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The American Journal of Managed Care May 2014
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Survival and Cost-Effectiveness of Hospice Care for Metastatic Melanoma Patients
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
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Survival and Cost-Effectiveness of Hospice Care for Metastatic Melanoma Patients

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
Hospice care is associated with improved median survival time for the patients diagnosed with metastatic melanoma, accompanied by decreased end-of-life costs.
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.

Cost Analysis

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.

Cost-Effectiveness Analysis

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

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.

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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