The American Journal of Managed Care

Survival and Cost-Effectiveness of Hospice Care for Metastatic Melanoma Patients | Page 3

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
Emanuel27 challenged studies showing cost savings with hospice care, noting that several methodological issues could invalidate the findings of cost savings for hospice care, such as selection bias, different time frames for assessing costs, fewer cost components evaluated, and generalizability of the studies. Since that 1996 report, the methodology for analyzing cost implications of hospice care has improved—for instance, more medical cost data are available for evaluation compared with the 1990s, when only Medicare Part A was available. Moreover, the author concluded that the use of hospice does not increase costs and does yield better quality of life and increased autonomy at the end of life.27 Of the inherent limitations to the use of retrospective claims data, our study’s main limitation was inability to obtain data on patient and provider preferences regarding hospice election. Another limitation is that the outcome variable examined was limited to survival time, which does not capture effects on quality of life; therefore, quality-adjusted life-years, the preferred measure in cost-effectiveness studies, cannot be estimated. This measure is of particular value for patients at the end of life. Hospice care aims to provide a better quality of life, and indeed, previous studies have shown better quality of life for patients who enroll in hospice care.28-30 However, that the survival time of patients enrolled in hospice was longer than that of patients not electing hospice remains notable. Another consideration is that patients who survived longer might have had more opportunity to use hospice care and for longer durations than those who survived for a shorter period of time. Finally, the years encompassed by our study predate the diffusion of targeted molecular agents such as vemurafenib and ipilimumab, which have recently been shown to improve outcomes for patients with metastatic melanoma. 31 Therefore, it remains to be seen whether continued treatment with newer lifeprolonging treatments such as those mentioned might mitigate the survival improvement associated with 4 or more days of hospice use observed in our study.


Our study showed a significantly longer median survival time for the patients diagnosed with metastatic melanoma who enrolled in 4 or more days of hospice care compared with those who had 0 to 3 days of hospice care, and this improved overall survival was accompanied by lower end-of-life costs. Our evaluation of the survival times and costs of care contributes to the understanding of the potential clinical and economic effects of hospice care on outcomes for patients with metastatic melanoma. Implications of our findings are that communication and education regarding the benefits of hospice care should be a particular priority for patients diagnosed with metastatic melanoma.

Take-Away Points

  • Patients who enrolled in hospice for 4 or more days showed longer median survival than patients who did not use hospice care or who enrolled in hospice care for only 1 to 3 days after diagnosis with metastatic melanoma.

  • Among patients who were enrolled in 4 or more days of hospice care, the end-of-life costs decreased by $14,680 in the model with the original cohort, and by $9576 in the model with the propensity score–matched cohort.

  • The incremental cost was $29,426 per life-year gained for patients who received 4 or more days of hospice care.
Author Affiliations: Department of Health Services Research, University of Texas, MD Anderson Cancer Center, Houston, TX (JH); Division of Management, Policy and Community Health, University of Texas School of Public Health, Houston, TX (JH, DRL, XLD); Division of Epidemiology and Disease Control, University of Texas School of Public Health, Houston, TX (XLD); Division of Biostatistics, University of Texas School of Public Health, Houston, TX (WC); Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX (TAB, BAG).

Source of Funding: This study was supported in part by a grant from the Agency for Healthcare Research and Quality (grant # R01-HS018956) and in part by a grant from the Cancer Prevention and Research Institute of Texas (Multi-Investigator Award grant # RP101207).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JH, DRL, TAB, BAG); analysis and interpretation of data (JH, XLD, WC, BAG); drafting of the manuscript (JH, XLD, TAB, BAG); critical revision of the manuscript for important intellectual content (JH, DRL, XLD, WC, TAB, BAG); statistical analysis (JH, XLD, WC, BAG); administrative, technical, or logistic support (JH); supervision (DRL, BAG).

Address correspondence to: B. Ashleigh Guadagnolo, MD, MPH, Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. E-mail: aguadagn@mdanderson .org.
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Issue: May 2014
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