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

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Taking care of terminally-ill patients at home - ... Introduction The majority of both terminal cancer patients and their family caregivers prefer to die at home ... – PowerPoint PPT presentation

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Title: 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 (pgt0.05).
  • The mean age was 67.913.3 in the HSPCS and
    69.113.1 in the HNSPCS. (pgt0.05)

10
Results
11
Results
12
Results
Last Year of Life Last Year of Life Last Year of Life Last 3 Months of Life Last 3 Months of Life Last 3 Months of Life Last Month of Life Last Month of Life Last Month of Life
      HNSPCS HSPCS P value HNSPCS HSPCS P value HNSPCS HSPCS P value
Ambulatory procedures Ambulatory procedures Ambulatory procedures 9 10 NS 3 5 NS 0 1 Plt0.005
Imaging Imaging Imaging 813 623 NS 312 205 NS 121 91 NS
Laboratory Laboratory Laboratory 36 5 NS 23 2 NS 4 0 NS
Consultations Consultations Consultations 37 28 NS 7 5 NS 1 1 NS
Hospitalization Hospitalization Hospitalization 7,238 4,414 lt0.01 3,855 2,083 lt0.01 1,818 849 Plt0.001
Day Hospitalization Day Hospitalization Day Hospitalization 1,196 1,158 NS 331 297 NS 96 59 NS
ER ER ER 111 120 NS 47 50 NS 18 16 NS
Doctor visit Doctor visit Doctor visit 13 16 NS 4 7 NS 1 2 NS
Oncology treatment Oncology treatment Oncology treatment 775 614 lt0.05 338 235 NS 94 106 NS
other other other 163 146 NS 40 42 NS 13 7 NS
TOTAL TOTAL TOTAL 10,392 7,133 lt0.01 4,961 2,930 Plt0.005 2,179 1,134 Plt0.001
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 providers 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.
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