Abstract
BackgroundInpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs.MethodsRetrospective cohort study using data from the Discharge Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital.ResultsThere were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement).ConclusionsIncreased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.
Highlights
Inpatient palliative care is associated with lower inpatient costs; this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset
Increased involvement of palliative care was associated with lower costs
There was large provincial variation in mean cost of terminal hospitalization episode with the highest median costs per day being in British Columbia (BC) British Columbia (Alberta) at $1250 (IQR 1022–1684) and the lowest median costs being in New Brunswick at $797 (IQR 657–1015)
Summary
Inpatient palliative care is associated with lower inpatient costs; this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs. In 2012 in Belgium, Canada, England, Germany, and Norway, the proportion of decedents who died in acute care hospitals ranged from 42 to 52% [1]. In 2018, 59.5% of all deaths in Canada occurred in hospital [2] These terminal hospitalizations (i.e., hospitalizations wherein a patient dies) are costly. Focusing on the last 180 days of life for patients with cancer, Canada had the highest per capita hospital expenditures at $21,840 USD, compared to the United States, Norway, Germany, Belgium, and the Netherlands [1]
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