Fewer American Cancer Patients Now Dying in Hospitals

Pam Harrison

January 21, 2016

Fewer cancer patients die in the hospital in the United States than in other developed countries, and the rate has fallen in recent decades, according to an international study.

In 2010, 22.2% of cancer patients in the United States died in the hospital, whereas data from the 1980s show that more than 70% did.

This rate is the lowest of seven developed countries that were studied. The highest rates were seen in Belgium (51.2%) and Canada (52.1%).

The study also showed that American patients who do die in the hospital spend fewer days in the hospital during the last 6 months of life than in the other countries.

However, at least twice as many American patients who die of cancer are admitted to the intensive care unit (ICU) in the last 6 months of life, and more American patients receive chemotherapy in the last 6 months of life than in any other country

The findings come from an international study of end-of-life practices, which was published in the special January 19 issue of JAMA devoted to dying.

"The essential take-away from the study is that there is great variability across the nations in end-of-life practices, but we know now that we can reduce the intensity of care at the end of life in the United States and in other nations, and we know we need to move end-of-life care out of hospitals," lead author Justin Bekelman, MD, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, said in an interview posted on the JAMA website.

"We know that end-of-life care is expensive, intensive, and not consistent with the wishes of our patients, and we also know that too many patients are still dying in the hospital in the United States, but what we didn't know is how the United States compares with other countries," he said.

Study Details

The International Consortium for End-of-Life Research systematically examined patterns of care, healthcare utilization, and expenditures in patients older than 65 years who died with cancer in hospitals in 2010.

Data were analyzed for Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States. The mean age of those who died in any country was 78.5 to 79.5 years.

"What we know now is that the United States does not have the worst end-of-life care, but that no country is optimal," senior author Ezekiel Emanuel, MD, PhD, chair of the Department of Medical Ethics and Health Policy at the Perelman School of Medicine, said in a statement. "All countries have deficits."

Table. Hospitalization Rates and Costs During the Last 6 Months of Life



Mean per capita days spent in hospital Hospital expenditures (US$)* Mean hospital expenditures per day (US$) Overall hospitalization rates for cancer patients >65 years
Belgium 27.7 $15,699 $567 88.7%
Canada 19.0 $21,840 $1149 87.1%
England 18.3 $9352 $510 82.7%
Germany 2.17 $16,221 $748 69.9%
Netherlands 17.8 $10,936 $614 76.5%
Norway 24.8 $19,783 $1064 82.6%
United States 10.7 $18,500 $1729 74.7%

*Physician costs were excluded from hospital expenditures for the United States; but with physician costs, hospital expenditures could be an average of 11.5% higher.

Much Higher Rate of ICU Admissions

Despite having the second lowest overall rate of hospitalization, at 74.7%, for patients with cancer older than 65 years, more cancer patients older than 65 who died in the hospital were admitted to the ICU during the last 6 months of life in the United States than in other countries (40.3% vs <18%).

And the mean length of stay per capita was higher in the United States than in other countries (3.6 vs <1.5 days).

More patients received chemotherapy during the last 6 months in the United States than in Belgium, Canada, Germany, Norway, and the Netherlands (38.7% vs 33.0% vs 29.1% vs 28.2% vs 23.7% vs 18.1%). Chemotherapy rates for England were not reported.

"Over the last 30 years, recognition of preferences for home-based end-of-life care and patients' rights to refuse medical interventions and economic pressures to lower end-of-life costs and expand hospice use have all played an important role in advancing end-of-life care," Dr Bekelman and colleagues conclude.

"Yet excessive utilization of high-intensity care near the end of life, particularly in the United States relative to other developed countries, underscores the need for continued progress to improve end-of-life practices," they add.

Being Mortal Author Responds

The United States now has perhaps the highest level of hospice capacity and use — and the highest likelihood of patients dying at home — in the developed world, Atul Gawande, MD, MPH, from the Harvard T.H. Chan School of Public Health in Boston, who is author of the recent book, Being Mortal, about end-of-life care in the United States, writes in an accompanying editorial. (The study authors cite more than 5300 hospices in the United States, two-thirds of which provide home-based care).

Nevertheless, Dr Gawande feels that medical care for the symptoms people experience at the end of life does not seem to have gotten better in recent years; in fact, it might have gotten worse, he suggests.

Furthermore, there are not nearly enough skilled palliative and geriatric specialists for the more than 2 million people each year in the United States who die from multiple causes, he writes.

"The vital goal almost all people want from medicine is not having a good death but having as good a life as possible all the way to the very end," Dr Gawande insists.

Evidence indicates that the medical profession is neglecting this goal, not just in the United States, but globally too, he adds.

"People everywhere have essential needs aside from just living longer," Dr Gawande states.

"Medical practices, research, and policies must ensure that clinicians have the skills to understand those needs and have the capabilities to serve them for patients with life-limiting illness," he adds. "Death is not an inherent failure. Neglect, however, is."

The study was partly supported by the Commonwealth Fund and the National Institute on Aging. Dr Emanuel reports receiving speaking fees from numerous companies and organizations, and stock ownership in Nuna. Dr Bekelman has disclosed no relevant financial relationships. Dr Gawande reports receiving royalties and payments from publishers and media outlets worldwide for his writing and other media on medicine, including for a book and documentary film on care at the end of life.

JAMA. 2016;351:272-283, 267-269. Abstract, Editorial


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