582123 research-article2015
PMJ0010.1177/0269216315582123Palliative MedicineKim et al.
Original Article
Does hospital need more hospice beds? Hospital charges and length of stays by lung cancer inpatients at their end of life: A retrospective cohort design of 2002–2012
Palliative Medicine 2015, Vol. 29(9) 808–816 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216315582123 pmj.sagepub.com
Sun Jung Kim1, Kyu-Tae Han2,3, Tae Hyun Kim3,4 and Eun-Cheol Park3,5
Abstract Background: Previous studies found that hospice and palliative care reduces healthcare costs for end-of-life cancer patients. Aim: To investigate hospital inpatient charges and length-of-stay differences by availability of hospice care beds within hospitals using nationwide data from end-of-life inpatients with lung cancer. Design: A retrospective cohort study was performed using nationwide lung cancer health insurance claims from 2002 to 2012 in Korea. Setting and participants: Descriptive and multi-level (patient-level and hospital-level) mixed models were used to compare inpatient charges and lengths of stay. Using 673,122 inpatient health insurance claims, we obtained aggregated hospital inpatient charges and lengths of stay from a total of 114,828 inpatients and 866 hospital records. Results: Hospital inpatient charges and length of stay drastically increased as patients approached death; a significant portion of hospital inpatient charges and lengths of stay occurred during the end-of-life period. According to our multi-level analysis, hospitals with hospice care beds tend to have significantly lower end-of-life hospital inpatient charges; however, length of stay did not differ. Hospitals with more hospice care beds were associated with reduction in hospital inpatient charges within 3 months before death. Conclusion: Higher end-of-life healthcare hospital charges were found for lung cancer inpatients who were admitted to hospitals without hospice care beds. This study suggests that health policy-makers and the National Health Insurance program need to consider expanding the use of hospice care beds within hospitals and hospice care facilities for end-of-life patients with lung cancer in South Korea, where very limited numbers of resources are currently available.
Keywords Hospice care, lung neoplasms, fees and charges, length of stay
What is already known about the topic? •• Healthcare costs of end-of-life cancer patients are very expensive; however, hospice and palliative care may reduce healthcare costs for end-of-life cancer patients.
1Department
of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Korea 2Department of Public Health, Yonsei University College of Medicine, Seoul, Korea 3Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea 4Department of Hospital Administration, Graduate School of Public Health, Yonsei University, Seoul, Korea
5Department
of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
Corresponding author: Eun-Cheol Park, Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. Email: [email protected]
Downloaded from pmj.sagepub.com at Univ. of Tasmania Library on September 26, 2015
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Kim et al.
What this paper adds? •• We found evidence that a significant portion of inpatient hospital charges and lengths of stay occurred during the end-of-life period. Hospitals with hospice care tend to have statistically significant lower end-of-life hospital charges for inpatients with lung cancer. In addition, hospitals with more hospice beds were associated with reduction in inpatient hospital charges within 3 months before death. Implications for practice, theory, or policy •• Expanded use of hospice beds within hospitals for end-of-life patients with lung cancer patients is required.
Introduction Over the past three decades, cancer has been the leading cause of death1 and is associated with the largest disease burden in Korea.2 Of all cancers, lung cancer has one of the highest fatality rates and is the leading cause of cancerrelated mortality in South Korea3 and worldwide.4 The latest statistics indicate that in 2010, there were 20,711 incident lung cancer cases (out of a total of 202,053 cancer cases; 71% male), 15,623 deaths (out of a total of 72,046 deaths; 73% male), and 43,564 prevalent lung cancer cases (total cancer prevalence: 960,654; 66% male) in Korea.5 In 2010, 72,046 cancer deaths were reported in Korea, with lung cancer accounting for 28.2% of all deaths, the highest cancer fatality rate in both males and females. Five-year survival rates for lung cancer are less than 20%, and the average survival time is approximately 6 months, one of the lowest survival rates, as most patients have advancedstage lung cancer at their initial diagnosis.5 Healthcare, in general, and cancer care, in particular, are very expensive.6 Moreover, the advancement of new cancer diagnostic and treatment methods contribute to rising costs for cancer care.7 These rising costs are outpacing inflation rates and each nation’s budgetary level; there are also questions regarding the cost–benefit of proven interventions by individuals and society.7 Ideally, more effective and less toxic care and treatments should be initiated; however, these innovations come at a greater expense.8 Healthcare utilization is statistically associated with dying, suggesting that a large proportion of expenditures occur in the last few months prior to death.9–11 In the United States, healthcare spending in the last year of life consumes approximately 27%–30% of the Medicare budget and has done so consistently over the past decades.11,12 Most of these costs were the result of life-sustaining care, with a significant portion of costs accrued from acute care in the final 30 days of life.12 Although patients with advanced cancer prefer to receive care and die at home,13,14 most patients die in hospitals.13–18 The structure and availability of healthcare resources appear to influence place of death more than the actual preference of patients and families.19–21 Previous studies confirmed that hospice care reduces total healthcare costs for the majority of Medicare
beneficiaries,22,23 and studies conducted in Europe and the United States revealed that the availability of palliative care and hospice programs may help avoid patient hospitalization and reduce costs.24–38 It has also been suggested that the establishment of palliative care programs is a way to improve the quality of life for terminally ill patients and their families and also to reduce utilization of expensive acute care hospital resources.39 Although hospice care was first introduced in 1960s in Korea, a reimbursement system for hospice care from the National Health Insurance (NHI) is not yet available; instead, costs are reimbursed as normal inpatient care where hospitals do not have incentive to acquire hospice beds, as these require more resources than ordinary beds.40 Around 10% of cancer deaths used hospice care in this country; an excess of demand over supply has been presented.41 In Korea, 70% of deaths occur at hospitals;42 however, no research has been conducted regarding healthcare charges and length-of-stay differences according to the availability of hospice beds within hospitals in this country. It is very important to have hospice beds in order to maintain a financially viable NHI program. In this retrospective cohort study, using 10 years of nationwide health insurance claim data for end-of-life patients with lung cancer, we sought to investigate differences in hospital inpatient charges and length of stay by hospice care availability within hospitals.
Methods Data collection and construction We collected all nationwide claim data from inpatients with lung cancer from 2002 to 2012 in November 2013. Lung cancer patients were defined according to the International Classification of Diseases-10 (ICD-10) codes C33–C34. This dataset contained health insurance claim details including inpatient costs covered by NHI, length of stay, admission date, date of death, age, sex, days in the intensive care unit (ICU), and days on a ventilator during hospitalization.
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In order to measure the severity of disease, we calculated the progression of lung cancer using the dataset. Using all previous claims, we identified the new lung cancer cases for each year. For example, we searched all claim records from 2002 to 2005 in order to detect new lung cancer cases in 2006. If a patient had no record from 2002 to 2005, then we assumed that the patient was newly diagnosed in 2006. Using this method, we calculated the year of diagnosis for lung cancer for all patients. We included only patients who died with lung cancer and transposed the dataset to a retrospective cohort design, with the death of each patient serving as the baseline. In order to investigate trends and factors influencing hospital inpatient charges and length of stay in patients with lung cancer, we aggregated each patient’s hospital inpatient charges and length of stay on a monthly basis up to 12 months before death. We selected the time period of 12 months before death to ascertain end-of-life lung cancer hospital inpatient charges and length of stay. Inpatient hospital charges are the sum of fee-for-service (FFS) claims for each patient’s hospitalization. With the establishment in South Korea of a NHI program in 1989, all types of hospitals generally use a FFS reimbursement system (hospitals submit claims to NHI and are then reimbursed).43 Patients have considerable freedom to choose and access care providers; there are no restrictions on the use of primary, secondary, and tertiary medical institutions, nor are there no penalties for repeated care.44,45 In Korea, the FFS catalog is negotiated by the government, providers, and other stakeholders every year. Using each year’s negotiated FFS catalog, we adjusted inpatient costs to 2002 levels, and to investigate the impact of hospice care, we created a dummy variable, namely, availability of hospice beds within hospitals. The mean foreign exchange (FX) rate was US$1 = 1251.20 South Korean Won (KRW) in 2002 (cf. mean 2012 FX rate: US$1 = 1126.88 KRW). We deleted the 2002 dataset as it was the baseline for measuring each patient’s cancer progression. Furthermore, we excluded patients diagnosed with lung cancer more than 5 years prior, assuming those patients had different costs and utilization patterns due to their longer survival times. Finally, we excluded patients with inpatient total costs of less than 200,000 KRW, assuming those hospitalizations were not relevant to inpatient cancer treatment. This study did not calculate non-covered services due to the limitations of the claim dataset. Hospital-level data included hospital classification (large: more than 300 beds; small: less than 299 beds) and structural factors such as the number of beds, number of specialists, number of nurses, teaching status (presence of residents), and number of hospice beds. The hospital-level data were obtained from the agency for Health Insurance Review and Assessment Services. Using 673,122 inpatient health insurance claims, we obtained aggregated healthcare charges and utilization data from a total of 114,828 patient records and 866 hospitals.
Statistical analysis First, we examined the characteristics of nationwide inpatients with lung cancer and hospitals where the patients were admitted at their time of death. Then, we examined trends of hospital inpatient charges and lengths of stay by monthly intervals up to 12 months before death. Student’s t-test and an analysis of variance were used to compare mean hospital inpatient charges and length of stay by hospice care availability. We used multi-level mixed models by employing the “Proc Mixed” procedure and random intercept effects from SAS in order to account for hierarchical data structure. The unit of analysis was individual patients nested within hospitals, and the model analyzed the patient-level and hospital-level characteristics together. We used the model in order to avoid problems created by possible nesting of patient-level observations within clusters (hospitals) and overestimation of significance. We adjusted patient-level and hospital-level confounders. We sought to investigate each patient’s hospital inpatient charges for the last 1, 3, 6, and 12 months as well as the length of stay before death. SAS 9.2 (SAS Institute, Cary, NC, USA) was used for all calculations and analyses. All statistical tests were two tailed, and we rejected null hypotheses of no significant difference if p values were less than 0.05. This study was approved by the Institutional Review Board of Graduate School of Public Health, Yonsei University (IRB Number: 2014-203) and also followed STROBE guidelines.
Results An overall trend of hospital inpatient charges and length of stay by patients with lung cancer at the end of their lives is presented in Figure 1. Hospital inpatient charges, length of stay, and rate of patient admission drastically increased until death, particularly in the last 3 months before death. Table 1 shows the baseline characteristics of nationwide patients with lung cancer and the hospitals where they were admitted. As our study investigates hospital inpatient charges and length of stay retrospectively from time at death, 114,828 patients met our cohort definition. Most patients were male, and the mean age was 68.4 years. More than 80% of patients died during their diagnosis year (year 1: 52.3%) or in the following year (year 2: 31.3%). More patients were admitted to large teaching hospitals without hospice care. Table 2 depicts the entire episode, as well as the last 1, 3, 6, and 12 months of hospital charges and length of stay for inpatients with lung cancer, by availability of hospice care within hospitals. We found that a significant portion of hospital inpatient charges and lengths of stay occurred at the end of life, and hospitals with hospice care had episodes with higher hospital charges and lengths of stay; however, this difference was not statistically significant in the last 1 and 3 months before death. Hospitals with hospice care
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Kim et al.
Figure 1. Discounted hospital inpatient charges and length of stay among nationwide patients with lung cancer at the end of life.
were more likely to be large teaching hospitals yet rank lower in terms of hospital structural factors (i.e. fewer numbers of beds, nurses, and physicians). The results of the multi-level mixed model analysis are presented in Table 3. The results were conducted by designated periods (the last 1, 3, 6, and 12 months before death) and showed that hospitals with hospice care tended to have significantly lower hospital inpatient charges for lung cancer, yet not for length of stay. Patients with lung cancer who had more ICU days, a higher admission frequency, more ventilator days, higher episode hospital charges, and earlier death from the point of diagnosis were associated with higher end-of-life hospital charges. Large hospitals and teaching hospitals were associated with higher hospital inpatient charges as well. Other hospital-level variables were also significant, although the effect was minimal. We conducted this analysis by adding an interaction variable (hospice care × time); however, none of the coefficients were significant in any model. Due to the skewing of distribution for hospital inpatient charges and length of stay, we conducted a sensitivity analysis by taking the natural log of each dependent variable (Table 4). The results were the same, and the effect of hospice care was greatest in the last 1 and 3 months before death (a more than 2% reduction in hospital inpatient
charges). A sensitivity analysis conducted only with hospitals with hospice care is presented in Table 5. The results show that a greater number of hospice beds were associated with a reduction in hospital inpatient charges within the last 3 months before death for patients with lung cancer (0.39% and 0.23% reduction in charges for each hospice months before death, bed increase for 1 and 3 respectively).
Discussion In this study, we examined the association between hospice care and individual patients with lung cancer, regarding hospital inpatient charges and length of stay at the end-oflife stage. The nationwide dataset used for this study spanned over a decade and included all patients with lung cancer in the NHI program. We used multi-level mixed models to compare hospital inpatient charges and length of stay within the last 1, 3, 6, and 12 months before death. Our results agree with those of previous research that most patients were hospitalized at the end of their life, particularly in the last 3 months before death. Most inpatient charges occurred in that period as well. Regarding the impact of hospice care availability, patients admitted to hospitals with hospice care used fewer inpatient hospital
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Table 1. Characteristics of inpatients with lung cancer and hospitals at the time of death.
Patient characteristics Number of patients Sex Male Female Years of cancer progression at death 1 = death at diagnosed year 2 = death within 2 years after diagnosis 3 = death within 3 years after diagnosis 4 = death within 4 years after diagnosis 5 = death within 5 years after diagnosis Age at death (years)a Episode admission frequencya Episode ICU daysa Episode ventilator daysa Hospital characteristics Number of inpatients within hospice care hospitals Yes No Number of inpatients by hospital type Large Small Number of inpatients by hospital teaching status Teaching Nonteaching Number of bedsa Number of nursesa Number of physiciansa
N
%
114,828
87,586 27,242
76.3 23.7
60,110 35,941 11,231 4506 3040 68.4 5.2 1.1 1.4
52.3 31.3 9.8 3.9 2.6 10.7 5.6 5.8 7.2
29,660 85,168
25.8 74.2
106,114 8714
92.4 7.6
94,480 20,348 867.0 515.3 384.0
82.3 17.7 592.7 485.9 376.1
ICU: intensive care unit; SD: standard deviation. aMeans/SD.
resources; however, no differences were found in length of stay. The results of our study deliver a significant message to policy-makers and the NHI program: the high cost of endof-life care for inpatients with lung cancer may have no impact on extending life as compared to hospice care, although significant hospital inpatient charge reductions were found in hospice care hospitals. As noted, palliative care is a way to improve the quality of life of terminally ill patients and their families, as well as to reduce the utilization of expensive life-sustaining acute care hospital resources.39 Few studies are available regarding cancer pain and psychosocial intervention, according to a recently conducted meta-analysis in Korea; additionally, further studies are also needed on the quality of care patients with cancer receive, as the number of patients with cancer has dramatically increased in Korea.5 Hospice care and palliative care are other areas that could use improvement, as there are an estimated 1 million cancer survivors, accounting for 1.9% of the entire population in Korea, who have received life-extending cancer
treatment.46 In Korea, hospice care is only available at a limited number of hospitals and with a limited number of hospice beds (44 hospitals, 707 total hospice beds). An expansion of hospice bed numbers within hospitals as well as specialized hospice care facilities is required for a financially viable NHI program, as hospice care reduces the overall lung cancer burden and provides a greater quality of life to patients. The dataset we used, encompassing data from the last decade of all nationwide lung cancer inpatients as well as the hospitals where they were admitted, contributes to the robustness of our study. The increase in the number of adults living with advanced and complex chronic illnesses and the increase in expenditures for these patients highlight the need for efficient models, such as palliative care that delivers quality services to complex patient populations.33 This study has several limitations worth noting, and caution must be taken when interpreting the study’s results or attempting to generalize its findings. Although we analyzed all nationwide inpatient claims for lung cancer
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Kim et al. Table 2. Hospital inpatient charges and length of stay for lung cancer patients and hospital characteristics by hospice care availability. With hospice care
Without hospice care
p
Mean (KRW)
SD
Mean (KRW)
SD
Patient level Episode cost Last 1 month Last 3 months Last 6 months Last 12 months Episode LOS Last 1 month Last 3 months Last 6 months Last 12 months
12,286,122 1,830,040 4,900,559 7,048,656 9,339,277 51.2 8.0 22.4 31.6 40.6
12,226,949 2,749,945 5,573,019 7,476,771 9,527,855 51.3 9.3 21.7 31.0 40.2
11,629,398 1,854,019 4,839,049 6,823,869 8,880,810 50.1 8.0 22.3 31.3 39.6
12,177,256 2,916,323 5,839,024 7,716,447 9,637,487 53.2 9.3 22.0 31.6 41.0
Hospital level Number of hospitals Number of hospice beds Hospital teaching statusa Teaching Nonteaching Hospital typea Large Small Number of beds Number of nurses Number of physicians
44 14.2
822
5.8
32 12
72.7% 27.3%
38 6 809.1 433.7 319.5
86.4% 13.6% 245.5 211.5 150.4
111 711 271 551 887.2 543.7 406.5
PMJ0010.1177/0269216315582123Palliative MedicineKim et al.
Original Article
Does hospital need more hospice beds? Hospital charges and length of stays by lung cancer inpatients at their end of life: A retrospective cohort design of 2002–2012
Palliative Medicine 2015, Vol. 29(9) 808–816 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216315582123 pmj.sagepub.com
Sun Jung Kim1, Kyu-Tae Han2,3, Tae Hyun Kim3,4 and Eun-Cheol Park3,5
Abstract Background: Previous studies found that hospice and palliative care reduces healthcare costs for end-of-life cancer patients. Aim: To investigate hospital inpatient charges and length-of-stay differences by availability of hospice care beds within hospitals using nationwide data from end-of-life inpatients with lung cancer. Design: A retrospective cohort study was performed using nationwide lung cancer health insurance claims from 2002 to 2012 in Korea. Setting and participants: Descriptive and multi-level (patient-level and hospital-level) mixed models were used to compare inpatient charges and lengths of stay. Using 673,122 inpatient health insurance claims, we obtained aggregated hospital inpatient charges and lengths of stay from a total of 114,828 inpatients and 866 hospital records. Results: Hospital inpatient charges and length of stay drastically increased as patients approached death; a significant portion of hospital inpatient charges and lengths of stay occurred during the end-of-life period. According to our multi-level analysis, hospitals with hospice care beds tend to have significantly lower end-of-life hospital inpatient charges; however, length of stay did not differ. Hospitals with more hospice care beds were associated with reduction in hospital inpatient charges within 3 months before death. Conclusion: Higher end-of-life healthcare hospital charges were found for lung cancer inpatients who were admitted to hospitals without hospice care beds. This study suggests that health policy-makers and the National Health Insurance program need to consider expanding the use of hospice care beds within hospitals and hospice care facilities for end-of-life patients with lung cancer in South Korea, where very limited numbers of resources are currently available.
Keywords Hospice care, lung neoplasms, fees and charges, length of stay
What is already known about the topic? •• Healthcare costs of end-of-life cancer patients are very expensive; however, hospice and palliative care may reduce healthcare costs for end-of-life cancer patients.
1Department
of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Korea 2Department of Public Health, Yonsei University College of Medicine, Seoul, Korea 3Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Korea 4Department of Hospital Administration, Graduate School of Public Health, Yonsei University, Seoul, Korea
5Department
of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
Corresponding author: Eun-Cheol Park, Department of Preventive Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. Email: [email protected]
Downloaded from pmj.sagepub.com at Univ. of Tasmania Library on September 26, 2015
809
Kim et al.
What this paper adds? •• We found evidence that a significant portion of inpatient hospital charges and lengths of stay occurred during the end-of-life period. Hospitals with hospice care tend to have statistically significant lower end-of-life hospital charges for inpatients with lung cancer. In addition, hospitals with more hospice beds were associated with reduction in inpatient hospital charges within 3 months before death. Implications for practice, theory, or policy •• Expanded use of hospice beds within hospitals for end-of-life patients with lung cancer patients is required.
Introduction Over the past three decades, cancer has been the leading cause of death1 and is associated with the largest disease burden in Korea.2 Of all cancers, lung cancer has one of the highest fatality rates and is the leading cause of cancerrelated mortality in South Korea3 and worldwide.4 The latest statistics indicate that in 2010, there were 20,711 incident lung cancer cases (out of a total of 202,053 cancer cases; 71% male), 15,623 deaths (out of a total of 72,046 deaths; 73% male), and 43,564 prevalent lung cancer cases (total cancer prevalence: 960,654; 66% male) in Korea.5 In 2010, 72,046 cancer deaths were reported in Korea, with lung cancer accounting for 28.2% of all deaths, the highest cancer fatality rate in both males and females. Five-year survival rates for lung cancer are less than 20%, and the average survival time is approximately 6 months, one of the lowest survival rates, as most patients have advancedstage lung cancer at their initial diagnosis.5 Healthcare, in general, and cancer care, in particular, are very expensive.6 Moreover, the advancement of new cancer diagnostic and treatment methods contribute to rising costs for cancer care.7 These rising costs are outpacing inflation rates and each nation’s budgetary level; there are also questions regarding the cost–benefit of proven interventions by individuals and society.7 Ideally, more effective and less toxic care and treatments should be initiated; however, these innovations come at a greater expense.8 Healthcare utilization is statistically associated with dying, suggesting that a large proportion of expenditures occur in the last few months prior to death.9–11 In the United States, healthcare spending in the last year of life consumes approximately 27%–30% of the Medicare budget and has done so consistently over the past decades.11,12 Most of these costs were the result of life-sustaining care, with a significant portion of costs accrued from acute care in the final 30 days of life.12 Although patients with advanced cancer prefer to receive care and die at home,13,14 most patients die in hospitals.13–18 The structure and availability of healthcare resources appear to influence place of death more than the actual preference of patients and families.19–21 Previous studies confirmed that hospice care reduces total healthcare costs for the majority of Medicare
beneficiaries,22,23 and studies conducted in Europe and the United States revealed that the availability of palliative care and hospice programs may help avoid patient hospitalization and reduce costs.24–38 It has also been suggested that the establishment of palliative care programs is a way to improve the quality of life for terminally ill patients and their families and also to reduce utilization of expensive acute care hospital resources.39 Although hospice care was first introduced in 1960s in Korea, a reimbursement system for hospice care from the National Health Insurance (NHI) is not yet available; instead, costs are reimbursed as normal inpatient care where hospitals do not have incentive to acquire hospice beds, as these require more resources than ordinary beds.40 Around 10% of cancer deaths used hospice care in this country; an excess of demand over supply has been presented.41 In Korea, 70% of deaths occur at hospitals;42 however, no research has been conducted regarding healthcare charges and length-of-stay differences according to the availability of hospice beds within hospitals in this country. It is very important to have hospice beds in order to maintain a financially viable NHI program. In this retrospective cohort study, using 10 years of nationwide health insurance claim data for end-of-life patients with lung cancer, we sought to investigate differences in hospital inpatient charges and length of stay by hospice care availability within hospitals.
Methods Data collection and construction We collected all nationwide claim data from inpatients with lung cancer from 2002 to 2012 in November 2013. Lung cancer patients were defined according to the International Classification of Diseases-10 (ICD-10) codes C33–C34. This dataset contained health insurance claim details including inpatient costs covered by NHI, length of stay, admission date, date of death, age, sex, days in the intensive care unit (ICU), and days on a ventilator during hospitalization.
Downloaded from pmj.sagepub.com at Univ. of Tasmania Library on September 26, 2015
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Palliative Medicine 29(9)
In order to measure the severity of disease, we calculated the progression of lung cancer using the dataset. Using all previous claims, we identified the new lung cancer cases for each year. For example, we searched all claim records from 2002 to 2005 in order to detect new lung cancer cases in 2006. If a patient had no record from 2002 to 2005, then we assumed that the patient was newly diagnosed in 2006. Using this method, we calculated the year of diagnosis for lung cancer for all patients. We included only patients who died with lung cancer and transposed the dataset to a retrospective cohort design, with the death of each patient serving as the baseline. In order to investigate trends and factors influencing hospital inpatient charges and length of stay in patients with lung cancer, we aggregated each patient’s hospital inpatient charges and length of stay on a monthly basis up to 12 months before death. We selected the time period of 12 months before death to ascertain end-of-life lung cancer hospital inpatient charges and length of stay. Inpatient hospital charges are the sum of fee-for-service (FFS) claims for each patient’s hospitalization. With the establishment in South Korea of a NHI program in 1989, all types of hospitals generally use a FFS reimbursement system (hospitals submit claims to NHI and are then reimbursed).43 Patients have considerable freedom to choose and access care providers; there are no restrictions on the use of primary, secondary, and tertiary medical institutions, nor are there no penalties for repeated care.44,45 In Korea, the FFS catalog is negotiated by the government, providers, and other stakeholders every year. Using each year’s negotiated FFS catalog, we adjusted inpatient costs to 2002 levels, and to investigate the impact of hospice care, we created a dummy variable, namely, availability of hospice beds within hospitals. The mean foreign exchange (FX) rate was US$1 = 1251.20 South Korean Won (KRW) in 2002 (cf. mean 2012 FX rate: US$1 = 1126.88 KRW). We deleted the 2002 dataset as it was the baseline for measuring each patient’s cancer progression. Furthermore, we excluded patients diagnosed with lung cancer more than 5 years prior, assuming those patients had different costs and utilization patterns due to their longer survival times. Finally, we excluded patients with inpatient total costs of less than 200,000 KRW, assuming those hospitalizations were not relevant to inpatient cancer treatment. This study did not calculate non-covered services due to the limitations of the claim dataset. Hospital-level data included hospital classification (large: more than 300 beds; small: less than 299 beds) and structural factors such as the number of beds, number of specialists, number of nurses, teaching status (presence of residents), and number of hospice beds. The hospital-level data were obtained from the agency for Health Insurance Review and Assessment Services. Using 673,122 inpatient health insurance claims, we obtained aggregated healthcare charges and utilization data from a total of 114,828 patient records and 866 hospitals.
Statistical analysis First, we examined the characteristics of nationwide inpatients with lung cancer and hospitals where the patients were admitted at their time of death. Then, we examined trends of hospital inpatient charges and lengths of stay by monthly intervals up to 12 months before death. Student’s t-test and an analysis of variance were used to compare mean hospital inpatient charges and length of stay by hospice care availability. We used multi-level mixed models by employing the “Proc Mixed” procedure and random intercept effects from SAS in order to account for hierarchical data structure. The unit of analysis was individual patients nested within hospitals, and the model analyzed the patient-level and hospital-level characteristics together. We used the model in order to avoid problems created by possible nesting of patient-level observations within clusters (hospitals) and overestimation of significance. We adjusted patient-level and hospital-level confounders. We sought to investigate each patient’s hospital inpatient charges for the last 1, 3, 6, and 12 months as well as the length of stay before death. SAS 9.2 (SAS Institute, Cary, NC, USA) was used for all calculations and analyses. All statistical tests were two tailed, and we rejected null hypotheses of no significant difference if p values were less than 0.05. This study was approved by the Institutional Review Board of Graduate School of Public Health, Yonsei University (IRB Number: 2014-203) and also followed STROBE guidelines.
Results An overall trend of hospital inpatient charges and length of stay by patients with lung cancer at the end of their lives is presented in Figure 1. Hospital inpatient charges, length of stay, and rate of patient admission drastically increased until death, particularly in the last 3 months before death. Table 1 shows the baseline characteristics of nationwide patients with lung cancer and the hospitals where they were admitted. As our study investigates hospital inpatient charges and length of stay retrospectively from time at death, 114,828 patients met our cohort definition. Most patients were male, and the mean age was 68.4 years. More than 80% of patients died during their diagnosis year (year 1: 52.3%) or in the following year (year 2: 31.3%). More patients were admitted to large teaching hospitals without hospice care. Table 2 depicts the entire episode, as well as the last 1, 3, 6, and 12 months of hospital charges and length of stay for inpatients with lung cancer, by availability of hospice care within hospitals. We found that a significant portion of hospital inpatient charges and lengths of stay occurred at the end of life, and hospitals with hospice care had episodes with higher hospital charges and lengths of stay; however, this difference was not statistically significant in the last 1 and 3 months before death. Hospitals with hospice care
Downloaded from pmj.sagepub.com at Univ. of Tasmania Library on September 26, 2015
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Kim et al.
Figure 1. Discounted hospital inpatient charges and length of stay among nationwide patients with lung cancer at the end of life.
were more likely to be large teaching hospitals yet rank lower in terms of hospital structural factors (i.e. fewer numbers of beds, nurses, and physicians). The results of the multi-level mixed model analysis are presented in Table 3. The results were conducted by designated periods (the last 1, 3, 6, and 12 months before death) and showed that hospitals with hospice care tended to have significantly lower hospital inpatient charges for lung cancer, yet not for length of stay. Patients with lung cancer who had more ICU days, a higher admission frequency, more ventilator days, higher episode hospital charges, and earlier death from the point of diagnosis were associated with higher end-of-life hospital charges. Large hospitals and teaching hospitals were associated with higher hospital inpatient charges as well. Other hospital-level variables were also significant, although the effect was minimal. We conducted this analysis by adding an interaction variable (hospice care × time); however, none of the coefficients were significant in any model. Due to the skewing of distribution for hospital inpatient charges and length of stay, we conducted a sensitivity analysis by taking the natural log of each dependent variable (Table 4). The results were the same, and the effect of hospice care was greatest in the last 1 and 3 months before death (a more than 2% reduction in hospital inpatient
charges). A sensitivity analysis conducted only with hospitals with hospice care is presented in Table 5. The results show that a greater number of hospice beds were associated with a reduction in hospital inpatient charges within the last 3 months before death for patients with lung cancer (0.39% and 0.23% reduction in charges for each hospice months before death, bed increase for 1 and 3 respectively).
Discussion In this study, we examined the association between hospice care and individual patients with lung cancer, regarding hospital inpatient charges and length of stay at the end-oflife stage. The nationwide dataset used for this study spanned over a decade and included all patients with lung cancer in the NHI program. We used multi-level mixed models to compare hospital inpatient charges and length of stay within the last 1, 3, 6, and 12 months before death. Our results agree with those of previous research that most patients were hospitalized at the end of their life, particularly in the last 3 months before death. Most inpatient charges occurred in that period as well. Regarding the impact of hospice care availability, patients admitted to hospitals with hospice care used fewer inpatient hospital
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Palliative Medicine 29(9)
Table 1. Characteristics of inpatients with lung cancer and hospitals at the time of death.
Patient characteristics Number of patients Sex Male Female Years of cancer progression at death 1 = death at diagnosed year 2 = death within 2 years after diagnosis 3 = death within 3 years after diagnosis 4 = death within 4 years after diagnosis 5 = death within 5 years after diagnosis Age at death (years)a Episode admission frequencya Episode ICU daysa Episode ventilator daysa Hospital characteristics Number of inpatients within hospice care hospitals Yes No Number of inpatients by hospital type Large Small Number of inpatients by hospital teaching status Teaching Nonteaching Number of bedsa Number of nursesa Number of physiciansa
N
%
114,828
87,586 27,242
76.3 23.7
60,110 35,941 11,231 4506 3040 68.4 5.2 1.1 1.4
52.3 31.3 9.8 3.9 2.6 10.7 5.6 5.8 7.2
29,660 85,168
25.8 74.2
106,114 8714
92.4 7.6
94,480 20,348 867.0 515.3 384.0
82.3 17.7 592.7 485.9 376.1
ICU: intensive care unit; SD: standard deviation. aMeans/SD.
resources; however, no differences were found in length of stay. The results of our study deliver a significant message to policy-makers and the NHI program: the high cost of endof-life care for inpatients with lung cancer may have no impact on extending life as compared to hospice care, although significant hospital inpatient charge reductions were found in hospice care hospitals. As noted, palliative care is a way to improve the quality of life of terminally ill patients and their families, as well as to reduce the utilization of expensive life-sustaining acute care hospital resources.39 Few studies are available regarding cancer pain and psychosocial intervention, according to a recently conducted meta-analysis in Korea; additionally, further studies are also needed on the quality of care patients with cancer receive, as the number of patients with cancer has dramatically increased in Korea.5 Hospice care and palliative care are other areas that could use improvement, as there are an estimated 1 million cancer survivors, accounting for 1.9% of the entire population in Korea, who have received life-extending cancer
treatment.46 In Korea, hospice care is only available at a limited number of hospitals and with a limited number of hospice beds (44 hospitals, 707 total hospice beds). An expansion of hospice bed numbers within hospitals as well as specialized hospice care facilities is required for a financially viable NHI program, as hospice care reduces the overall lung cancer burden and provides a greater quality of life to patients. The dataset we used, encompassing data from the last decade of all nationwide lung cancer inpatients as well as the hospitals where they were admitted, contributes to the robustness of our study. The increase in the number of adults living with advanced and complex chronic illnesses and the increase in expenditures for these patients highlight the need for efficient models, such as palliative care that delivers quality services to complex patient populations.33 This study has several limitations worth noting, and caution must be taken when interpreting the study’s results or attempting to generalize its findings. Although we analyzed all nationwide inpatient claims for lung cancer
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Kim et al. Table 2. Hospital inpatient charges and length of stay for lung cancer patients and hospital characteristics by hospice care availability. With hospice care
Without hospice care
p
Mean (KRW)
SD
Mean (KRW)
SD
Patient level Episode cost Last 1 month Last 3 months Last 6 months Last 12 months Episode LOS Last 1 month Last 3 months Last 6 months Last 12 months
12,286,122 1,830,040 4,900,559 7,048,656 9,339,277 51.2 8.0 22.4 31.6 40.6
12,226,949 2,749,945 5,573,019 7,476,771 9,527,855 51.3 9.3 21.7 31.0 40.2
11,629,398 1,854,019 4,839,049 6,823,869 8,880,810 50.1 8.0 22.3 31.3 39.6
12,177,256 2,916,323 5,839,024 7,716,447 9,637,487 53.2 9.3 22.0 31.6 41.0
Hospital level Number of hospitals Number of hospice beds Hospital teaching statusa Teaching Nonteaching Hospital typea Large Small Number of beds Number of nurses Number of physicians
44 14.2
822
5.8
32 12
72.7% 27.3%
38 6 809.1 433.7 319.5
86.4% 13.6% 245.5 211.5 150.4
111 711 271 551 887.2 543.7 406.5
