The challenge of sustainability in healthcare systems: frequency and cost of diagnostic procedures in end-of-life cancer patients

The challenge of sustainability in healthcare systems: frequency and cost of diagnostic... Background Literature data on the overuse and misuse of diagnostic procedures leading to end-of-life aggressiveness are scarce due to the limited amount of estimated economic waste. This study investigated the potential overuse of diagnostic procedures in a population of end-of-life patients. Methods This is a retrospective study on consecutive advanced patients admitted into two Italian hospices. Frequency and relative costs of X-ray imaging, CT scans, MRI, and interventional procedures prescribed in the 3 months before admission were collected in patient electronic charts and/or in administrative databases. We conducted a deeper analysis of 83 cancer patients with a diagnosis of at least 1 year before admission to compare the number of examinations performed at two distant time periods. Results Out of 541 patients, 463 (85.6%) had at least one radiological exam in the 3 months before last admission. The mean radiological exam number was 3.9 ± 3.2 with a relative mean cost of 278.60 ± 270.20 € per patient with a statistically significant (p < 0.001) rise near death. In the 86-patient group, a higher number of procedures was performed in the last 3 months of life than in the first quarter of the year preceding last admission (38.43 ± 28.62 vs. 27.95 ± 23.21, p < 0.001) with a consequent increase in cost. * Ilaria Massa Oriana Nanni ilaria.massa@irst.emr.it oriana.nanni@irst.emr.it Romina Rossi William Balzi romina.rossi@irst.emr.it william.balzi@irst.emr.it Marco Maltoni Mattia Altini marcocesare.maltoni@irst.emr.it mattia.altini@irst.emr.it Raffaella Bertè Unit of Biostatistics and Clinical Trials, Istituto Scientifico r.berte@ausl.pc.it Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014 Meldola, Italy Monica Bosco Healthcare Administration, Istituto Scientifico Romagnolo per lo m.bosco@ausl.pc.it Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014 Meldola, Italy Davide Cassinelli d.cassinelli@ausl.pc.it Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, Valentina Vignola 29100 Piacenza, Italy v.vignola@ausl.pc.it Department of Oncology and Hematology, Guglielmo da Saliceto Luigi Cavanna Hospital, Via Taverna 49, 29100 Piacenza, Italy l.cavanna@ausl.pc.it Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Flavia Foca Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, flavia.foca@irst.emr.it 47014 Meldola, Italy Monia Dall’Agata Palliative Care Unit, Valerio Grassi Hospice, Forlimpopoli Hospital, monia.dallagata@irst.emr.it Via Duca D’Aosta 33, 47034 Forlimpopoli, Italy 2202 Support Care Cancer (2018) 26:2201–2208 Conclusions Patients nearing death are subjected to a high level of Bdiagnostic aggressiveness.^ Further studies on the integration of palliative care into the healthcare pathway could impact the appropriateness of interventions, quality of care, and, ultimately, estimated costs. . . . . Keywords Appropriateness Diagnostic procedures End of life Diagnostic aggressiveness Healthcare sustainability Introduction subgroup of the same population, we compared the frequency of various procedures performed in 12 to 9 months before the Literature studies have identified some factors as indicators of last admission to hospice and in the 3 months before death, aggressive care and poor quality of cancer care near the end of determining the respective costs. life (EoL) [1]. Earle and colleagues categorized some indica- tors into three major areas: (a) access to the emergency room and admission to hospital or intensive care unit; (b) lack of or very late referral to hospice; and (c) overuse of chemotherapy Patients and methods very near death [2]. Other authors created scoring tools for quantifying the aggressiveness of care based on the prevalence This retrospective study was conducted on a population of of these indexes [3–6]. consecutive advanced cancer patients deceased in the hospices The increasing debate on how cancer patients are treated at of the cities of Piacenza and Forlì (Emilia-Romagna Region) EoL confirms that this topic is multidimensional and delicate. in the 3 months before hospice admission. The areas of Palliative care has been identified as an appropriate means of Piacenza and Forlì are similar in terms of population and addressing patient needs in this setting, positively impacting available health services. The study covered the period from three major aspects: patient quality of life, healthcare service January 2012 to June 2013 for Piacenza and from June 2013 misutilization, and costs. to June 2014 for Forlì. The rise of costs for cancer care worldwide [7] affects all We collected the following information for each patient: age, the parties involved: patients, caregivers [8], and the sex, primary cancer site, length of hospice stay, and number of healthcare system. In particular, the expenditure for cancer accesses to the Radiology Department. The frequency and type care in the USA was estimated in 2006 to rise from $104 to of diagnostic and interventional radiological exams performed over $173 billion by 2020 [9, 10]. In Italy, as oncology care on the patients in the 90 days before their admission to hospice running costs are at risk of undermining healthcare sustain- were recorded and coded as: X-ray, computed tomography ability, it is crucial to limit inappropriate interventions (CT) scan, magnetic resonance imaging (MRI), and interven- throughout the entire care pathway [11]. tional procedures (fine-needle biopsy of the lung, positioning of Medical oncologists can directly and indirectly determine arterial catheter, ascending pyelography, biliary drainage, posi- most of the costs related to cancer care. For example, such tioning of urethral stent). For analysis purposes, the hospice expenditures can be reduced if diagnostic imaging is per- preadmission period was divided as follows: 90–61 days formed when a true benefit is shown, or if EoL discussions (M-3), 60–31 days (M-2), and 30–1 days (M-1) before admis- are promoted, as a result of good healthcare planning [9, 12, sion. Frequency, type, and costs of examinations were calculat- 13]. Literature data on the overuse and misuse of both imaging ed for each of the three periods. For a subgroup of patients from and invasive diagnostic procedures at EoL are currently scarce Forlì diagnosed with cancer up to 1 year before admission, an [14–17], probably due the limited amount of estimated eco- in-depth analysis was carried out for two distinct periods: 365– nomic waste. Previous studies have shown the considerable 275 days (M12/9) and 90–1 days (M3/0) before admission. use of high-cost diagnostic imaging at EoL, with about one In addition to X-ray, CTscan, MRI, and invasive procedures, third of IV-stage-disease patients undergoing at least one high- we considered for analysis all healthcare procedures, such as cost imaging procedure in the last 30 days of life [15]. ultrasound, electrocardiogram (ECG) and nuclear medicine This study investigated the potential overuse of diagnostic tests, visits, hematological exams, radiotherapy, intravenous procedures in a population of patients approaching EoL, with chemotherapy, and other therapeutic services. We reported the the aim of outlining the employed resources in such a chal- cost of each procedure performed in an outpatient setting. For lenging context [15], and defining what and how many pro- the procedures performed in an inpatient setting, we estimated cedures were performed nearer death than in earlier phases. In the costs of the overall inpatient stay. The Regional Healthcare detail, we firstly counted the number of diagnostic procedures Range of Fees table was used to determine the costs of the undergone by the population of two hospices in a retrospec- exams in both centers. The study was approved by the local tive study, estimating the associated costs. Secondly, in a ethics committee of each participating center. Support Care Cancer (2018) 26:2201–2208 2203 Table 1 Population characteristics, radiological exams performed in the which collects data from the three Radiology Units of the dis- 90 days before hospice admission, and relevant costs trict public hospitals. In Forlì, patients’ data were linked with the regional administrative database of the Hospital Discharged Population characteristics No. (%) Card (HDC) for inpatients, Specialistic Assistance (SA) for Total population 541 outpatients, and Emergency Room (ER) in order to retrieve Male 296 (55) all the performed radiological procedures. For the in-depth anal- Female 245 (45) ysis at the hospice in Forlì, patients were selected by the date of Age (years, mean ± SD (range)) 73 ± 12 (28–100) diagnosis retrieved from the electronic health records and con- Length of hospice stay (days, mean ± SD (range)) 17 ± 18 (0–147) firmed by the Cancer Registry,andsubsequentlymatchedtothe Primary cancer site administrative data through an automated and validated system Lung 137 (25.3) of record linkage. All performed healthcare procedures were Colon 60 (11.1) extracted from the HDC, SA and ER databases. Stomach 43 (8.0) Pancreas 38 (7.0) Statistical analysis Breast 42 (7.8) Head and neck 31 (5.7) Patient characteristics, number of exam, and costs were Liver 26 (4.8) expressed as mean ± standard deviations for continuous vari- Bladder 27 (5.0) ables, and counts (%) for categorical variables. For continuous variables, also minimum and maximum values of distributions Other sites 137 (25.3) Patients undergoing exams were reported. To evaluate the presence of an exponential growth over time for the number of the examined patients, Patients undergoing at least 1 exam 463 (85.6) the number and the cost of the exams performed in the None 78 (14.4) 3 months before death, generalized linear models were esti- 1 109 (23.5) mated on natural logarithm of the three measures considering 2 110 (23.8) time as an independent variable. Wald p value tests for expo- 3 96 (20.7) nential trend were reported. A p value < 0.05 was considered 4 73 (15.8) statistically significant. For the analysis of the subgroup of 5 33 (7.1) patients with a cancer diagnosis of up to 1 year prior to hospice 6 or more 42 (9.1) admission, absolute and relative variations were calculated. Radiological examinations (N)2091 All statistical analyses were performed using Stata 14.1 for Mean per patient ± SD (exams) 3.9 ± 3.2 Windows (StataCorp LP, College Station, TX). 25, 50, and 75 percentiles 1, 3, 5 By type of exam X-ray 1198 (57.3) Results CT scan 796 (38.1) MRI 61 (2.9) We found a total of 541 deceased cancer patients in the two Interventional procedures 36 (1.7) hospices during the considered periods with 17 ± 18 days of Costs mean last hospice stay (range, 0–147). The general character- Total cost of exams 150,698.00 € istics of the study population are reported in Table 1. Table 1 Mean per patient ± SD 278.60 € ± 270.20 € also shows that a total of 463 (85.6%) patients underwent ≥ 1 25, 50, and 75 percentiles 41.8, 225.2, 447.3 radiological exam in the 3 months before last admission. Of By type of exam these, 76.5 and 9.1% underwent ≥2and ≥6radiological X-ray 25,773.40 € exams, respectively. The mean of radiological exams was CT scan 104,291.10 € 3.9 ± 3.2 per patient, with a total of 2091 radiological exams MRI 15,904.40 € performed on 541 patients. If calculated on the 463 patients Interventional procedures 4729.10 € that underwent ≥ 1 exam, the mean number of exams per patient rose to 4.51 ± 3.0. Data sources Even though the majority of performed exams was repre- sented by X-ray (1198, 57.3%), 893 (42.7%) CT scans, MRI, In both centers, patients were identified through hospice elec- and interventional exams were performed in the last 90 days tronic patient charts, from which date of death was retrieved. In before last admission to hospice. The total cost of the exams Piacenza, patients’ data were cross-checked with the Radiology was 150,698.00 €. The distribution of the costs among the Information System archive of the Radiology Department, patients shows that for 162 (30%) cases, the cost was lower 2204 Support Care Cancer (2018) 26:2201–2208 Fig. 1 Cost distribution among 541 patients (€) 278.6 Paents* *each column represents a single paent than 2780.65 €, whereas for 54 (10%) cases, the cost was Subdividing the 90-day period in three periods of higher than 45,758.60 €. The mean cost was 325.50 € per 1 month each (M-3, M-2, M-1) (Table 2)and examining patient undergoing exams, and 278.60 per patient in the pop- the trend of the performed examinations, we noticed a ulation (Fig. 1). The total cost for CT scans, MRI, and inter- clear increase in the trend approaching hospice admission. ventional exams was 124,924.60 €, accounting for 83.0% of In fact, 37.3, 41.6, and 64.0% of patients performed ≥ 1 the global expense. The mean number of exams and cost per radiological exam at M-3, M-2, and M-1, respectively patient in the two towns was similar (data not shown). (p = 0.002). Also, the number of the exams performed Table 2 Number of examined patients by radiological exams and number of radiological exams by type of exam 3 months (M-3), 2 months (M-2), and 1 month (M-1) before last hospice admission M-3 M-2 M-1 p value Wald N (%) N (%) N (%) statistic Patients undergoing at least 1 exam 202 (37.3) 225 (41.6) 346 (64.0) 0.002 By type of exam X-ray 142 (26.3) 159 (29.4) 287 (53.0) 0.007 CT scan 92 (17.0) 127 (23.5) 173 (32.0) < 0.001 MRI 11 (2.0) 20 (3.7) 22 (4.1) 0.031 Interventional procedures 5 (0.9) 10 (1.8) 12 (2.2) 0.015 Radiological exams Radiological exams 446 (21.3) 625 (29.9) 1020 (48.8) < 0.001 Mean per patient 0.8 ± 1.4 1.2 ± 1.8 1.9 ± 2.3 – 25, 50, and 75 percentiles 0, 0, 1 0, 0, 2 0, 1, 3 – By type of exam X-ray 243 (54.5) 315 (50.4) 640 (62.7) < 0.001 Mean per patient 0.4 ± 1.0 0.6 ± 1.2 1.2 ± 1.7 – CT scan 187 (41.9) 276 (44.2) 333 (32.6) < 0.001 Mean per patient 0.3 ± 0.9 0.5 ± 1.1 0.6 ± 1.1 – MRI 11 (2.5) 22 (3.5) 28 (2.7) 0.003 Mean per patient 0.0 ± 0.1 0.0 ± 0.2 0.1 ± 0.3 – Interventional procedures 5 (1.1) 12 (1.9) 19 (1.9) < 0.001 Mean per patient 0.0 ± 0.1 0.0 ± 0.2 0.0 ± 0.3 – Cost (€) 541 Support Care Cancer (2018) 26:2201–2208 2205 Table 3 Cost of procedures (€) 3 months (M-3), 2 months (M-2), and 1 month (M-1) before last hospice admission M-3 M-2 M-1 p value Wald statistic Total cost of exams 33,698.20 € (22.4%) 51,088.80 € (33.9%) 65,911.00 € (43.7%) < 0.001 Mean total cost/patient 62.30 ± 143.00 94.40 ± 169.60 121.80 ± 181.80 – 25, 50, and 75 percentiles 0, 0, 34.90 0, 0, 101.80 0, 23.20, 188.00 – Cost by type of exam X-ray 5152.10 € (3.4%) 6828.00 € (4.5%) 13,793.50 € (9.2%) < 0.001 Mean per patient 9.50 ± 21.10 12.60 ± 27.60 25.50 ± 38.50 – CT scan 24,566.20 € (16.3%) 36,563.50 € (24.3%) 43,161.20 € (28.6%) < 0.001 Mean per patient 45.40 ± 118.40 67.60 ± 144.90 79.80 ± 142.60 – MRI 3234.40 € (2.1%) 6182.30 € (4.1%) 6487.70 € (4.3%) 0.051 Mean per patient 6.00 ± 48.40 11.40 ± 61.10 12.00 ± 70.40 – Interventional procedures 745.50 € (0.5%) 1515.00 € (1.0%) 2468.70 € (1.6%) < 0.001 Mean per patient 1.40 ± 15.70 2.80 ± 21.60 4.60 ± 30.80 – increased nearing hospice admission: 446 (21.3%) at M-1, Discussion 625 (29.9%) at M-2, and 1020 (48.8%) at M-3 (p < 0.001). This trend was reflected in the mean number Our results confirmed the increase in the number of diagnostic of exams performed per patient, which increased from less exams carried out in the last months of a patient’slife, which, than 1 (0.8 ± 1.4) at M-3 to almost 2 (1.9 ± 2.3) at M-1. however, did not always offer an advantage in terms of sur- As showninTable 2, the examined patients and number vival [6, 18]. In our study, considering the number of patients of radiological exams increased from M-3 to M-2 and undergoing at least one radiological exam in the 90 days be- from M-2 to M-1. fore last admission to hospice, we found that both the number Table 3 shows that the total costs of the exams were of exams and the relevant costs had a statistically significant 33,698.20 € at M-3, 51,088.80 € at M-2, and 65,911.00 € increase approaching death. A total of 37.3 and 64.0% of at M-1 and were significantly different (p <0.001). The patients underwent at least one radiological exam up to mean cost per patient was twofold higher at M-1 than at 3 months and up to 1 month before hospice admission, M-3 (62.30 € ±143.00 € at M-3, 94.40 € ± 169.60 at M-2, respectively. and 121.80 € ± 181.80 € at M-1). The analysis of the use As imaging procedures have no diagnostic purpose in ad- of the resources for the 86-patient group (55% females, vanced patients, they can be justified only in view of the mean age 67.23 ± 13.71 years) diagnosed with cancer up management of acute symptoms, evaluation of disease pro- to 1 year before last hospice admission shows that the gression, and assessment of treatment effect. The latter can be primary cancer sites were the gastrointestinal tract useful for evaluating whether to discontinue and/or change the (22.1%), the breast (15.1%), the lung (14.0%), and others treatment line [6, 14, 15, 18]. The use of diagnostic imaging, (48.8%). At M3/0, the total number of performed proce- however, is still widespread despite the present guidelines dures was 3305, of which 2613 (79.1%) were performed [19]. In particular, we observed that it did not reduce as death on outpatients, and 692 (20.9%) on inpatients. At M12/9, was nearing; rather, it increased, resulting in higher healthcare the total number of performed procedures was 2404, of costs. We also noticed a rising number of diagnostic invasive which 2008 (83.5%) were performed on outpatients and procedures from M3 to M1, even if the absolute number was 396 (16.5%) on inpatients. We observed a higher number low. The role of these procedures is as yet unclear. On the one of procedures performed in the inpatient than in the out- hand, given that their palliative purpose supports their appro- patient setting from M12/9 to M3/0 with an absolute in- priateness at EoL [20], we would expect a more intensive use crease of 901 exams (relative increase +37.5%) nearing than that seen in our case mix. On the other hand, their inva- death. The mean number of exams (±SD) ranged from siveness and potential comorbidity should be carefully evalu- 27.95 ± 23.21 at M12/9 to 38.43 ± 28.62 at M3/0. As ated against any real therapeutic benefit [15]. regards the costs, we found that before the last admission We firmly believe that costs for healthcare services in the they amounted to 735,990.70 € at M3/0 and to 553,814.10 last year of life are high, despite the fact that a recent study has € at M12/9, with an absolute difference of 182,176.50 €, advocated the Bmyth^ of a costly EoL care, which would and a relative increase of the global expenses by 32.9% represent only a minority of the total annual expenditure in approaching admission (Table 4). the USA [21]. However, most authors agree in considering the 2206 Support Care Cancer (2018) 26:2201–2208 Table 4 Costs at two different time periods (M3/0 and M12/9) for 86 patients from diagnosis (at least 1 year before death) to death Variable M3/0 M12/9 Differences M3/0–M12/9 Absolute Relative % Total exams 3305 2404 + 901 + 37.5 Mean per patient ± SD 38.43 ± 28.62 27.95 ± 23.21 25, 50, and 75 percentiles 16, 33, 53 10.25, 22, 40.50 Total costs for outpatients 54,599.10 € 91,158.10 € − 36,559.00 € − 40.1 Total costs for inpatients 681,391.60 € 462,656.00 € 218,735.50 € +47.3 Total costs (overall) 735,990.70 € 553,814.10 € 182,176.50 € +32.9 By type of exam Hematological exams (N) 1830 1046 + 784 + 75.0 Mean per patient ± SD 21.28 ± 23.69 12.16 ± 17.09 25, 50, and 75 percentiles 2.25, 13, 33 0, 3.5, 17.5 X-ray (N) 150 61 + 89 + 145.9 Mean per patient ± SD 1.74 ± 1.70 0.71 ± 1.18 25, 50, and 75 percentiles 0, 1, 3 0, 0, 1 CT scan (N) 124 118 + 6 + 5.1% Mean per patient ± SD 1.44 ± 1.47 1.37 ± 1.52 25, 50, and 75 percentiles 0, 1, 2.75 0, 1, 2 MRI (N)13 15 − 2 − 13.3 Mean per patient ± SD 0.15 ± 0.58 0.17 ± 0.65 25, 50, 75 and percentiles 0, 0, 0 0, 0, 0 Invasive procedures (N) 137 41 + 96 + 234.1 Mean per patient ± SD 1.59 ± 2.56 0.48 ± 0.95 25, 50, 75 and percentiles 0, 1, 2 0, 0, 1 Intravenous chemotherapy (N) 116 190 − 74 − 38.9 Mean per patient ± SD 1.35 ± 2.04 2.21 ± 3.99 25, 50, and 75 percentiles 0, 0, 2 0, 0, 3 Other therapeutic services (N) 240 163 + 77 + 47.2 Mean per patient ± SD 2.79 ± 3.41 1.90 ± 3.44 25, 50, and 75 percentiles 0, 2, 4 0, 0, 3 Radiotherapy (N)91 397 − 306 − 77.1 Mean per patient ± SD 1.06 ± 3.74 4.62 ± 13.04 25, 50, and 75 percentiles 0, 0, 0 0, 0, 0 Visits (N) 388 285 + 103 + 36.1 Mean per patient ± SD 4.51 ± 3.41 3.31 ± 4.41 25, 50, and 75 percentiles 2, 4, 7 1, 2, 4.75 Ultrasound, ECG, and nuclear medicine tests (N) 216 88 + 128 + 145.5 Mean per patient ± SD 2.51 ± 2.39 1.02 ± 1.41 25, 50, and 75 percentiles 0.25, 2, 4 0, 0, 1.75 N, number costs of EoL care a major item of healthcare expenditure. the latter is considered appropriate only in a few cases. Comparing data from the last 3 months of life with those from Conversely, the percentage of invasive procedures, such as 9 months back to 1 year before death in our subgroup analysis, X-ray, ultrasound, ECG, and nuclear medicine tests, showed we found that a higher number of procedures were performed an increase at EoL. From a methodological point of view, we at M3/0 for almost all the considered procedures, with higher adapted Yabroff’s[22] timeframe definitions (M12/9 and M3/ corresponding costs. Chemotherapy and radiotherapy admin- 0), interpreting M12/9 as the Bcontinuous care phase^ and istrations were the only procedures that were reasonably re- M3/0 as the BEoL phase.^ We acknowledge, however, that it duced by M3/0, as the former is usually avoided at EoL and is quite difficult to make any direct comparison with other Support Care Cancer (2018) 26:2201–2208 2207 studies on costs at EoL due to the different timeframes References adopted (i.e., 3 days [23], 7 days [24], or 30 days [14]before death). 1. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block SJ (2003) Identifying potential indicators of the quality of end-of-life cancer The main limitation of this retrospective study is the lack of care from administrative data. Clin Oncologia 21(6):1133–1138 any information about the clinical indications or the patient’s 2. Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, preferences for these procedures. 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Am J Public Health 105(12):2411–2415. https:// clinical practice guideline update. J Clin Oncol 35(1):96–112. doi.org/10.2105/AJPH.2015.302889 https://doi.org/10.1200/JCO.2016.70.1474 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Supportive Care in Cancer Springer Journals

The challenge of sustainability in healthcare systems: frequency and cost of diagnostic procedures in end-of-life cancer patients

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Copyright © 2018 by The Author(s)
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Medicine & Public Health; Oncology; Nursing; Nursing Research; Pain Medicine; Rehabilitation Medicine
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0941-4355
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10.1007/s00520-018-4067-7
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Abstract

Background Literature data on the overuse and misuse of diagnostic procedures leading to end-of-life aggressiveness are scarce due to the limited amount of estimated economic waste. This study investigated the potential overuse of diagnostic procedures in a population of end-of-life patients. Methods This is a retrospective study on consecutive advanced patients admitted into two Italian hospices. Frequency and relative costs of X-ray imaging, CT scans, MRI, and interventional procedures prescribed in the 3 months before admission were collected in patient electronic charts and/or in administrative databases. We conducted a deeper analysis of 83 cancer patients with a diagnosis of at least 1 year before admission to compare the number of examinations performed at two distant time periods. Results Out of 541 patients, 463 (85.6%) had at least one radiological exam in the 3 months before last admission. The mean radiological exam number was 3.9 ± 3.2 with a relative mean cost of 278.60 ± 270.20 € per patient with a statistically significant (p < 0.001) rise near death. In the 86-patient group, a higher number of procedures was performed in the last 3 months of life than in the first quarter of the year preceding last admission (38.43 ± 28.62 vs. 27.95 ± 23.21, p < 0.001) with a consequent increase in cost. * Ilaria Massa Oriana Nanni ilaria.massa@irst.emr.it oriana.nanni@irst.emr.it Romina Rossi William Balzi romina.rossi@irst.emr.it william.balzi@irst.emr.it Marco Maltoni Mattia Altini marcocesare.maltoni@irst.emr.it mattia.altini@irst.emr.it Raffaella Bertè Unit of Biostatistics and Clinical Trials, Istituto Scientifico r.berte@ausl.pc.it Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014 Meldola, Italy Monica Bosco Healthcare Administration, Istituto Scientifico Romagnolo per lo m.bosco@ausl.pc.it Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014 Meldola, Italy Davide Cassinelli d.cassinelli@ausl.pc.it Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, Valentina Vignola 29100 Piacenza, Italy v.vignola@ausl.pc.it Department of Oncology and Hematology, Guglielmo da Saliceto Luigi Cavanna Hospital, Via Taverna 49, 29100 Piacenza, Italy l.cavanna@ausl.pc.it Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Flavia Foca Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, flavia.foca@irst.emr.it 47014 Meldola, Italy Monia Dall’Agata Palliative Care Unit, Valerio Grassi Hospice, Forlimpopoli Hospital, monia.dallagata@irst.emr.it Via Duca D’Aosta 33, 47034 Forlimpopoli, Italy 2202 Support Care Cancer (2018) 26:2201–2208 Conclusions Patients nearing death are subjected to a high level of Bdiagnostic aggressiveness.^ Further studies on the integration of palliative care into the healthcare pathway could impact the appropriateness of interventions, quality of care, and, ultimately, estimated costs. . . . . Keywords Appropriateness Diagnostic procedures End of life Diagnostic aggressiveness Healthcare sustainability Introduction subgroup of the same population, we compared the frequency of various procedures performed in 12 to 9 months before the Literature studies have identified some factors as indicators of last admission to hospice and in the 3 months before death, aggressive care and poor quality of cancer care near the end of determining the respective costs. life (EoL) [1]. Earle and colleagues categorized some indica- tors into three major areas: (a) access to the emergency room and admission to hospital or intensive care unit; (b) lack of or very late referral to hospice; and (c) overuse of chemotherapy Patients and methods very near death [2]. Other authors created scoring tools for quantifying the aggressiveness of care based on the prevalence This retrospective study was conducted on a population of of these indexes [3–6]. consecutive advanced cancer patients deceased in the hospices The increasing debate on how cancer patients are treated at of the cities of Piacenza and Forlì (Emilia-Romagna Region) EoL confirms that this topic is multidimensional and delicate. in the 3 months before hospice admission. The areas of Palliative care has been identified as an appropriate means of Piacenza and Forlì are similar in terms of population and addressing patient needs in this setting, positively impacting available health services. The study covered the period from three major aspects: patient quality of life, healthcare service January 2012 to June 2013 for Piacenza and from June 2013 misutilization, and costs. to June 2014 for Forlì. The rise of costs for cancer care worldwide [7] affects all We collected the following information for each patient: age, the parties involved: patients, caregivers [8], and the sex, primary cancer site, length of hospice stay, and number of healthcare system. In particular, the expenditure for cancer accesses to the Radiology Department. The frequency and type care in the USA was estimated in 2006 to rise from $104 to of diagnostic and interventional radiological exams performed over $173 billion by 2020 [9, 10]. In Italy, as oncology care on the patients in the 90 days before their admission to hospice running costs are at risk of undermining healthcare sustain- were recorded and coded as: X-ray, computed tomography ability, it is crucial to limit inappropriate interventions (CT) scan, magnetic resonance imaging (MRI), and interven- throughout the entire care pathway [11]. tional procedures (fine-needle biopsy of the lung, positioning of Medical oncologists can directly and indirectly determine arterial catheter, ascending pyelography, biliary drainage, posi- most of the costs related to cancer care. For example, such tioning of urethral stent). For analysis purposes, the hospice expenditures can be reduced if diagnostic imaging is per- preadmission period was divided as follows: 90–61 days formed when a true benefit is shown, or if EoL discussions (M-3), 60–31 days (M-2), and 30–1 days (M-1) before admis- are promoted, as a result of good healthcare planning [9, 12, sion. Frequency, type, and costs of examinations were calculat- 13]. Literature data on the overuse and misuse of both imaging ed for each of the three periods. For a subgroup of patients from and invasive diagnostic procedures at EoL are currently scarce Forlì diagnosed with cancer up to 1 year before admission, an [14–17], probably due the limited amount of estimated eco- in-depth analysis was carried out for two distinct periods: 365– nomic waste. Previous studies have shown the considerable 275 days (M12/9) and 90–1 days (M3/0) before admission. use of high-cost diagnostic imaging at EoL, with about one In addition to X-ray, CTscan, MRI, and invasive procedures, third of IV-stage-disease patients undergoing at least one high- we considered for analysis all healthcare procedures, such as cost imaging procedure in the last 30 days of life [15]. ultrasound, electrocardiogram (ECG) and nuclear medicine This study investigated the potential overuse of diagnostic tests, visits, hematological exams, radiotherapy, intravenous procedures in a population of patients approaching EoL, with chemotherapy, and other therapeutic services. We reported the the aim of outlining the employed resources in such a chal- cost of each procedure performed in an outpatient setting. For lenging context [15], and defining what and how many pro- the procedures performed in an inpatient setting, we estimated cedures were performed nearer death than in earlier phases. In the costs of the overall inpatient stay. The Regional Healthcare detail, we firstly counted the number of diagnostic procedures Range of Fees table was used to determine the costs of the undergone by the population of two hospices in a retrospec- exams in both centers. The study was approved by the local tive study, estimating the associated costs. Secondly, in a ethics committee of each participating center. Support Care Cancer (2018) 26:2201–2208 2203 Table 1 Population characteristics, radiological exams performed in the which collects data from the three Radiology Units of the dis- 90 days before hospice admission, and relevant costs trict public hospitals. In Forlì, patients’ data were linked with the regional administrative database of the Hospital Discharged Population characteristics No. (%) Card (HDC) for inpatients, Specialistic Assistance (SA) for Total population 541 outpatients, and Emergency Room (ER) in order to retrieve Male 296 (55) all the performed radiological procedures. For the in-depth anal- Female 245 (45) ysis at the hospice in Forlì, patients were selected by the date of Age (years, mean ± SD (range)) 73 ± 12 (28–100) diagnosis retrieved from the electronic health records and con- Length of hospice stay (days, mean ± SD (range)) 17 ± 18 (0–147) firmed by the Cancer Registry,andsubsequentlymatchedtothe Primary cancer site administrative data through an automated and validated system Lung 137 (25.3) of record linkage. All performed healthcare procedures were Colon 60 (11.1) extracted from the HDC, SA and ER databases. Stomach 43 (8.0) Pancreas 38 (7.0) Statistical analysis Breast 42 (7.8) Head and neck 31 (5.7) Patient characteristics, number of exam, and costs were Liver 26 (4.8) expressed as mean ± standard deviations for continuous vari- Bladder 27 (5.0) ables, and counts (%) for categorical variables. For continuous variables, also minimum and maximum values of distributions Other sites 137 (25.3) Patients undergoing exams were reported. To evaluate the presence of an exponential growth over time for the number of the examined patients, Patients undergoing at least 1 exam 463 (85.6) the number and the cost of the exams performed in the None 78 (14.4) 3 months before death, generalized linear models were esti- 1 109 (23.5) mated on natural logarithm of the three measures considering 2 110 (23.8) time as an independent variable. Wald p value tests for expo- 3 96 (20.7) nential trend were reported. A p value < 0.05 was considered 4 73 (15.8) statistically significant. For the analysis of the subgroup of 5 33 (7.1) patients with a cancer diagnosis of up to 1 year prior to hospice 6 or more 42 (9.1) admission, absolute and relative variations were calculated. Radiological examinations (N)2091 All statistical analyses were performed using Stata 14.1 for Mean per patient ± SD (exams) 3.9 ± 3.2 Windows (StataCorp LP, College Station, TX). 25, 50, and 75 percentiles 1, 3, 5 By type of exam X-ray 1198 (57.3) Results CT scan 796 (38.1) MRI 61 (2.9) We found a total of 541 deceased cancer patients in the two Interventional procedures 36 (1.7) hospices during the considered periods with 17 ± 18 days of Costs mean last hospice stay (range, 0–147). The general character- Total cost of exams 150,698.00 € istics of the study population are reported in Table 1. Table 1 Mean per patient ± SD 278.60 € ± 270.20 € also shows that a total of 463 (85.6%) patients underwent ≥ 1 25, 50, and 75 percentiles 41.8, 225.2, 447.3 radiological exam in the 3 months before last admission. Of By type of exam these, 76.5 and 9.1% underwent ≥2and ≥6radiological X-ray 25,773.40 € exams, respectively. The mean of radiological exams was CT scan 104,291.10 € 3.9 ± 3.2 per patient, with a total of 2091 radiological exams MRI 15,904.40 € performed on 541 patients. If calculated on the 463 patients Interventional procedures 4729.10 € that underwent ≥ 1 exam, the mean number of exams per patient rose to 4.51 ± 3.0. Data sources Even though the majority of performed exams was repre- sented by X-ray (1198, 57.3%), 893 (42.7%) CT scans, MRI, In both centers, patients were identified through hospice elec- and interventional exams were performed in the last 90 days tronic patient charts, from which date of death was retrieved. In before last admission to hospice. The total cost of the exams Piacenza, patients’ data were cross-checked with the Radiology was 150,698.00 €. The distribution of the costs among the Information System archive of the Radiology Department, patients shows that for 162 (30%) cases, the cost was lower 2204 Support Care Cancer (2018) 26:2201–2208 Fig. 1 Cost distribution among 541 patients (€) 278.6 Paents* *each column represents a single paent than 2780.65 €, whereas for 54 (10%) cases, the cost was Subdividing the 90-day period in three periods of higher than 45,758.60 €. The mean cost was 325.50 € per 1 month each (M-3, M-2, M-1) (Table 2)and examining patient undergoing exams, and 278.60 per patient in the pop- the trend of the performed examinations, we noticed a ulation (Fig. 1). The total cost for CT scans, MRI, and inter- clear increase in the trend approaching hospice admission. ventional exams was 124,924.60 €, accounting for 83.0% of In fact, 37.3, 41.6, and 64.0% of patients performed ≥ 1 the global expense. The mean number of exams and cost per radiological exam at M-3, M-2, and M-1, respectively patient in the two towns was similar (data not shown). (p = 0.002). Also, the number of the exams performed Table 2 Number of examined patients by radiological exams and number of radiological exams by type of exam 3 months (M-3), 2 months (M-2), and 1 month (M-1) before last hospice admission M-3 M-2 M-1 p value Wald N (%) N (%) N (%) statistic Patients undergoing at least 1 exam 202 (37.3) 225 (41.6) 346 (64.0) 0.002 By type of exam X-ray 142 (26.3) 159 (29.4) 287 (53.0) 0.007 CT scan 92 (17.0) 127 (23.5) 173 (32.0) < 0.001 MRI 11 (2.0) 20 (3.7) 22 (4.1) 0.031 Interventional procedures 5 (0.9) 10 (1.8) 12 (2.2) 0.015 Radiological exams Radiological exams 446 (21.3) 625 (29.9) 1020 (48.8) < 0.001 Mean per patient 0.8 ± 1.4 1.2 ± 1.8 1.9 ± 2.3 – 25, 50, and 75 percentiles 0, 0, 1 0, 0, 2 0, 1, 3 – By type of exam X-ray 243 (54.5) 315 (50.4) 640 (62.7) < 0.001 Mean per patient 0.4 ± 1.0 0.6 ± 1.2 1.2 ± 1.7 – CT scan 187 (41.9) 276 (44.2) 333 (32.6) < 0.001 Mean per patient 0.3 ± 0.9 0.5 ± 1.1 0.6 ± 1.1 – MRI 11 (2.5) 22 (3.5) 28 (2.7) 0.003 Mean per patient 0.0 ± 0.1 0.0 ± 0.2 0.1 ± 0.3 – Interventional procedures 5 (1.1) 12 (1.9) 19 (1.9) < 0.001 Mean per patient 0.0 ± 0.1 0.0 ± 0.2 0.0 ± 0.3 – Cost (€) 541 Support Care Cancer (2018) 26:2201–2208 2205 Table 3 Cost of procedures (€) 3 months (M-3), 2 months (M-2), and 1 month (M-1) before last hospice admission M-3 M-2 M-1 p value Wald statistic Total cost of exams 33,698.20 € (22.4%) 51,088.80 € (33.9%) 65,911.00 € (43.7%) < 0.001 Mean total cost/patient 62.30 ± 143.00 94.40 ± 169.60 121.80 ± 181.80 – 25, 50, and 75 percentiles 0, 0, 34.90 0, 0, 101.80 0, 23.20, 188.00 – Cost by type of exam X-ray 5152.10 € (3.4%) 6828.00 € (4.5%) 13,793.50 € (9.2%) < 0.001 Mean per patient 9.50 ± 21.10 12.60 ± 27.60 25.50 ± 38.50 – CT scan 24,566.20 € (16.3%) 36,563.50 € (24.3%) 43,161.20 € (28.6%) < 0.001 Mean per patient 45.40 ± 118.40 67.60 ± 144.90 79.80 ± 142.60 – MRI 3234.40 € (2.1%) 6182.30 € (4.1%) 6487.70 € (4.3%) 0.051 Mean per patient 6.00 ± 48.40 11.40 ± 61.10 12.00 ± 70.40 – Interventional procedures 745.50 € (0.5%) 1515.00 € (1.0%) 2468.70 € (1.6%) < 0.001 Mean per patient 1.40 ± 15.70 2.80 ± 21.60 4.60 ± 30.80 – increased nearing hospice admission: 446 (21.3%) at M-1, Discussion 625 (29.9%) at M-2, and 1020 (48.8%) at M-3 (p < 0.001). This trend was reflected in the mean number Our results confirmed the increase in the number of diagnostic of exams performed per patient, which increased from less exams carried out in the last months of a patient’slife, which, than 1 (0.8 ± 1.4) at M-3 to almost 2 (1.9 ± 2.3) at M-1. however, did not always offer an advantage in terms of sur- As showninTable 2, the examined patients and number vival [6, 18]. In our study, considering the number of patients of radiological exams increased from M-3 to M-2 and undergoing at least one radiological exam in the 90 days be- from M-2 to M-1. fore last admission to hospice, we found that both the number Table 3 shows that the total costs of the exams were of exams and the relevant costs had a statistically significant 33,698.20 € at M-3, 51,088.80 € at M-2, and 65,911.00 € increase approaching death. A total of 37.3 and 64.0% of at M-1 and were significantly different (p <0.001). The patients underwent at least one radiological exam up to mean cost per patient was twofold higher at M-1 than at 3 months and up to 1 month before hospice admission, M-3 (62.30 € ±143.00 € at M-3, 94.40 € ± 169.60 at M-2, respectively. and 121.80 € ± 181.80 € at M-1). The analysis of the use As imaging procedures have no diagnostic purpose in ad- of the resources for the 86-patient group (55% females, vanced patients, they can be justified only in view of the mean age 67.23 ± 13.71 years) diagnosed with cancer up management of acute symptoms, evaluation of disease pro- to 1 year before last hospice admission shows that the gression, and assessment of treatment effect. The latter can be primary cancer sites were the gastrointestinal tract useful for evaluating whether to discontinue and/or change the (22.1%), the breast (15.1%), the lung (14.0%), and others treatment line [6, 14, 15, 18]. The use of diagnostic imaging, (48.8%). At M3/0, the total number of performed proce- however, is still widespread despite the present guidelines dures was 3305, of which 2613 (79.1%) were performed [19]. In particular, we observed that it did not reduce as death on outpatients, and 692 (20.9%) on inpatients. At M12/9, was nearing; rather, it increased, resulting in higher healthcare the total number of performed procedures was 2404, of costs. We also noticed a rising number of diagnostic invasive which 2008 (83.5%) were performed on outpatients and procedures from M3 to M1, even if the absolute number was 396 (16.5%) on inpatients. We observed a higher number low. The role of these procedures is as yet unclear. On the one of procedures performed in the inpatient than in the out- hand, given that their palliative purpose supports their appro- patient setting from M12/9 to M3/0 with an absolute in- priateness at EoL [20], we would expect a more intensive use crease of 901 exams (relative increase +37.5%) nearing than that seen in our case mix. On the other hand, their inva- death. The mean number of exams (±SD) ranged from siveness and potential comorbidity should be carefully evalu- 27.95 ± 23.21 at M12/9 to 38.43 ± 28.62 at M3/0. As ated against any real therapeutic benefit [15]. regards the costs, we found that before the last admission We firmly believe that costs for healthcare services in the they amounted to 735,990.70 € at M3/0 and to 553,814.10 last year of life are high, despite the fact that a recent study has € at M12/9, with an absolute difference of 182,176.50 €, advocated the Bmyth^ of a costly EoL care, which would and a relative increase of the global expenses by 32.9% represent only a minority of the total annual expenditure in approaching admission (Table 4). the USA [21]. However, most authors agree in considering the 2206 Support Care Cancer (2018) 26:2201–2208 Table 4 Costs at two different time periods (M3/0 and M12/9) for 86 patients from diagnosis (at least 1 year before death) to death Variable M3/0 M12/9 Differences M3/0–M12/9 Absolute Relative % Total exams 3305 2404 + 901 + 37.5 Mean per patient ± SD 38.43 ± 28.62 27.95 ± 23.21 25, 50, and 75 percentiles 16, 33, 53 10.25, 22, 40.50 Total costs for outpatients 54,599.10 € 91,158.10 € − 36,559.00 € − 40.1 Total costs for inpatients 681,391.60 € 462,656.00 € 218,735.50 € +47.3 Total costs (overall) 735,990.70 € 553,814.10 € 182,176.50 € +32.9 By type of exam Hematological exams (N) 1830 1046 + 784 + 75.0 Mean per patient ± SD 21.28 ± 23.69 12.16 ± 17.09 25, 50, and 75 percentiles 2.25, 13, 33 0, 3.5, 17.5 X-ray (N) 150 61 + 89 + 145.9 Mean per patient ± SD 1.74 ± 1.70 0.71 ± 1.18 25, 50, and 75 percentiles 0, 1, 3 0, 0, 1 CT scan (N) 124 118 + 6 + 5.1% Mean per patient ± SD 1.44 ± 1.47 1.37 ± 1.52 25, 50, and 75 percentiles 0, 1, 2.75 0, 1, 2 MRI (N)13 15 − 2 − 13.3 Mean per patient ± SD 0.15 ± 0.58 0.17 ± 0.65 25, 50, 75 and percentiles 0, 0, 0 0, 0, 0 Invasive procedures (N) 137 41 + 96 + 234.1 Mean per patient ± SD 1.59 ± 2.56 0.48 ± 0.95 25, 50, 75 and percentiles 0, 1, 2 0, 0, 1 Intravenous chemotherapy (N) 116 190 − 74 − 38.9 Mean per patient ± SD 1.35 ± 2.04 2.21 ± 3.99 25, 50, and 75 percentiles 0, 0, 2 0, 0, 3 Other therapeutic services (N) 240 163 + 77 + 47.2 Mean per patient ± SD 2.79 ± 3.41 1.90 ± 3.44 25, 50, and 75 percentiles 0, 2, 4 0, 0, 3 Radiotherapy (N)91 397 − 306 − 77.1 Mean per patient ± SD 1.06 ± 3.74 4.62 ± 13.04 25, 50, and 75 percentiles 0, 0, 0 0, 0, 0 Visits (N) 388 285 + 103 + 36.1 Mean per patient ± SD 4.51 ± 3.41 3.31 ± 4.41 25, 50, and 75 percentiles 2, 4, 7 1, 2, 4.75 Ultrasound, ECG, and nuclear medicine tests (N) 216 88 + 128 + 145.5 Mean per patient ± SD 2.51 ± 2.39 1.02 ± 1.41 25, 50, and 75 percentiles 0.25, 2, 4 0, 0, 1.75 N, number costs of EoL care a major item of healthcare expenditure. the latter is considered appropriate only in a few cases. Comparing data from the last 3 months of life with those from Conversely, the percentage of invasive procedures, such as 9 months back to 1 year before death in our subgroup analysis, X-ray, ultrasound, ECG, and nuclear medicine tests, showed we found that a higher number of procedures were performed an increase at EoL. From a methodological point of view, we at M3/0 for almost all the considered procedures, with higher adapted Yabroff’s[22] timeframe definitions (M12/9 and M3/ corresponding costs. Chemotherapy and radiotherapy admin- 0), interpreting M12/9 as the Bcontinuous care phase^ and istrations were the only procedures that were reasonably re- M3/0 as the BEoL phase.^ We acknowledge, however, that it duced by M3/0, as the former is usually avoided at EoL and is quite difficult to make any direct comparison with other Support Care Cancer (2018) 26:2201–2208 2207 studies on costs at EoL due to the different timeframes References adopted (i.e., 3 days [23], 7 days [24], or 30 days [14]before death). 1. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block SJ (2003) Identifying potential indicators of the quality of end-of-life cancer The main limitation of this retrospective study is the lack of care from administrative data. Clin Oncologia 21(6):1133–1138 any information about the clinical indications or the patient’s 2. Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, preferences for these procedures. 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Journal

Supportive Care in CancerSpringer Journals

Published: Feb 1, 2018

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