were in the non-hospice group and 17 (20.2%) were in the hospice group. Demographic, histologic and staging characteristics as well as platinum sensitivity were similar between the two groups before the last 60 days of life. Mean number of chemotherapy cycles before the study period was also similar (20.4 and 21.0, respectively). However, during the study period, the mean total cost per patient in the non-hospice group was $59,319 versus $15,164 in the hospice group ( P = 0.0001). A significant difference in cost was noted for mean inpatient days ($6584 vs. $1629, P = 0.0007), radiology ($6063 vs. $2343, P = 0.003), laboratory ($12,281 vs. $2026, P = 0.0004) and pharmacy charges ($13,650 vs. $4465, P = 0.0017) as well as for treating physician per patient ($112,707 vs. $34,677, P = 0.04). Overall survival for the two groups was the same. Conclusions. Our findings demonstrate that there is a significant cost difference with no appreciable improvement in survival between ovarian cancer patients treated aggressively versus those enrolled in hospice at the EOL. These data suggest that earlier hospice enrollment is beneficial. Furthermore, cost variations between physicians and patients imply that education may be an important variable. D 2005 Elsevier Inc. All rights reserved. Keywords: Ovarian cancer; Resource utilization; End of life; Costs; Hospice care

Introduction Over the past decade, national attention has focused upon rapidly escalating health care costs. This is particularly poignant given the limited pool of financial resources coupled with expensive novel medical technologies and a * Corresponding author. Fax: +1 212 305 3412. E-mail address: [email protected] (T.J. Herzog). 0090-8258/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2005.07.102

growing elderly population. Rising health care costs have sparked a surge of literature regarding the economics of health care. However, literature regarding the costs of caring for terminally ill patients at the end of life (EOL), particularly with advanced cancer, remains sparse. Ovarian cancer accounts for more deaths than any other gynecologic malignancy. An estimated 25,600 new cases will be diagnosed in the United States, and 16,100 deaths will ensue in 2004 alone [1]. Patients with advanced

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ovarian cancer are living longer with aggressive cytoreductive surgery and the availability of a rapidly expanding menu of chemotherapeutic agents. However, most patients with recurrent progressive ovarian cancer embark on a slow but steady decline in functional status at the EOL. During that time, it is often difficult for physicians and families alike to recognize when further aggressive treatment measures are futile rather than beneficial. Physicians caring for such patients are then faced with the decision whether to continue treatment or offer the patient hospice care. Not surprisingly, significant differences in patient management can be found between individual physicians and patients at the EOL. The goal of this study was to compare the total cost of hospital-based resources utilized in ovarian cancer patients during their last 60 days of life for those managed mostly on hospice versus those not enrolled in hospice. We also set out to determine what factors are influential in the decision to manage patients on hospice versus aggressively and whether any of the interventions at the EOL contributed significantly to prolonging survival and/or improving patients’ quality of life.

Materials and methods Study approval was obtained from the Washington University School of Medicine Human Studies Committee. The study population was comprised of patients who had received the majority of their treatment at Barnes-Jewish Hospital for ovarian cancer who expired between 1999 and 2003. Hospital and office records were reviewed for demographic data as well as initial treatment regimen, response and recurrence rates, histologic type, grade and stage. Patients’ age at diagnosis and at death were identified. The total number of chemotherapy cycles and regimens used during the patients’ disease course were collected. Date of death was determined from death certificates. Billing records were analyzed during the 60 days prior to death for the cost of all inpatient and outpatient visits. Costs were categorized into radiologic, laboratory, pharmacy and operating room charges as well as inpatient room/care and critical care costs. Miscellaneous hospital charges, including nursing care, housekeeping costs and physical, occupational and respiratory therapy charges were similarly obtained. The duration of inpatient admissions, including the length of intensive care unit (ICU) stays, was recorded. The number of outpatient visits, for physician appointments and chemotherapy administrations, was obtained. The length of hospice enrollment, if applicable, was noted. Patients were divided into two groups based on their length of hospice enrollment during their last 60 days of life, defined as the study period. The patients managed on hospice for greater than 10 days during this time formulated the hospice group, and those enrolled for less than 10 days encompassed the non-hospice group. The Mann –Whitney

U and Kruskal – Wallis tests aided in analyzing the itemized and total costs of hospital-based resources utilized during the last 60 days of life. The Student’s t test then compared factors between the two groups. Overall survival was compared using Kaplan – Meier statistics.

Results Eighty-eight patients fitting enrollment criteria expired from ovarian cancer during the years 1999 –2003. Four patients were excluded from further analysis as death occurred shortly after diagnosis from other medical comorbidities. Sixty-seven patients (79.8%) spent less than 10 days enrolled in hospice during their last 60 days of life (the non-hospice group). Seventeen patients (20.2%) were enrolled in hospice for greater than 10 days during their last 60 days of life (the hospice group). Demographic, histologic and staging characteristics were similar between the two groups, as illustrated in Table 1. The mean age at diagnosis was 58.4 years in the nonhospice group, compared to 61.3 years in the hospice group ( P = 0.399). The majority of patients in each cohort had Stage IIIC or IV disease at initial presentation: specifically, 62 of 67 patients (92.5%) in the non-hospice group and 16 of 17 patients (94.1%) in the hospice group. Papillary serous adenocarcinoma was the predominate histology type within each cohort. The majority of patients in each group were white, 86.6% compared to 100%, in the non-hospice and hospice groups, respectively. The mean number of chemotherapy cycles prior to the last 60 days of life per patient was 20.4 in the non-hospice group and 21.0 in the hospice group ( P = 0.841). All patients analyzed were initially treated with platinum-based chemotherapy. Various second-line agents were utilized once disease recurrence was detected. The number of patients with platinum-sensitive versus platinum-resistant disease was similar between the two groups ( P = 0.158). During the last 60 days of life, patients aggressively managed (non-hospice group) were hospitalized a mean of 11.2 days (range 0 to 40 days), while those in the hospice

Table 1 Patient demographics and disease characteristics Characteristic

Non-hospice

Hospice

Total eligible patients Age at diagnosis, years

67 (79.8%) 31 – 87 (mean 58.4) 36 – 92 (mean 61.3) 62 (92.5%) 32 (47.8%) 58 (86.6%) 0 – 66 (mean 20.4) 25 (37.3%)

17 (20.2%) 43 – 82 (mean 61.3) 45 – 85 (mean 63.5) 16 (94.1%) 8 (47.1%) 17 (100%) 0 – 53 (mean 21) 5 (29.4%)

Age at death, years Stage IIIC or IV Papillary serous histology Caucasian race # Chemotherapy cycles before study period, per patient # Platinum-resistant patients

P 0.399 0.456

0.841 0.158

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group spent a mean of 3.6 days as inpatients (range 0 to 23 days; P = 0.005). Twelve patients out of 67 in the nonhospice group had intensive care unit (ICU) stays, ranging from 1 to 22 days in duration. The leading causes for ICU transfers were respiratory failure in six patients and sepsis in five patients. No patients in the hospice group had ICU admissions during the study period. Seventeen patients incurred operating room expenses during their last 2 months of life, 16 of whom were in the non-hospice group. Ten of these patients underwent surgical procedures for large and small bowel obstructions. The number of outpatient visits, for chemotherapy administrations, office appointments, etc., was similar between the groups, mean per patient 3.5 and 2.8, respectively ( P = 0.513). The cost of all medical care during the last 60 days of life between the two groups is highlighted in Tables 2 and 3. The mean cost per day was $969 per patient in the nonhospice group compared to $333 per patient in the hospice group ( P = 0.0011). The cost of inpatient care was significantly higher in the non-hospice group. The mean cost per patient for room and inpatient care was $6584 (range $0 –$42,404) in the non-hospice cohort compared to $1629 (range $0 – $10,550) in the hospice cohort ( P = 0.0007). Similarly, a striking difference was noted between ancillary hospital charges, including nursing care, housekeeping costs and physical, occupational and respiratory therapy charges. The mean cost for these services per patient was $6956 (range $0– $47,121) in the non-hospice and $596 (range $0– $3212) in the hospice cohorts, respectively ( P  0.0001). These dramatic cost variations reflect the differences in duration of inpatient care between the two groups. As is demonstrated in Table 2, a dramatic difference in cost was noted per patient within each cohort. The mean cost per patient for radiology services was $6063 (range $0 –$19,350) in the non-hospice compared to $2343 (range $0 –$11,372) in the hospice group ( P = 0.003). Radiology services included imaging studies, such as computed tomography (CT) scans, ventilation – perfusion studies, X-rays, ultrasounds, echocardiograms and magnetic resonance imaging examinations. The mean cost per patient for laboratory services in the nonhospice group was $12,281 (range $0– $119,165) and in the

Table 2 Hospital-based resources utilized per patient during the last 60 days of lifea Hospital-based resource

Non-hospice

Hospice

Inpatient room/care 6584 (0 – 42,404) 1629 Ancillary inpatient 6956 (0 – 47,121) 596 services Radiology 6063 (0 – 19,350) 2343 Laboratory 12,281 (0 – 119,165) 2026 Pharmacy 13,650 (0 – 60,402) 4465 Outpatient services 7854 (0 – 28,259) 3334 Total cost 59,319 15,164 a

P

(0 – 10,550) 0.0007 (0 – 3212) <0.0001 (0 – 11,372) (0 – 13,637) (0 – 26,509) (0 – 19,874)

Mean cost in US dollars, with range included in ().

0.003 0.0004 0.0017 0.033 0.0001

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Table 3 Total cost of hospital-based resources Hospital-based service

% of total

Inpatient care Intensive care unit Total inpatient services Radiology Laboratory Pharmacy Chemotherapy Operating room Outpatient services Total

23 3 (26) 11 21 24 (10) 4 14 100%

hospice group was $2025 (range $0– $13,637) ( P = 0.0004). Laboratory services included routine hematology and chemistry studies as well as blood transfusions. Pharmacy charges for antibiotics, analgesics, routine medications and chemotherapeutic agents were also significantly higher in the non-hospice cohort, $13,650 per patient (range $0– $60,402) versus $4464 per patient (range $0– $26,509) in the hospice group ( P = 0.0017). This was partly due to the significant difference in chemotherapy administration between the two groups. Fifty of the 84 total patients received chemotherapy during their last 60 days of life, 45 patients in the non-hospice group (67%) and 5 patients in the hospice group (7%). As illustrated in Table 4, the non-hospice group received a mean of 1.3 cycles per patient, with a range of 0 – 7 cycles. In contrast, the hospice group received 0.6 cycles per patient, with a range of 0 – 4 cycles. This resulted in a total cost of $414,856 for chemotherapy treatment, 42% of the pharmacy charges but only 10% of the overall cost of care during the study period. Patients in the non-hospice group received their last chemotherapy cycle on average 7 weeks before their death. A wide range of last treatment interval was observed, however, from 9 days to 8 months prior to expiration. In the hospice group, the average time from the last chemotherapy treatment to death was 4 months. Of the aforementioned categories, outpatient charges were the most similar between the cohorts. The mean outpatient cost per non-hospice patient was $7854 (range $0– $28,259) compared to $3334 per hospice patient (range $0 –$19,874) ( P = 0.033). Outpatient costs included visits for physician appointments, chemotherapy administrations and various standard outpatient procedures. As depicted in Fig. 1, an analysis of the mean cost per treating physician yielded vastly different results. The mean cost per physician per patient ranged widely from $34,677 to Table 4 Chemotherapy administration per patient # Chemotherapy cycles

Non-hospice

Hospice

P

Before study period (n = 76) During study period (n = 50)

0 – 66 (mean 20.4) 0–7 (mean 1.3)

0 – 53 (mean 21) 0–4 (mean 0.6)

0.841 0.016

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Fig. 1. The average cost difference per patient among the physicians.

$112,707 ( P = 0.04). The average age at death was 61.3 years in the non-hospice group and 63.5 years in the hospice group. Despite significant cost differences between the two groups, overall survival measured by Kaplan –Meier statistics was the same, as demonstrated in Fig. 2. The mean survival was 32.4 months from diagnosis to death in the nonhospice group and 40.8 months in the hospice group ( P = 0.3026). The hospice group spent a mean of 47 days during their last 2 months of life enrolled in hospice, whereas the non-hospice group spent a mean of 0.6 days.

Discussion Ovarian cancer accounts for more deaths than any other gynecologic malignancy. Ovarian cancer is the fifth most common cancer among women and is the fourth cause of all cancer deaths [1]. The majority of patients are diagnosed with Stage III – IV disease and are treated with surgical debulking

and combination chemotherapy with paclitaxel and platinum, with response rates ranging between 60 and 80% [2– 5]. Nearly 80% of these patients will recur resulting in 5-year survival rates of 14 to 32% [2 –5]. Progressive or recurrent disease greater than 6 months from initial treatment can be retreated with platinum-based agents. Response rates range from 27 to 60% with a median survival of 1 year [2– 5]. Patients who recur or progress less than 6 months from initial treatment are considered platinum-resistant and are treated with a number of second-line agents, with response rates ranging from 12 to 30% with a 9-month median survival [5– 8]. Given the nature of recurrent ovarian cancer and the shortlived efficacy of second-line agents, the treatment goals with these agents are predominantly palliative. Although studies addressing health care economics are becoming more prevalent, literature regarding the costs of caring for terminally ill patients at the EOL, particularly with advanced cancer, still remains sparse. EOL care annually consumes 10– 12% of all national health care expenditures [9,10]. Approximately 25 – 27% of Medicare expenditures are spent annually on patients during their last 60 days of life [9,10]. Studies suggest hospice services decrease EOL expenditures by 25– 40% [10,11]. In the United States, no studies to date have evaluated resource utilization in general at the EOL in ovarian cancer patients. Several European and Canadian studies, however, have addressed the resource implications of caring for advanced cancer patients at the EOL. These industrialized nations utilize socialized and nationalized medicine as their modes of health care delivery so a keen emphasis is placed on health care costs and the allocation of resources. One such study from London retrospectively reviewed fifty patients’ charts with advanced breast cancer [12]. These authors

Fig. 2. Survival distribution for the hospice and non-hospice groups.

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evaluated outpatient visits, inpatient admissions, surgical and chemotherapeutic treatments, laboratory and radiologic studies and home care management [12]. Over half of the costs were attributed to inpatient admissions, and the mean treatment cost was 7620 pounds (approximately $15,000) per patient [12]. A Canadian study by Doyle et al. similarly evaluated the resource utilization in advanced ovarian cancer treatment. These researches analyzed the resources utilized from initiating second- or third-line chemotherapy in forty patients until death via a retrospective chart review [13]. The mean cost was $53,000 per patient, with a range between $4800 and $162,900 [13]. Once again, greater than 50% of costs were attributed to inpatient care [13]. Authors of both studies conclude that analyzing the costs of managing advanced and progressive cancer is important to optimize use of limited resources. Strategies to reduce inpatient admissions would not only decrease health care costs, but also potentially improve patients’ quality of life. Financial burdens from cancer management have been shown to reduce quality of life [14]. 87% of cancer patients in one report described large financial hardships from their diagnosis and subsequent treatment [14,15]. An analysis of palliative care costs from home in patients with end-stage cancer from The Netherlands found a 2/3 reduction in health care costs by transferring end of life care from the hospital to the home setting, to say nothing about the intangible costs of home care during this valuable time [16]. In our study, the mean total cost per patient in the nonhospice group was $59,319 versus $15,164 per patient in the hospice group ( P = 0.0001). This average cost of aggressive care during the last 60 days of life was similar to Doyle’s data analyzing mean costs once salvage chemotherapy was initiated. In their study, however, 62% of the total costs were attributed to inpatient care, whereas chemotherapeutic agents accounted for 21% of the total costs [13]. As Table 3 illustrates, inpatient care accounted for only 26% of the total costs in our study. Laboratory and pharmacy expenses each consumed a substantial portion of the total costs, 21% and 24%, respectively. Of the pharmacy charges, only 10% of the total cost of care came from chemotherapeutic agents and their administration. Therefore, a significant portion of our expenditures were allocated to resources which did not impact the disease process itself. An analysis of the mean cost per treating physician yielded strikingly different results. The mean cost per physician per patient ranged widely from $34,677 to $112,707 ( P = 0.04). This large cost difference illustrates that individual practice patterns affect costs. Why, as demonstrated in Fig. 1, did one physician spend so much more per patient? The duration of inpatient care was drastically different and likely accounted for the vast cost differences among the physicians. The $113,000 reflected care for patients who spent approximately half of their last 60 days hospitalized. We illustrate this point as studies have shown that physicians are not well informed regarding

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treatment costs and educating physicians alone has been shown to reduce expenditures [14,17,18]. The costs of home hospice and hospice facilities are noteworthy. Although not specifically analyzed in this study, these services do incur costs to the health care system. In Missouri, the cost for home hospice is approximately $110 per day. This cost includes nursing visits, medications and equipment. Similarly, an average hospice facility charges $150 per day. If a patient, for example, was enrolled in hospice for the entire last 60 days of her life, the total cost would be $6600 for home hospice and $9000 for a hospice facility. These costs are substantially lower than the hospital costs incurred by our patients. A complex and intricate question for treating physicians is predicting when cancer patients are entering the EOL. This is of paramount importance when discussing hospice enrollment and other EOL issues. One recent study by von Gruenigen et al. discussed this issue in ovarian cancer patients [19]. These authors retrospectively analyzed indications for hospitalizations during the last year of life in patients with progressive ovarian cancer to address whether chemotherapy should be continued and whether the EOL was approaching. They discovered a significant increase 6 months before death in the number of hospitalizations for bowel obstructions, pleural effusions and ascites [19]. They concluded that hospitalizations for these serious clinical events should be considered an indication that the EOL is approaching, and further chemotherapy is of little benefit [19]. With this in mind, our next avenue of exploration is to analyze our study population to assess whether these same EOL indicators were present. These clinical indicators and others may signify that cancer patients are entering the terminal phase of life, and thus hospice discussions, rather than aggressive treatment measures, may be most beneficial. Our findings demonstrate that there is a significant cost difference with no appreciable improvement in survival between ovarian cancer patients treated aggressively versus on hospice at the EOL. Although not significant, patients in the hospice group actually lived longer despite decreased interventions and cost. Furthermore, cost variations between physicians imply that educational initiatives aimed at physicians and patients may be an important strategy for cost control. References [1] Jemal A, Tiwari RC, Murray T, Ghafoor A, Samuels A, Ward E, et al. Cancer statistics. CA Cancer J Clin 2004;54(1):8 – 29. [2] Markman M, Rothman R, Hakes T, Reichman B, Hoskins W, Rubin S, et al. Second-line platinum therapy in patients with ovarian cancer previously treated with cisplatin. J Clin Oncol 1991; 9(3):389 – 93. [3] van der Burg ME, Hoff AM, van Lent M, Rodenburg C, van Putten W, Stoter G. Carboplatin and cyclophosphamide salvage therapy for ovarian cancer patients relapsing after cisplatin combination chemotherapy. Eur J Cancer 1991;27(3):248 – 50.

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