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Vol 103 Issue 11 Warren Transcript

Kristine Crane: Welcome to the JNCI Podcast. Advanced lung cancer patients in the United States die more often at home than in the hospital compared to their counterparts in Ontario. This is just one finding from a recent JNCI study that compared end of life care in the two systems. I talked with Dr. Joan Warren of The National Cancer Institute who led the study. So what did your study look at?

Joan Warren: This study was the collaboration between a group of investigators at The National Cancer Institute and in Ontario. And what we set out to do is to really look at the care at the end of life for people with advanced lung cancer. And we could do this because in both the United States and Canada there's government sponsored healthcare for the elderly. The United States is through the Medicare program and in Canada each province has universal healthcare for all of their residents. We selected Ontario because it's the most populous Canadian province. And in both Ontario and in the United States there are cancer registries that collect information about cancer incidents and the stage of the disease and the site of the disease and the cancer registry data had been linked to health claims which allowed us to look at healthcare in the last five months of life. And we could use those health claims to identify if the person got chemotherapy, if they went to the hospital, if they were in an emergency room and if they died in hospital.

Kristine Crane: Let's talk about your findings a little bit in general. What was the most surprising or interesting finding?

Joan Warren: Well we were really surprised to find that for the Ontario patients they were much more likely to use hospital and emergency room services compared to patients in the United States. As I noted, patients who are at the end of life, particularly in the last month of life use a lot of healthcare. So both the U.S. and Ontario patients were using healthcare but in Ontario the hospital and emergency room services were much greater. Ontario patients-- in the last month of life, about 36 patients of U.S. patients had an emergency room visit compared with 50 percent of Ontario patients and hospital admissions, about 40 percent of U.S. patients had a hospital admission compared to about 55 percent of Ontario patients. So those are pretty big differences in terms of in acute care service use. In addition, in hospital deaths were very different, about 20 percent of the U.S. population died in hospital compare with 40 percent in Ontario.

Kristine Crane: So there's a growing trend of people dying in the home in the U.S. that is not being seen in Canada.

Joan Warren: Well there are many more in hospital deaths in Ontario than there were in the United States.

Kristine Crane: And how may we account for this difference?

Joan Warren: Well in the United States under the Medicare program, Medicare has established a formalized hospice program that's been in place for a number of years. And the hospice program in the United States is really community based; it wants to keep patients at home. And not only is it a quality of life measure but hospices also have a strong financial-- they get a lump sum payment from Medicare and they have a strong financial interest in keeping patients out of the hospital. So I think this is the primary thing driving it. In Ontario there is no formal hospice program. Ontario offers a lot of palliative care services, supportive care for people at the end of life through inpatient palliative care units, home based-- home care physicians as [ph?] it's either in the either outpatient or the home setting but it's just not a formal structured program like the hospice program is under Medicare.

Kristine Crane: Do you think that that's something that might change or that perhaps Canada could learn from the U.S. given that people everywhere seem to have a growing preference for dying at home?

Joan Warren: Ontario has taken a look at this and I know that they are trying to expand-- to reduce the number of patients who are dying in hospital. They're taking efforts to try to provide more supportive services to allow people to die at home. In both the U.S. and in Ontario, studies have shown patients really do prefer to die at home.

Kristine Crane: Let's talk a little bit about the trend for chemotherapy usage. What similarities or differences did you see there?

Joan Warren: Well this is really where it was quite interesting. The average survival after advanced lung cancer diagnosis is six months. And so we realized we had a mixed group of people who have been diagnosed with lung cancer for a while and people who were newly diagnosed and we were concerned that the people who were newly diagnosed might get treatment for the initial diagnosis as well as end of life care so we split our group into short term survivors and longer term survivors which are people who lived longer than six months. And for the short term survivors we really noted some pretty marked differences between the U.S. and Ontario. For the U.S. patients, about a third of them at five months prior to death were given chemotherapy whereas in the Ontario patients it was about a little less than ten percent. These short term survivors are people who are newly diagnosed and so it means that in the United States these patients are offered or given chemotherapy much more frequently than in Ontario.

Kristine Crane: I mean that seems to sort of confirm the belief that in the U.S. doctors tend to be a little bit more aggressive.

Joan Warren: We don't understand exactly what is causing this. This could be the physician perception about the benefit of chemotherapy differences between Ontario and the U.S. It could be patient preference that in the U.S. people who are newly diagnosed with life threatening disease may say, "Please treat me," or want to take an initial course of treatment. And in the United States oncologists also at this time could derive some financial benefit from prescribing chemotherapy to their patients.

Kristine Crane: Given all your findings, where do you think that we go from here?

Joan Warren: I think that it's an opportunity-- I mean we were a little bit surprised because as you alluded to, I think we had expected to see much higher healthcare, much more intense and much more-- I don't like the word aggressive, but much more intense healthcare in the United States but we were surprised to find actually a much different picture. I think both healthcare systems could learn from our findings. First and foremost is that the chemotherapy use that we saw among the U.S. patients I think it would be an opportunity for both physicians and their patients to evaluate if there was any potential benefit of this because you don't give chemotherapy unless you have a significant probability of cure or life prolongation and that is not necessarily the case with this particular population. But on the other hand I think Ontario has an opportunity to assess their healthcare system and say what can we do to provide a more formalized system of support that will allow people to die in a setting outside of the hospital. It is important to note that-- I want to say one thing about hospice care. Hospice care in the U.S. is primarily home based and while it keeps people out of the hospital and it saves the Medicare system a lot of money, it is not a panacea, it really places a significant burden on the family and friends and informal caregivers to step up and provide the care because it is primarily home based.

Kristine Crane: Okay. So in other words, a hospice nurse will come in for a limited period each day but the burden of sort of around the clock care has to fall on the family members or private caregivers?

Joan Warren: Yes.

Kristine Crane: What are the implications for the economic burden of end of life care here?

Joan Warren: Well when we undertook this study we realized we needed to split the analysis into two components. The first component was really to evaluate how do treatment patterns differ between the U.S. and Ontario. And that's what we've done in the current study. What this doesn't address is what the cost of care-- how does cost of care differ between Ontario and the United States and that is something that needs to get done that's a logical follow up to what we've done because it's not only what is the burden in terms of hospitalizations or the burden of care but also what is the economic burden both to the healthcare system and to individual patients.

Kristine Crane: That was Dr. Joan Warren, an epidemiologist at The National Cancer Institute. For a transcript of this interview or to listen to other JNCI Podcasts please visit our Web site at This is Kristine Crane. Thank you for listening.

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