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Studies
investigate Health Care at the End of Life
Newswise — Patients with advanced cancer who
discuss end-of-life care with their
physicians appear to have lower health care
costs in the final week of life than those
who do not, according to a report in the
most recent issue of Archives of Internal
Medicine, one of the JAMA/Archives journals.
A second report finds that black and
Hispanic patients tend to have higher health
care costs at the end of life than white
patients, despite dying of similar causes.
Two other articles in the same issue examine
dying patients’ feelings of abandonment by
physicians and reasons that patients request
physician aid in dying in Oregon.
A disproportionate share of medical costs
occur at the end of life, according to
background information in the first article.
Almost one-third of Medicare expenditures
are attributable to the 5 percent of
beneficiaries who die each year, and about
one-third of expenses in the last year of
life are spent in the final month.
Previous studies suggest that most of these
costs result from life-sustaining care,
including resuscitation and mechanical
ventilation.
Baohui Zhang, M.S., of the Dana-Farber
Cancer Institute, Boston, and colleagues
studied 603 patients who were part of the
Coping With Cancer study, funded by the
National Institute of Mental Health and the
National Cancer Institute.
At the beginning of the study—between 2002
and 2007—188 (31.2 percent) reported
discussing their wishes about end-of-life
care with their physicians. They were then
followed up through death.
In the final week of life, patients who
reported having end-of-life discussions with
their physicians had average aggregate
health care costs of $1,876, compared with
$2,917 for patients who did not.
Formal and informal caregivers who were
interviewed after patients’ deaths reported
that those with higher costs also had a
worse quality of death in their final week.
In the second article about end-of-life
costs, Amresh Hanchate, Ph.D., of Boston
University School of Medicine, and
colleagues report on an analysis of data
from 158,780 Medicare beneficiaries who died
in 2001.
In the last six months of life, costs varied
significantly by racial and ethnic
background—costs for whites averaged
$20,166, compared with $26,704 for blacks
and $31,702 for Hispanics.
“Although 40 percent to 60 percent of these
excess differences are associated with
geography, i.e., living in
high–medical-expenditure areas, substantial
differences remain, even after adjustment
for many patient characteristics in addition
to geographic variables,” the authors write.
“Strikingly higher rates of use of intensive
end-of-life treatments such as ICU
[intensive care unit] and ventilators
account for most of these residual
differences.”
“Therefore, at life’s end, minorities often
receive more expensive but not necessarily
life-enhancing care,” they conclude.
“It is unclear how much of this was actively
sought, or the extent to which racial and
ethnic differences are principally driven by
how choices are presented or how they are
‘heard.’ These would be fruitful questions
for future research.”
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