Survival and Cost-Effectiveness of Hospice Care for Metastatic Melanoma Patients | Page 2
Published Online: May 20, 2014
Jinhai Huo, PhD, MD, MPH; David R. Lairson, PhD; Xianglin L. Du, MD, PhD; Wenyaw Chan, PhD; Thomas A. Buchholz, MD; and B. Ashleigh Guadagnolo, MD, MPH
The cost-effectiveness analysis utilized the mean of costs from all 3 phases of cancer care and survival. The incremental cost-effectiveness ratio (ICER) = (C1 - C2) / (E1 - E2) = ΔC / ΔE, where Cx equals cost of group x and Ex is effectiveness at group x, with the quotient representing cost per life-year gained. In the cost-effectiveness model, a bootstrap simulation analysis was implemented to assess the statistical uncertainty. We performed an analysis with 1000 bootstrap estimates of the ICER in both the original cohort and the 1:5 matched cohort. Statistical analysis was conducted using SAS version 9.3 (SAS Institute, Inc, Cary, North Carolina).
Patient and Tumor Characteristics
Characteristics of the entire cohort and matched cohort as well as univariate analysis of hospice use and patient characteristics are shown in Table 1. Of 862 patients, 225 (26%) had no hospice care after diagnosis, 523 (61%) had 1 to 3 days of hospice care, and 114 (13%) had 4 or more days of hospice care. All covariates were evenly balanced in the matched cohort.
At the end of the 60-month study period, the unadjusted survival curves for the entire cohort categorized by hospice use are shown in Figure 1A. The median survival time was 6.1 months for patients who did not enroll in hospice, 6.5 months for patients who enrolled in hospice for 1 to 3 days, and 10.2 months for patients who enrolled in hospice for 4 or more days. The survival curves for the propensity score–matched cohort after combining the groups of patients with no hospice use or only 1 to 3 days of hospice use are shown in Figure 1B. The overall survival rates at all-time points for the patients enrolling in 4 or more days of hospice care were significantly better than those for the comparison group (log-rank test, P <.001). In Cox proportional hazards models, 4 or more days of hospice care was associated with an improvement in survival when adjusting for other characteristics (Table 2). The estimated improvements in survival for 4 or more days of hospice use were similar in the original-cohort Cox proportional hazards model (HR, 0.63; 95% CI, 0.52-0.77, P <.0001) and propensity score–matched model (HR, 0.66; 95% CI, 0.54-0.81, P <.0001). Patients enrolled in 4 or more days of hospice care had 3.9 months longer median survival time in the unmatched cohort model (P <.0001), and 3.3 months longer median survival time in the propensity score–matched cohort model (P <.0001). The findings were similar across various models and cohorts, suggesting that the overall association between 4 or more days of hospice use and reduced mortality was not affected by statistical modeling methods.
The mean overall costs of care from diagnosis until death for patients with metastatic melanoma was $56,266 for patients who received no hospice care, $49,411 for patients enrolled in 1 to 3 days of hospice care, and $66,022 for patients enrolled in 4 or more days of hospice care. As shown in Figure 2 (A, B, and C), patients with 4 or more days of hospice care had lower costs in the last 3 months of life than did patients from the other 2 groups (P <.0001, $14,594 vs $22,647 for the patients with 1-3 days of hospice care, vs $28,923 for patients with no hospice care). The end-of-life costs of care for patients with 1 to 3 days of hospice care were also lower than those of patients who received no hospice care.
Predictors of End-of-Life Cost
We found age and use of hospice care to be the only factors significantly associated with end-of-life costs. Among patients who were enrolled in 4 or more days of hospice care, the end-of-life costs decreased by $14,680 (P <.0001) in the model with the original cohort, and by $9576 (P <.0001) in the model with propensity score–matched cohort.
As shown in Figure 3A, mean incremental cost was $29,426 (95% CI, $723-$63,634) per life-year gained for patients who received 4 or more days of hospice care. The incremental cost increased to $33,209 (95% CI, $12,852- $66,280) per life-year gained in the propensity score–matched cohort in Figure 3B.
We observed that patients who enrolled in hospice for 4 or more days experienced longer median survival than patients who did not use hospice care or who enrolled in hospice care for only 1 to 3 days after being diagnosed with metastatic melanoma. We performed sensitivity analyses to examine the survival time for a relatively homogeneous cohort in which we excluded patients who died within 3 months of diagnosis to eliminate those with particularly rapid pace of disease. The positive association between 4 or more days of hospice use and longer survival was similar to that for the initial study cohort.
Our results are consistent with those of previous studies showing that election of hospice care does not shorten survival after metastatic cancer diagnosis.5,6 In a study by Connor and colleagues, patients with congestive heart failure, lung cancer, or pancreatic cancer who enrolled in hospice experienced significantly longer median overall survival than those who did not. Our findings that median survival time did not differ between patients who received no hospice care and those who only received 1 to 3 days of hospice care is consistent with results from Earle and colleagues,17 suggesting that a short stay in hospice may not impact survival.7,18-20
We also found that the costs of care in the final 3 months of life were lower among patients who received 4 or more days of hospice care after metastatic melanoma diagnosis. Other researchers have shown that patients close to the end of life who received hospice care incurred less cost than other patients.21,22 Pyenson and colleagues analyzed Medicare claims from 1999 to 2000 and found that hospice enrollment was a significant predictor of lower costs among patients with congestive heart failure, liver cancer, and pancreatic cancer, even when controlling for age and gender.21 The cost difference we observed between the patients receiving 4 or more days of hospice care and those who received 0 to 3 days of hospice care is consistent with that observed by Pyenson and colleagues. Furthermore, our observed incremental cost-effectiveness ratio for patients who received 4 or more days of hospice care ($29,000 per life-year gained) lies well below the current willingness- to-pay thresholds.23
Our study has current policy relevance given that the proportion of Medicare expenditures during the last year of life has been stable for 20 years, with 26.9% to 30.6% of all Medicare expenditures occurring during that interval.24 Furthermore, Lubitz and colleagues found that 70% of total costs of care is attributable to the consumption of healthcare resources in the last 6 months of life, with the largest percentage of this cost burden falling to Medicare (61% of costs), followed by Medicaid (10%), other payers (12%), and patients or families (paying the remaining 18% out of pocket).24,25 Taylor and colleagues quantified the cost savings for the Medicare patients who received hospice care26 and found the average cost savings for hospice users to be $2309 for the last year of life compared with the costs of care for patients not receiving hospice care.26
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