Our findings demonstrate that advanced cancer patients who reported EOL conversations with physicians had lower medical costs in their final week of life compared to those who did not, which is largely a function of their more limited use of intensive interventions. In this study, higher health care costs were not associated with better outcomes at the EOL: there was no survival difference associated with health care expenditures, and patients who spent more in insured health care had worse quality of life in their final week of life. These results also support findings from another CwC study that life-sustaining care is associated with worse quality of death at the EOL. 19
One strength of this study is that the matched subjects did not differ in observed variables, including patients' socio-demographic characteristics, cancer type, recruitment sites, treatment preferences, or illness acknowledgment. Additionally, these variables were also examined as potential confounders and were controlled for if they remained significant in the multivariate analyses. Therefore, the results were drawn based upon a well balanced and adjusted study sample.
Our cost estimates may be conservative in terms of the relatively low frequency of intensive medical treatment compared to other studies of advanced cancer patients. For example, our study participants had lower rate of chemotherapy use (6.7% vs. 15.7%) compared to another study; 20
and they were less likely to die in the ICU (4.7% vs. 8.0%) 21
where the highest medical costs are often incurred. Study subjects also had higher rates of hospice use (74.3% vs. 38.8%) and were more likely to die at home (53.8% vs. 37.8%) compared to national averages and other studies. 22, 23
Despite this, and a relatively low power to detect differences in EOL care, our cost estimates yielded significant results.
Because this is an observational study we cannot conclude that there is a causal relationship between EOL conversations and cost differences in the last week of life. Although propensity score matching is one of the most robust methods to correct for selection bias in observables, it cannot account for hidden biases.
Another limitation is that cost estimates were based upon aggregated costs from national averages for hospitalizations, life-sustaining procedures and hospice care instead of medical claims data. Although this method may be viewed as less accurate, our cost estimates are comparable to other studies that used medical claims data.23,24
Like most studies of medical expenditures 2,3, 23,24
which rely heavily on costs covered by insurers or Medicare, this study likely underestimates the total cost of care given that it does not include out-patient services or out-of-pocket expenditures or opportunity costs incurred by patients and their caregivers for additional pharmaceutical and home care payments.
Moreover, the EOL care and patients' quality of life in the final week before death were reported by nurses or informal caregivers. Future research should use a consistent source of reporting of patient's quality of death and examine the way the relationship of the care provider to the patient affects assessment of patient's degree of comfort and quality of care. Additionally, we acknowledge that patients and caregivers may value care differently. Patients may consider extra dollars spent and more life-sustaining care worth the added expense whereas caregivers may devalue life-sustaining care. In addition, exclusion of unmatched subjects from the study may limit generalizability of the results to general population.
Lastly, the health care costs near the end of life rise exponentially. Further research is needed to examine whether the cost difference remains significant or not over a longer period of time close to death. A study following advanced cancer patients longitudinally over the final months of life with paired survey data and claims data to capture monthly measurements of costs might provide a more accurate and dynamic estimate of the impact of EOL conversations on health care costs in the period leading up to the patient's death.
Despite these limitations, our findings suggest a potential strategy for reducing medical care expenditures and improving patients' quality of life at the EOL. If the national proportion of reporting EOL discussions were increased to 50%, our results suggest that we would expect a cost difference of $76,466,891, between individuals who had EOL discussions versus who had not, based upon the total number of US cancer deaths/year. 25
There are several reasons to be cautious about this estimate. The cost differences we observed may decrease when generalized to an older population since medical costs at the EOL decline with increasing age, and the average age in our sample was 59 years. 26
Although propensity-score matching balanced differences among the recruitment sites, our study does not include all geographic areas in the United States which may be particularly important since there are documented regional differences in the intensity of EOL care. 27
Due to a lower rate of acute care and greater use of hospice care in our sample compared to the national population, the cost differences might increase when generalized to other areas with higher use of intensive care.
Nevertheless, our study suggests that increasing communication between patients and their physicians is associated with better outcomes and less expensive medical care. These results are consistent with other studies that have shown that the greatest cost differences come from a reduction in acute care services at the end of life.4, 28
Our study is unique in that it also suggests that these cost deductions are accompanied by a better quality of life for advanced cancer patients at the EOL. Policies that promote increased communication, such as direct reimbursement for EOL conversations, enhanced physician education about EOL communication, expansion of palliative care programs in hospitals and co-management of late stage cancer patients by oncologists and palliative care physicians, may be cost-effective ways to both improve care and reduce some of the rising health care expenditures.