Taking care of terminally-ill patients at home - the economic perspective revisited

1. Taking care of terminally-ill patients at home - the economic perspective revisited Oren Tamir, Yoram Singer, Pesach Shvartzman Palliat Med.2007; 21: 537-541

2. Introduction End-of-life care can be delivered in a variety of settings: • Inpatient hospice care • Inpatient ward within a general hospital • Palliative homecare (home hospice) • Homecare using the existing community-based medical services.

3. Introduction • The majority of both terminal cancer patients and their family caregivers prefer to die at home(Tang et al.) • Caregivers of patients who were cared for at home were more likely to report a favorable dying experience(Teno et al. ) • Similar findings were found among the Israeli population (Singer et al., Loven et al., Iecovich et al.).

4. Introduction • Home hospice care saves 31-64% of medical care costs • The main difference in accounted for by the reduced use of hospital services. • During the last six months of life, the mean medical costs for patients receiving hospice care at home are 27% less than for conventional care • The saving with hospital-based hospice care are less than 15%

5. The aim of our study • To evaluate health services utilization during the last year of life, in the Negev region and to compare terminally ill patients who have received home specialized palliative care services (HSPCS) compared to patients who died with no access to home specialized palliative care services (HNSPCS).

6. The Negev palliative care program • Home palliative care units (Beer-Sheva, Kiryat-Gat, and Rahat) • A consultation service for the Oncology Institute at Soroka University Medical Center (SUMC) • 28-35 patients on average at any given time, with about 120 patients per year. • Referrals are received through the Oncology Institute, primary care physicians or directly by the families and patients.

7. Study population: • 120 patients treated by the home specialized palliative care service (HSPCS) of Beer-Sheva and Kiryat-Gat who died between the years 1999-2000 • 515 patients who died in the same period, but had no access to the HSPCS (HNSPCS). • The HNSPCS group included patients who lived mainly in Beer-Sheva vicinity.

8. Data collection: • Health services utilization data were retrieved from the computerized database • All patients belong to Clalit Health Services (CHS), thus all utilization costs of all medical services are recorded in the same computer mainframe using the same pricing methods.

9. Results: • Age and gender distribution were similar in both groups. • the older age group (65 years or older) accounted for 69.7% vs. 73.3% respectively (p>0.05). • The mean age was 67.9±13.3 in the HSPCS and 69.1±13.1 in the HNSPCS. (p>0.05)

10. Results:

11. Results:

12. Results:

13. Discussion: • 10-12% of the total health care budget being spent during the last year of life (Stooker et al., Emanuel et al.) • One eighth of the health care provider’s total expenditure spent on patients in their last month of life (Lubitz et al., Riley et al.) • Nearly 55% of the total medical expenses during the last year of life were spent over the last three months of life (Liu et al.)

14. Discussion: • 27-30% of Medicare payments each year are for the 5-6% of Medicare beneficiaries who die in that year (Lubitz et al., McCall et al.) • In general, outcomes in a home palliative care setting showed improved satisfaction and better pain and symptom control (Finlay et al.) • Case-control patients matched by diagnosis and age treated in an inpatient palliative care unit compared with conventional care showed direct costs were 56% lower and total costs 57% lower (Finlay et al.)

15. Discussion: • In Israel, a study of Clalit Health Services (CHS) members, who died in 2001, showed that the average cost per capita during the last year of life was five times more than aged matched live patients (Bechar et al.)

16. Discussion: • The results of our study provide evidence that, for terminally ill cancer patients, health services costs are lower for patients enrolled at the HSPCS compared with those who were not. • Health services expenditures reduction is greater for periods closer to time of death, regardless of cancer type. • The cost differences between the groups are largely due to fewer acute admissions to hospital and oncology treatments.

17. Discussion: • In our previous work we found that death at home occurred for 80.3% of the patients with access to homecare and 20.5% of those without access. • There was a greater overall satisfaction with the caring experience of those whose loved ones died at home and had access to the homecare program.

18. Discussion: • In a prospective phase of our study (in process) preliminary data show a favorable experience and greater satisfaction amongst the HSPCS patients and their families.

19. conclusion • Given the large number of patients who die from cancer annually, the increasing strain on healthcare systems during the last year of life and the substantial cost reduction with home palliative care, we believe that home based palliative care has to be offered to all terminally ill cancer patients suitable for this service.