Background
Cancer is a leading cause of death globally, accounting for nearly 10 million deaths in 2020,1 and has a significant economic impact on patients, families, and the healthcare system.2 Studies show wide variation in the end-of-life (EoL) healthcare cost among patients dying with cancer.3–5 Understanding this variation and drivers of high costs can offer insights for policymakers, patients, and their families to anticipate and/or manage costs while preserving the quality of life of patients dying with cancer.
Several studies have assessed variation in EoL healthcare cost among patients with cancer by describing the average cost trend during specific time periods, such as the last year of life.6–10 They show a steep increase in healthcare cost during the last months of life, driven primarily by an increase in inpatient costs.11–14 However, due to a wide variation in the pattern of healthcare cost among patients with advanced cancer over time, it is possible that many patients do not follow a trajectory of steeply increasing cost during the last months of life. Furthermore, some patients may incur higher healthcare costs than others even earlier in their disease trajectory. An analysis of average cost trend is thus insufficient to inform policy and program efforts. A more nuanced assessment of heterogeneity in the pattern of EoL healthcare cost is required.
Thus, we first aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life in patients with a solid metastatic cancer and to compare this with the average cost trend during the same period. Although a few studies have assessed the heterogeneity in healthcare cost trajectories in the context of other diseases,15–18 only one study has done so in the context of metastatic cancer, and only for the last year of life.19
Second, we aimed to assess sociodemographic and clinical characteristics that predict membership of delineated trajectories. Based on previous studies showing the association of age,20–22 patient preference for life extension,6 and health insurance and socioeconomic status (SES)23–25 with healthcare costs, we hypothesized that younger patients, those preferring life extension over cost of care, those with a private health insurance, and those with higher SES would be more likely to follow a trajectory representing higher healthcare costs. Although healthcare costs have been shown to differ with cancer site, they vary widely across samples and contexts.12,26,27 Hence, we also assessed whether cancer site predicts membership of cost trajectories. Policymakers, patients, and families can better anticipate and budget healthcare costs by considering all of these observable factors.
Third, to better understand healthcare use and type of spending across the delineated cost trajectories, we assessed variation across delineated trajectories in total healthcare cost; outpatient and inpatient costs; total, planned, and unplanned hospital admissions; emergency department (ED) visits (in last 2 years of life); use of a palliative/hospice care service; and place of death. There is extensive literature showing that referral to palliative/hospice care reduces healthcare costs.28–30 We thus hypothesized that patients who access a palliative/hospice care service or who die in a hospice program will be more likely to have a trajectory with declining healthcare costs during the last months of life.
Patients and Methods
Setting
Cancer is the leading cause of death in Singapore, accounting for 28.4% of deaths in 2019.31 Approximately 30% of health expenditures in Singapore are out of pocket, greater than the average for high-income countries.32 A mandatory low-cost public health insurance with high deductibles (MediShield Life) partially meets patients’ hospitalization costs; day surgeries; and other, more expensive, recurring outpatient treatments, such as chemotherapy and radiotherapy.33–36 Individuals can top up this public health insurance coverage by purchasing private health insurance.37 Further details about Singapore’s healthcare system financing are provided in supplemental eAppendix 1 (available with this article at JNCCN.org).
Study Design and Participants
We used data from the COMPASS study (Cost of Medical Care of Patients with Advanced Serious Illness in Singapore), a cohort of 600 patients diagnosed with metastatic cancer. After they provided written consent, eligible patients (having a diagnosis of a solid metastatic cancer, aged ≥21 years, and a citizen or permanent resident of Singapore) were recruited between July 2016 and March 2018 from 2 major public hospitals.
Participants were surveyed at baseline and every 3 months until death, and their billing data (starting January 2015) were obtained from hospital records. The study was approved by the Institutional Review Board at SingHealth (2015/2781). Details of the study protocol are published elsewhere.38
Study Variables
Outcome: Total Healthcare Cost
We calculated total healthcare cost (gross cost before tax and subsidy) as the sum of inpatient, outpatient, ED, and pharmacy costs during the last 2 years of life based on patient billing dates and date of death. The cost includes payments made through all sources, including MediShield Life, private health insurance, MediSave, MediFund, and out of pocket. The costs were adjusted for inflation to 2019 Singapore dollars (SGD) using the consumer price index from the Department of Statistics, Singapore.39 For delineating the trajectories, we aggregated total healthcare costs for every 2 months.
Covariates
Socioeconomic Characteristics
From patients’ baseline surveys, we assessed patient age, sex, and type of housing (proxy for SES, classified as 1- to 2-room public, 3- to 4-room public, and 5-room public/private). More than 80% of Singapore’s population lives in public housing, and larger public and private housing signifies higher SES.40 We also assessed whether patients had any private health insurance (to top up their MediShield Life coverage).
Preference for Life Extension
Patients were asked if they would prefer treatment that extends life as much as possible or the treatment that costs them less. Response options were on scale of 1 to 9, with 1 representing extend life as much as possible at high cost and 9 representing no life extension at less cost. We used data from patients’ earliest surveys in their last 2 years of life.
Cancer Site
Cancer site was categorized as breast, gynecologic/genitourinary, gastrointestinal, respiratory, and other.
Healthcare Use
We assessed total number of hospital admissions, length of hospital stay, and number of ED visits from billing records for the last 2 years of patients’ lives. In addition, we asked patients in each survey whether they had ever used palliative/hospice care since diagnosis, including an inpatient, home care, or day care palliative/hospice care facility.
Place of Death
Place of death was assessed from medical records and caregiver reports and categorized as hospital, home, or hospice/care home.
Statistical Analysis
We first described the 2-year and 1-year mean total healthcare cost and its components and presented mean monthly healthcare cost for these durations. We used group-based trajectory modeling, a model-based clustering technique, to identify groups of individuals following a similar trajectory for an outcome of interest.41–44 We modeled log-transformed bimonthly total healthcare cost over the last 2 years of life. To identify the optimal number of trajectories and the polynomial function defining each trajectory, we first fitted models with one trajectory and sequentially increased the number of trajectories. For each specified number of trajectories, we started with a quintic polynomial function and moved down by an order of 1 if the specified function was not statistically significant. We retained the highest-order model that was significant. We considered the Bayesian information criterion, value of trajectory membership probability (≥5%), odds of correct classification (≥5), and average posterior probability (≥0.7) to choose the optimal number of trajectories, aiming for parsimony in the number of trajectories.43 More details about group-based trajectory modeling are provided in supplemental eAppendix 2.
We then assessed variation in 2-year and 1-year total healthcare costs, outpatient and inpatient costs, total number of hospital admissions, total length of hospital stay, number of ED visits (in last 2 years), use of palliative/hospice care service, and place of death across the delineated trajectories. Last, we ran a multivariable multinomial logistic regression model to investigate the predictors (age, type of housing, private health insurance status, preference for life extension, and cancer site) of trajectory group membership.
Results
Of the 600 patients, 354 died during the study period. A total of 353 patients had completed at least 1 survey in the last 2 years of life and constituted our analytic sample. The time axis was presented in 2-month intervals as time before death (0–24 months). The mean [SD] age for patients was 60.7 [10.6] years. More than half (54%) lived in 3- to 4-room public housing, 42% had a primary education or less, and 62% had private health insurance.
During the last 2 years of life, patients experienced a mean [SD] of 4.2 [3.0] hospital admissions (including unplanned admissions, 1.42 [1.89]) and 28.5 [28] days of hospital stay. Approximately 61% of the patients reported ≥1 ED visit (mean [SD], 2.49 [2.29]). Most patients died in the hospital (60%), followed by home (25%) and hospice/care home (14%) (Table 1).
Sample Characteristics
Mean Healthcare Cost
Patients incurred a mean total healthcare cost of SGD $95,931 (95% CI, $90,002–$101,859) in the last 2 years and SGD $60,021 ($55,992–$64,051) in the last year of life (USD $1 = SGD $1.35). The mean monthly total healthcare cost increased remarkably during the last year and the last month of life; mean monthly inpatient cost followed the same pattern. In contrast, mean monthly outpatient cost remained mostly stable, declining in the last month of life (Table 2). Over the last 2 years, outpatient and inpatient costs constituted, on average, approximately 62% and 37% of total healthcare cost, respectively.
Mean Healthcare Cost (in Singapore Dollars) Incurred by Patients
Healthcare Cost Trajectories
We selected a 4-trajectory model (Figure 1). Average posterior probability was 0.99 for each trajectory. Two of these trajectories were high cost: high and steadily increasing cost (mean total healthcare costs in last 2 years: SGD $109,134; 95% CI, $101,175–$117,093) and steeply increasing cost before the last year of life (SGD $93,275; 95% CI, $78,763–$107,788). The remaining 2 trajectories were low and steadily decreasing cost (SGD $75,054; 95% CI, $59,773–$90,336) and steeply increasing cost in the last year of life (SGD $64,988; 95% CI, $52,778–$77,197). These trajectories are described in detail in the following sections (Tables 3 and 4).
Trajectories of total healthcare costs during the last 2 years of life.
Abbreviation: SGD, Singapore dollars.
Citation: Journal of the National Comprehensive Cancer Network 20, 9; 10.6004/jnccn.2022.7038
Distribution of Healthcare Cost, Healthcare Use, and Place of Death, by Total Healthcare Cost Trajectories
Multinomial Logistic Regression for Predictors of Total Healthcare Cost Trajectory Membership
Low and Steadily Decreasing Cost (13%)
Patients in this trajectory showed a pattern of declining healthcare costs in their last year of life, incurring the lowest mean total healthcare cost (SGD $34,410; 95% CI, $25,946–$42,873), inpatient cost (SGD $14,350; 95% CI, $9,122–$19,578), and outpatient cost (SGD $19,630; 95% CI, $14,338–$24,922) compared with other trajectories. They experienced the lowest mean [SD] number of hospital admissions (2.78 [2.2]) and ED visits (44% with >1 ED visit) during the last 2 years of life and were most likely ever to have used a palliative/hospice care service (62%) and to die in hospice (27%). The mean [SD] age for patients in this trajectory was 64.4 [11.2] years.
Steeply Increasing Cost in the Last Year of Life (14%)
The mean [SD] age for patients in this trajectory was 60.2 [9.8] years. Compared with the low and steadily decreasing cost trajectory, younger patients (β [SE], −0.04 [0.02]; P=.07) and those living in larger 3- to 4-room public housing (vs 1–2-room public housing; 2.14 [1.15]; P=.06) were more likely to belong to this trajectory.
High and Steadily Increasing Cost (57%)
Patients in this trajectory showed a pattern of high total healthcare cost over last 2 years of life, further increasing during last months of life. These patients incurred the highest mean outpatient cost (SGD $70,194; 95% CI, $64,201–$76,187) and the highest mean [SD] number of hospital admissions (4.6 [3.2]) during last 2 years of life compared with other trajectories. Compared with the low and steadily decreasing cost trajectory, patients with health insurance (0.75 [0.37]; P=.04), those with a greater preference for life extension (−0.14 [0.07]; P=.06), and those with breast or respiratory cancer (1.12 [0.63] and 0.84 [0.46], respectively; both P=.07 vs gastrointestinal cancer) were more likely to belong to this trajectory.
Steeply Increasing Cost Before the Last Year of Life (16%)
Patients in this trajectory incurred the highest total healthcare cost during the last year of life (mean, SGD $68,016; 95% CI, $54,584–$81,448) among all trajectories. Over the last 2 years, these patients experienced the highest number of hospital admissions (mean [SD], 4.6 [2.7]), planned hospital admissions (3.4 [2.7]), and ED visits (66% with >1 ED visit) and the longest hospital stay (30.3 [25.4] days). They were also least likely to use palliative/hospice care service (14%) and most likely to die in a hospital (75%). The mean [SD] age of patients in this trajectory was 59.1 [10.4] years. Compared with the low and steadily decreasing cost trajectory, younger patients (−0.04 [0.02]; P=.05) were more likely to belong to this trajectory.
Discussion
We identified 4 distinct and heterogeneous trajectories for total healthcare cost during the last 2 years of life for patients with a solid metastatic cancer. This was in contrast to the average cost trend found in this study and previous literature10,12 showing that healthcare cost increases for most patients with cancer primarily during their last months of life.
Most (73%) of the patients in our sample belonged to high-cost trajectories, with 57% of them in the high and steadily increasing cost trajectory and another 16% in the steeply increasing cost before the last year of life trajectory. Patients with private health insurance, those with a high preference for life extension, and those with breast or respiratory cancer were more likely to belong to the high and steadily increasing cost trajectory. These characteristics have also previously been linked to higher healthcare costs.6,7,45 Longer survival rates coupled with the availability of expensive anticancer treatments have likely contributed to high healthcare costs for patients with breast or respiratory cancer.45,46 Younger patients were more likely to belong to the steeply increasing cost before the last year of life trajectory, similar to past studies showing higher healthcare costs among younger versus older patients.20–22 Consistent with the literature,8,26,47 patients in both of these high-cost trajectories had more planned hospitalizations, longer hospital stays, and were more likely to die in a hospital, indicating their high use of aggressive treatments.
Approximately 13% who followed a low and steadily decreasing cost trajectory were on average older, most cost-conscious (indicated by lowest preference for life extension vs cost), and most likely to use palliative/hospice care and to die in home/hospice, indicating their preference for less aggressive treatments, explaining their declining costs in the last 6 months before death. Patients in the steeply increasing cost before the last year of life trajectory did not incur any costs between 24 and 12 months before death, possibly because of a shorter interval between their diagnosis and death. They incurred the highest inpatient cost among all trajectories during the last year of life, however, and were least likely to use palliative/hospice care. A previous study showed a similar phenomenon among patients with cancer who died soon after their diagnosis.48
Our results have clinical and policy implications. First, we quantified patients’ total healthcare costs and the components during the last 2 years of life, and we showed their association with use of palliative/hospice care services. Policymakers, clinicians, patients, and families can use this information to anticipate, budget, and manage healthcare costs and to promote an early and systematic referral to palliative care services in efforts to reduce cost while improving patient quality of life.49–51 Notably, in our study, only 35% and 14% of patients in the 2 high-cost trajectories ever received care from a palliative/hospice service. Second, because >70% of patients incurred high healthcare costs through the last 2 years of life, measures to reduce healthcare costs should focus not just on the last months of life. The association of the high and steadily increasing cost trajectory with certain observable factors, such as having private health insurance, greater preference for life extension, and having breast cancer, provides an indication of which patient subgroups may benefit most from better budgeting and managing of healthcare costs. Potential strategies for alternative payment models, such as partial capitated payments52 or case-based reimbursements implemented with appropriate care quality measures, can be explored to reduce healthcare costs.
The main strength of our study is that, unlike other studies using solely administrative data to assess healthcare cost trajectories, we merged administrative data with patient survey data, allowing us to investigate how patient-reported factors, such as preference for life extension and SES, influence membership of healthcare cost trajectories.
Our study also has limitations. First, because we used survey data, our sample size is smaller than in other studies relying solely on administrative data to assess healthcare costs. Second, we did not have information on date of diagnosis of metastatic cancer, cost of palliative/hospice services, and indirect costs of cancer care, such as those related to caregiving and loss of patient/caregiver productivity. Third, although the generalizability of our study results outside of Singapore needs to be explored in future studies, we expect that patients in most developed countries would also follow heterogeneous patterns of healthcare costs.
Conclusions
The present study showed that, on average, monthly healthcare cost increases in the last months of life among patients with a solid metastatic cancer. However, there is heterogeneity in the pattern of healthcare costs during the last 2 years of life. Notably, >70% of the patients incurred high healthcare costs throughout their last 2 years of life, with those with private health insurance, greater preference for life extension, breast or respiratory cancer, and younger age being at a higher risk. Policymakers, clinicians, patients, and families can use this information to better anticipate, budget, and manage healthcare costs.
Acknowledgments
We thank the COMPASS study group for their contributions. The COMPASS study group included Rebecca A. Dent, Nesaretnam Barr Kumarakulasinghe, Yin Bun Cheung, Ravindran Kanesvaran, Alethea Chung Pheng Yee, Noreen Chan, Huei Yaw Wu, Soh Mun Chin, Hum Yin Mei Allyn, Grace Meijuan Yang, Patricia Soek Hui Neo, Richard Harding, and Lee Lai Heng.
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