End-of-life conversations associated with lower medical expenses

Few physicians are eager to discuss end-of-life care with their patients. Yet such conversations may result in better quality of life for patients and could lower national health care expenditures for cancer care alone by tens of millions of dollars each year, according to a study led by Harvard researchers at Dana-Farber Cancer Institute.

As reported today in the Archives of Internal Medicine, investigators interviewed 603 advanced-cancer patients about whether they had end-of-life (EOL) conversations with their physicians. The researchers calculated the final week health care costs of patients who reported such conversations and compared them with the costs incurred by patients who did not.

They found that patients who reported having an EOL conversation had an estimated average of $1,876 in health care expenses during their final week of life, compared with $2,917 for those who didn’t, a difference of $1,041, or 36 percent.  Higher costs — typically the result of more intensive, life-prolonging care — were also associated with a worse quality of death during patients’ final week. In addition, patients typically did not live longer if they received intensive care.

“We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive, burdensome, noncurative care, like being on a ventilator in an intensive care unit, to less costly comfort care provided at home or in hospice, which most patients and their families say they would prefer,” said the study’s senior author, Holly Prigerson, of Dana-Farber, and an associate professor of psychiatry at Harvard Medical School.

“As the nation looks to ways to improve patient care and reduce costs of health care, end-of-life conversations should be considered,” Prigerson said. “Policies that promote increased communication, such as incentives for end-of-life conversations, may be cost-effective ways to both improve care and reduce some of the rising health care expenditures.”

Previous studies have shown that a disproportionate share of health care spending in the United States is incurred at the end of life and that patients who speak with their physicians about end-of-life preferences have fewer life-sustaining procedures and lower rates of intensive care admission. 

The study by Prigerson and her colleagues suggests a direct link between communications at the end of life with lower health care costs and better quality of life for patients with advanced cancers.

The paper is part of a multi-institutional study called Coping With Cancer. Funded by the National Institute of Mental Health and the National Cancer Institute, the study tracks the health and psychological state of 627 patients nationwide with advanced cancer.

Although the study doesn’t purport to show a cause-and-effect relationship between EOL conversations and lower medical costs, it does suggest a strategy for reducing such costs and for improving patients’ quality of life as death approaches, noted Prigerson, who is also on faculty at Brigham and Women’s Hospital (BWH). If the national proportion of patients reporting EOL discussions was increased to 50 percent, the annual cost savings could be more than $76 million, researchers estimated, based on the annual number of U.S. cancer deaths.

The study’s lead author is Baohui Zhang, of Dana-Farber. Co-authors are Susan Block of Dana-Farber and BWH; Alexi Wright, Craig Earle, and Matthew Nilsson of Dana-Farber; Haiden Huskamp, of Harvard Medical School; Matthew Maciejewski, of the University of North Carolina and the Durham (N.C.) Veterans Affairs Medical Center; and Paul Maciejewski of BWH.