Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries

JAMA. 2016 Jan 19;315(3):272-83. doi: 10.1001/jama.2015.18603.


Importance: Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest.

Objective: To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.

Design, setting, and participants: Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012.

Main outcomes and measures: Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services.

Results: The United States (cohort of decedents aged >65 years, N = 211,816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21,054; 51.2%), Canada (N = 20,818; 52.1%), England (N = 97,099; 41.7%), Germany (N = 24,434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21,840), Norway (US $19,783), and the United States (US $18,500), intermediate in Germany (US $16,221) and Belgium (US $15,699), and lower in the Netherlands (US $10,936) and England (US $9342). Secondary analyses showed similar results.

Conclusions and relevance: Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.

Publication types

  • Comparative Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Distribution
  • Aged
  • Aged, 80 and over
  • Attitude to Death
  • Belgium
  • Canada
  • Developed Countries* / economics
  • Developed Countries* / statistics & numerical data
  • Emergency Service, Hospital / economics
  • Emergency Service, Hospital / statistics & numerical data
  • England
  • Female
  • Germany / epidemiology
  • Health Care Costs*
  • Hospital Charges
  • Hospital Mortality*
  • Hospitalization / economics
  • Hospitalization / statistics & numerical data
  • Humans
  • Intensive Care Units / economics
  • Intensive Care Units / statistics & numerical data
  • Lung Neoplasms / economics
  • Lung Neoplasms / mortality
  • Lung Neoplasms / nursing
  • Male
  • Neoplasms* / drug therapy
  • Neoplasms* / economics
  • Neoplasms* / mortality
  • Neoplasms* / nursing
  • Netherlands
  • Norway
  • Patient Preference
  • Retrospective Studies
  • Sex Distribution
  • Terminal Care / economics*
  • Terminal Care / statistics & numerical data*
  • Time Factors
  • United States / epidemiology