We know the United States has an expensive system compared to other developed countries, and it appears that we don’t always get a much better quality of care for paying more. End-of-life care has been cited as one source of our high spending. A fourth of Medicare’s spending, for example, is in the last year of beneficiaries’ lives. Researchers looked at care for cancer patients near death in seven developed countries, and made some interesting observations. (JAMA Article) The study includes Belgium, Canada, England, Germany, the Netherlands, Norway and the United States and uses data from 2010. The researchers looked at location of death, hospitalizations, ER use, ICU use, and chemotherapy visits for persons over 65. Both rates of utilization and total spending were studied. The average age of the patients was around 79. The most common diagnosis was lung cancer, although the US had a higher than average rate of prostate cancer. In most of these countries about half the decedents passed away in acute care hospitals; the US was an outlier at only 22%, along with the Netherlands at 29%. This suggests we are doing a better job than most countries of not having people die in the hospital. Most patients say they prefer to die at home or hospice. In the last 180 days of life, the US also had a low percent of patients who were hospitalized and the lowest number of days in the hospital.
On the other hand, the US had high rates of ICU use compared to the other countries. ICUs are expensive. In the last 30 days of life, the US had intermediate rates of hospitalization, as did most countries, but the US had low number of days, while again showing greater use of ICUs. In the last 180 days of life, the US had the highest rate of chemotherapy visits, with 39% of patients receiving therapy, compared to a low of 18% in the Netherlands. In the last 30 days of life, chemotherapy was substantially lower in all countries, and the US was more in the middle of the pack. In the last 180 days, per capita hospital spending was higher in Canada, Norway and the US and per day spending was noticeably higher in the US. Similar trends prevailed for the last 30 days of life. My interpretation is that we see once again that utilization in the US is probably not at inappropriate levels, that our problem is more likely to be unit prices. It also could be that when we do hospitalize patients our greater use of ICU results in better care that gets patients out of hospitals faster. And, assuming it is consistent with patient preferences, we do an excellent job of having patients not die in the hospital. So, in a fairly significant respect, the United States’ health system appears to be performing as well or better than that of other developed countries.