In this study, we compared care at the end of life for elderly NSCLC patients who died of cancer in the United States and Ontario. Both groups used health-care services extensively in the last 5 months of life, particularly during the last month of life. These findings are consistent with earlier studies that have reported high levels of health-care use by cancer patients at the end of life (11
Chemotherapy was given to statistically significantly more SEER–Medicare patients than Ontario patients, with the differences greatest among short-term survivors. The lower rate of chemotherapy use among Ontario patients may reflect differences between Ontario and the United States in patients’ or physicians’ perceptions regarding the benefit of chemotherapy for elderly patients with advanced lung cancer. The US physicians in our study may have been more willing to administer chemotherapy in response to professional societies’ recommendations in the mid-1990s that chemotherapy may benefit a select number of NSCLC patients with advanced disease (26
). In addition, oncologists paid by Medicare can profit from the administration of specific chemotherapy agents whereas oncologists in Ontario do not have a financial incentive to prescribe chemotherapy.
During the last month of life, SEER–Medicare patients had statistically significantly lower rates of hospitalization than Ontario patients. This difference may be attributable to no formal hospice program being available to Ontario patients. More than 58% of SEER–Medicare patients were in hospice during their last month of life. Medicare pays hospices a daily-capitated payment to cover all care related to the patient’s terminal illness and will only provide additional reimbursement for inpatient hospitalizations if the patient’s acuity of care exceeds what can be provided in another setting or for short-term respite care (28
). Because hospices are financially responsible for all other hospital care, they have a strong incentive to keep patients out of ERs and limit hospital use. A previous study of SEER–Medicare colorectal and lung cancer patients reported that only 4% of patients had a hospitalization following enrollment in hospice (2
). We observed that SEER–Medicare patients who were admitted to hospital had ICU admission rates more than double those of Ontario patients. These patients were likely not in hospice because hospice programs would make efforts to avoid expensive ICU services for their patients.
Although there is no formal hospice program in Ontario, we found extensive use of palliative care, especially in the last 30 days when the number of patients per 100 PM receiving community supportive services exceeded 85. Despite the high use of community palliative services, 55% of Ontario patients had a hospital admission during the last month of life. It appears that most Ontario patients who were hospitalized in the last 30 days of life were admitted for supportive care. More than half of all Ontario patients died in hospital, 2.5-fold more than observed among SEER–Medicare patients. A study that evaluated the use of hospital care at the end of life for lung cancer patients in Ontario reported that 90% of Ontario lung cancer decedents who were hospitalized in the 2 weeks before death had a “do not resuscitate” order on their chart (15
The disparity in the number of in-hospital deaths between Ontario and the SEER–Medicare patients may reflect differences in health systems or patient preference regarding care at the end of life. Data from surveys of terminal cancer patients in Canada demonstrate that up to 80% of respondents would prefer to die at home (29
), a perspective shared by their families. However, moving care for dying patients to the home setting can be demanding for family members in terms of physical needs and loss of time from work. Surveys of patients and community-based palliative care providers in Ontario have found that dying patients have experienced unmet needs and challenges in coordinating palliative care (30
). In 2005, the Ontario Ministry of Health established networks to improve the coordination of end-of-life care and shift palliative care from the hospital to home. The impact of the initiative is still being assessed, although it appears that the number of in-hospital deaths and ER visits in Ontario has not changed following implementation of these new programs (32
The type and patterns of health-care use also varied for short- and longer-term survivors. In both SEER–Medicare and Ontario cohorts, rates of patients with ER visits and hospitalizations were statistically significantly higher for short-term survivors than for longer-term survivors, perhaps reflecting a blend of health care for a newly diagnosed lung cancer and services related to the end of life for these recently diagnosed patients. The higher rates of ER visits and hospitalizations observed across all months for Ontario short-term survivors relative to Medicare short-term survivors may reflect differences in the two groups in terms of the time it takes to access the needed care. This explanation is supported by the fact that rates of ER visits and hospitalizations were similar for Ontario and SEER–Medicare longer-term survivors in months 3–5 before death. Longer-term survivors may have had time to organize support services, arrange for experienced caregivers, and be referred to palliative care. A recent study that examined the reasons that terminal cancer patients in Ontario went to the ER concluded that many of the visits may have been avoided with comprehensive and coordinated palliative care and better symptom control at home (33
The differences we observed in patterns of health-care use between elderly lung cancer patients in the United States and Ontario are likely to extend to the total costs of care. Because of many differences in coverage policies, payment of physicians, and submission of claims, comparing costs of care is exceedingly complex and was not included in our analysis. Despite these challenges, efforts to systematically measure comparable costs of end-of-life care in these two health-care systems are needed to provide a better understanding of the complete burden of the different structures of care.
Our study had several important strengths. The population-based data used in the analysis included large numbers of NSCLC patients with government-funded health care. We were able to evaluate the trajectory of care that NSCLC patients received across multiple care settings (home, ER, and hospital) during the last 5 months of life. The comprehensiveness of these data provided a detailed picture of much of the care given at the end of life. The NSCLC patients in our analysis had very high rates of hospitalization and poor survival following diagnosis. By using person-day estimates, we limited the analysis to only those patients who were “at risk” of receiving that type of care. This approach resulted in a more accurate estimate of the rate of service use than if we had included all patients. Finally, we limited our analysis to specific types of health care that were comparable between the SEER–Medicare and Ontario data.
Our study also had several limitations. We used administrative data to capture patients’ treatment. Administrative data do not include information about noncovered services or patients’ treatment choices. We could not identify palliative care offered to Medicare patients because there was no billing code to identify palliative services. There were challenges to identifying end-of-life care provided to patients in nursing homes. We could capture care for Medicare patients who are in skilled nursing facilities, but these facilities are limited to patients who require skilled services such as intravenous medications or physical therapy. Medicare does not cover care in long-term care facilities, and as a result, patients receiving supportive services in long-term care facilities were not included. In Ontario, nursing home stays are not covered by OHIP and there are no bills from these facilities. As a result of these limitations in the data, it is not possible to compare the use of palliative care in hospital and nursing home settings between lung cancer patients in the United States and Ontario.
We used a retrospective approach, identifying patients who died and evaluating their care in the last 5 months before death. The retrospective approach to evaluating care at the end of life has been debated because it may capture patients who do not appear to their physicians to be likely to die in the immediate future, and these patients may have received care that was different from patients who are clearly in the last months of life (34
). Others have suggested that end-of-life studies based on prospective cohorts are also limited because it is difficult to identify with certainty which patients are dying (35
). To reduce the likelihood that patients in our study included those not dying of cancer, we restricted our samples to patients with advanced disease at diagnosis who had cancer reported as the cause of death.
In conclusion, we compared health care during the last 5 months of life between Ontario and the United States for elderly patients with advanced NSCLC. In both countries, patients used a large amount of health-care resources. Our study revealed marked differences in the patterns of service delivery at the end of life in Ontario and the United States, likely reflecting differences between their health systems in the organization of end-of-life care. Our findings related to the use of chemotherapy and the ICU support commonly held perceptions that patients in the United States tend to receive more intensive health-care services than in Canada. However, we found that use of hospital and ER services were statistically significantly higher in Ontario. The findings from this study will inform health planners and policy makers in each country regarding current patterns of end-of-life care, and where there may be opportunities for changing practice patterns or programs. This information will help enlighten the current public debate regarding the intensity and benefit of health care for treatments of patients at the end of life.