Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis

Impact of health spending on hospitalization rates in Baltic countries: a comparative analysis

INTRODUCTION

This study examines the association between healthcare indicators and hospitalization rates in three high-income European countries, namely Estonia, Latvia, and Lithuania, from 2015 to 2020.

METHOD

We used a sex-stratified generalized additive model (GAM) to investigate the impact of select healthcare indicators on hospitalization rates, adjusted by general economic status-i.e., gross domestic product (GDP) per capita.

RESULTS

Our findings indicate a consistent decline in hospitalization rates over time for all three countries. The proportion of health expenditure spent on hospitals, the number of physicians and nurses, and hospital beds were not statistically significantly associated with hospitalization rates. However, changes in the number of employed medical doctors per 10,000 population were statistically significantly associated with changes of hospitalization rates in the same direction, with the effect being stronger for males. Additionally, higher GDP per capita was associated with increased hospitalization rates for both males and females in all three countries and in all models.

CONCLUSIONS

The relationship between healthcare spending and declining hospitalization rates was not statistically significant, suggesting that the healthcare systems may be shifting towards primary care, outpatient care, and on prevention efforts.

Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer

OBJECTIVE

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use.

STUDY DESIGN

A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life.

RESULTS

Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52).

CONCLUSION

Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

The economics of nature's healing touch: A systematic review and conceptual framework of green space, pharmaceutical prescriptions, and healthcare expenditure associations

Green spaces play a crucial role in promoting sustainable and healthy lives. Recent evidence shows that green space also may reduce the need for healthcare, prescription medications, and associated costs. This systematic review provides the first comprehensive assessment of the available literature examining green space exposure and its associations with healthcare prescriptions and expenditures. We applied Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search MEDLINE, Scopus, and Web of Science for observational studies published in English through May 6, 2023. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 26 studies that met the inclusion criteria and were included in our review. Among these, 20 studies (77 % of the total) showed beneficial associations of green space exposure with healthcare prescriptions or expenditures. However, most studies had risks of bias, and the overall strength of evidence for both outcomes was limited. Based on our findings and related bodies of literature, we present a conceptual framework to explain the possible associations and complex mechanisms underlying green space and healthcare outcomes. The framework differs from existing green space and health models by including upstream factors related to healthcare access (i.e., rurality and socioeconomic status), which may flip the direction of associations. Additional research with lower risks of bias is necessary to validate this framework and better understand the potential for green space to reduce healthcare prescriptions and expenditures.

End-of-life expenditure on health care for the older population: a scoping review

BACKGROUND

The existing evidence shows that the pattern of health expenditure differs considerably between people at the end-of-life and people in other periods of their lives. The awareness of these differences, combined with a detailed analysis of future mortality rates is one of the key pieces of information needed for health spending prognoses. The general objective of this review was to identify and map the existing empirical evidence on end-of-life expenditure related to health care for the older population.

METHODS

To achieve the objective of the study a systematic scoping review was performed. There were 61 studies included in the analysis. The project has been registered through the Open Science Framework.

RESULTS

The included studies cover different kinds of expenditure in terms of payers, providers and types of services, although most of them include analyses of hospital spending and nearly 60% of analyses were conducted for insurance expenditure. The studies provide very different results, which are difficult to compare. However, all of the studies analyzing expenditure by survivorship status indicate that expenditure on decedents is higher than on survivors. Many studies indicate a strong relationship between health expenditure and proximity to death and indicate that proximity to death is a more important determinant of health expenditure than age per se. Drawing conclusions on the relationship between end-of-life expenditure and socio-economic status would be possible only by placing the analysis in a broader context, including the rules of a health system's organization and financing. This review showed that a lot of studies are focused on limited types of care, settings, and payers, showing only a partial picture of health and social care systems in the context of end-of-life expenditure for the older population.

CONCLUSION

The results of studies on end-of-life expenditure for the older population conducted so far are largely inconsistent. The review showed a great variety of problems appearing in the area of end-of-life expenditure analysis, related to methodology, data availability, and the comparability of results. Further research is needed to improve the methods of analyses, as well as to develop some analysis standards to enhance research quality and comparability.

Hospital use and cancer treatment by age and socioeconomic status in the last year of life: A Norwegian population-based study of patients dying of cancer

INTRODUCTION

Cancer is the leading cause of death in Norway. In this nationwide study we describe the number and causes of hospital admissions and treatment in the final year of life for patients who died of cancer, as well as the associations to age and socioeconomic status (SES).

MATERIALS AND METHODS

From nationwide registries covering 2010-2014, we identified all patients who were diagnosed with cancer 12-60 months before death and had cancer as their reported cause of death. We examined the number of overnight hospital stays, causes of admission, and treatment (chemotherapy, radiotherapy, surgical procedures) offered during the last year of life by individual (age, sex, comorbidity), cancer (type, stage, months since diagnosis), and socioeconomic variables (co-residential status, income, education).

RESULTS

The analytical sample included 17,669 patients; 8,247 (47%) were female, mean age was 71.7 years (standard deviation 13.7). At diagnosis, 31% had metastatic disease, while 29% had an intermediate or high comorbidity burden. Altogether, 94% were hospitalized during their final year, 82% at least twice, and 33% six times or more. Patients spent a median of 23 days in hospital (interquartile range 11-41), and altogether 38% died there. Younger age, bladder and ovarian cancer, not living alone, and higher income were associated with having ≥6 hospitalizations. Cancer-related diagnoses were the main causes of hospitalizations (65%), followed by infections (11%). Around 51% had ≥1 chemotherapy episode, with large variations according to patient age and SES; patients who were younger, did not live alone, had high education, and high income received more chemotherapy. Radiotherapy was received by 15% and declined with age, and the variation according to SES characteristics was minor. Of the 12,940 patients with a cancer type where surgery is a main treatment modality, only 835 (6%) underwent surgical procedures for their primary tumor in the last year of life.

DISCUSSION

Most patients who die of cancer are hospitalized multiple times during the last year of life. Hospitalizations and treatment decline with advancing age. Living alone and having low income is associated with fewer hospitalizations and less chemotherapy treatment. Whether this indicates over- or undertreatment across various groups warrants further exploration.

Disparities and determinants of place of death: Insights from the Utah Population Database

To better understand determinants and potential disparities in end of life, we model decedents' place of death with explanatory variables describing familial, social, and economic resources. A retrospective cohort of 204,041 decedents and their family members are drawn from the Utah Population Database family caregiving dataset. Using multinomial regression, we model place of death, categorized as at home, in a hospital, in another location, or unknown. The model includes family relationship variables, sex, race and ethnicity, and a socioeconomic status score, with control variables for age at death and death year. We identified the effect of a family network of multiple caregivers, with 3+ daughters decreasing odds of a hospital death by 17 percent (OR: 0.83 [0.79, 0.87], p < 0.001). Place of death also varies significantly by race and ethnicity, with most nonwhite groups more likely to die in a hospital. These determinants may contribute to disparities in end of life.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study

BACKGROUND

Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA.

METHODS

We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis.

RESULTS

All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values.

CONCLUSION

This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Cross-national differences in wealth inequality in health services and caregiving used near the end of life

Background

Socioeconomic inequality in access to and use of health services and social care provided near the end of life, or end-of-life care (EOLC), is not well understood in many countries. We examined wealth inequality in EOLC-hospital, nursing home, and hospice use and receipt of formal and informal caregiving-in 22 countries in Europe, Asia (South Korea), and North America (United States, Mexico).

Methods

We used harmonized data from nationally representative studies of people aged 50 and older that collected information on healthcare utilisation and caregiving receipt in the time preceding death. We categorized countries according to their level of public long-term care (LTC) spending and examined EOLC prevalence across countries. We used logistic regression models to estimate wealth inequality in each type of EOLC.

Findings

In the USA the least wealthy had more hospital (OR 1.30, p = 0.008) and nursing home/care use (OR 1.88, p < 0.001). In South Korea the least wealthy had more nursing home/care use (OR 2.24, p = 0.003). The least wealthy in high LTC Europe had less hospice use (OR 0.56, p = 0.003). The least wealthy were also less likely to be hospitalized in European countries with low LTC spending (OR 0.81, p = 0.04), but more likely to receive informal caregiving (OR 1.25, p = 0.033). Formal care was more common among the least wealthy in high LTC Europe (OR 1.57, p = 0.002), the USA (OR 1.42, p < 0.001) and South Korea (OR 1.69, p = 0.028), but less common among the least wealthy in Mexico (OR 0.17, p < 0.001).

Interpretation

Wealth inequality in EOLC exists across countries and reflects differences in the organization, financing, and delivery of care in different countries. The findings highlight the need to consider equity in current and future plans to improve EOLC access.

Funding

United States National Institute on Aging Grant R01AG030153.

Socioeconomic differences in inpatient care expenditure in the last year of life among older people: a retrospective population-based study in Stockholm County

OBJECTIVES

To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life.

DESIGN

Retrospective population-based study.

SETTING

Stockholm County.

PARTICIPANTS

Decedents ≥65 years in 2015 (N=13 538).

OUTCOME

ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018.

RESULTS

There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care.

CONCLUSION

Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

Disparities in healthcare expenditures according to economic status in cancer patients undergoing end-of-life care

Backgrounds

A desire for better outcome influences cancer patients’ willingness to pay. Whilst cancer-related costs are known to have a u-shaped distribution, the actual level of healthcare utilized by patients may vary depending on income and ability to pay. This study examined patterns of healthcare expenditures in the last year of life in patients with gastric, colorectal, lung, and liver cancer and analyzed whether differences exist in the level of end-of-life costs for cancer care according to economic status.

Methods

This study is a retrospective cohort study which used data from the Korean National Elderly Sampled Cohort, 2002 to 2015. End-of-life was defined as 1 year before death. Economic status was classified into three categorical variables according to the level of insurance premium (quantiles). The relationship between the dependent and independent variables were analyzed using multiple gamma regression based on the generalized estimated equation (GEE) model.

Results

This study included 3083 cancer patients, in which total healthcare expenditure was highest in the high-income group. End-of-life costs increased the most in the last 3 months of life. Compared to individuals in the ‘middle’ economic status group, those in the ‘high’ economic status group (RR 1.095, 95% CI 1.044–1.149) were likely to spend higher amounts. The percentage of individuals visiting a general hospital was highest in the ‘high’ economic status group, followed by the ‘middle’ and ‘low’ economic status groups.

Conclusion

Healthcare costs for cancer care increased at end-of-life in Korea. Patients of higher economic status tended to spender higher amounts of end-of-life costs for cancer care. Further in-depth studies are needed considering that end-of-life medical costs constitute a large proportion of overall expenditures. This study offers insight by showing that expenditures for cancer care tend to increase noticeably in the last 3 months of life and that differences exist in the amount spent according economic status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09373-y.

Variations in utilisation of colorectal cancer services in South Australia indicated by MBS/PBS benefits: a benefit incidence analysis

OBJECTIVE

This study investigated variations in healthcare expenditure for colorectal cancer (CRC) patients in South Australia by socioeconomic position (SEP) and remoteness area.

METHODS

Benefits incidence analysis (BIA) was used to examine healthcare expenditure and utilisation in relation to CRC patients by SEP and remoteness areas. Utilisation data was obtained for patients diagnosed with CRC in 2003-2013 from a dataset linked to a population-based cancer registry, Medicare Benefits Scheme (MBS), Pharmaceutical Benefits Scheme (PBS), hospital and death data. Concentration indices estimated the distribution of health expenditure on MBS, MBS palliative care, PBS and general practitioners. Costs of claims data and length of stay in hospital were used as indicators of healthcare utilisation.

RESULTS

The results indicated that MBS palliative healthcare services utilisation favoured the more advantaged groups for both SEP and remoteness area (Concentration index (CI)= 0.1681, t-value=54.42 (SEP) and CI=0.1546, t-value=41.64). MBS expenditure was also favourable to the more advantaged groups (CI: 0.0785 and 0.0493).PBS and MBS general practitioner expenditure were equal (-0.0093 to 0.0250).

CONCLUSION

Overall MBS and PBS healthcare expenditure for CRC patients was close to equality, however utilisation of MBS-funded palliative healthcare services was less concentrated in low SEP and more remote areas. Implications for public health: Whether the differences in palliative healthcare utilisation supplied by private providers are offset by other services requires investigation to determine if there is a need for initiatives to improve equality and give greater support to those who choose to die at home.

Medical Cannabis and Utilization of Nonhospice Palliative Care Services: Complements and Alternatives at End of Life

Background and Objectives

There is a need to know more about cannabis use among terminally diagnosed older adults, specifically whether it operates as a complement or alternative to palliative care. The objective is to explore differences among the terminal illness population within the Illinois Medical Cannabis Program (IMCP) by their use of palliative care.

Research Design and Methods

The study uses primary, cross-sectional survey data from 708 terminally diagnosed patients, residing in Illinois, and enrolled in the IMCP. We compared the sample on palliative care utilization through logistic regression models, examined associations between palliative care and self-reported outcome improvements using ordinary least squares regressions, and explored differences in average pain levels using independent t-tests.

Results

115 of 708 terminally diagnosed IMCP participants were receiving palliative care. We find increased odds of palliative care utilization for cancer (odds ratio [OR] [SE] = 2.15 [0.53], p < .01), low psychological well-being (OR [SE] = 1.97 [0.58], p < .05), medical complexity (OR [SE] = 2.05 [0.70], p < .05), and prior military service (OR [SE] = 2.01 [0.68], p < .05). Palliative care utilization is positively associated with improvement ratings for pain (7.52 [3.41], p < .05) and ability to manage health outcomes (8.29 [3.61], p < .01). Concurrent use of cannabis and opioids is associated with higher pain levels at initiation of cannabis dosing (p < .05).

Discussion and Implications

Our results suggest that cannabis is largely an alternative to palliative care for terminal patients. For those in palliative care, it is a therapeutic complement used at higher levels of pain.

Costs for Statutorily Insured Dental Services in Older Germans 2012-2017

OBJECTIVES

We assessed the costs of dental services in statutorily insured, very old (geriatric) Germans.

METHODS

A comprehensive sample of very old (≥75 years) people insured at a large Northeastern statutory insurer was followed over 6 years (2012-2017). We assessed dental services costs for: (1) examination, assessments and advice, (2) operative, (3) surgical, (4) prosthetic, (5) periodontal, (6) preventive and (7) outreach services. Association of utilization with: (1) sex, (2) age, (3) region, (4) social hardship status, (5) International Disease Classification (ICD-10) diagnoses and (6) Diagnoses Related Groups (DRGs) was explored.

RESULTS

404,610 individuals with a mean (standard deviation, SD) age 81.9 (5.4 years) were followed, 173,733 did not survive follow-up. Total mean costs were 129.61 (310.97) euro per capita; the highest costs were for prosthetic (54.40, SD 242.89 euro) and operative services (28.40, SD 68.38 euro), examination/advice (21.15, SD 28.77 euro), prevention (13.31, SD 49.79 euro), surgery (5.91, SD 23.91 euro), outreach (4.81, SD 28.56 euro) and periodontal services (1.64, SD 7.39 euro). The introduction of new fee items for outreach and preventive services between 2012 and 2017 was reflected in costs. Total costs decreased with increasing age, and this was also found for all service blocks except outreach and preventive services. Costs were higher in those with social hardship status, and in Berlin than Brandenburg and Mecklenburg-Western Pomerania. Certain general health conditions were associated with increased or decreased costs.

CONCLUSIONS

Costs were associated with sex, social hardship status, place of living and general health conditions.

CLINICAL SIGNIFICANCE

Dental services costs for the elderly in Germany are unequally distributed and, up to a certain age or health status, generated by invasive interventions mainly. Policy makers should incentivize preventive services earlier on and aim to distribute expenses more equally.