Economics of unrelieved cancer pain

Diagnosis Related Groups, managed care contracts and capitation, hospitals had little incentive to control costs. Now hospitals have shifted to a more cost-effective environment by striving for improved patient clinical outcomes, satisfaction, and functionality while also acknowledging the need for fiscal restraint. For society at large and especially oncology patients in pain, the risk in this shift is an underutilization of resources to relieve pain driven by the the mistaken belief that good pain management takes too much time and is therefore an expensive “luxury. ” However, the reality is that unrelieved cancer pain results in patient suffering, decreased quality of life and ultimately higher medical and non-medical costs—due to increased likelihood of patient and family lost wages and higher utilization of medical services, such as emergency department visits and unnecessary hospitalizations. Between 30 and 50 percent of cancer patients in active treatment and 70 to 90 percent of those with advanced disease experience moderate to severe pain.1 Cancer pain may be acute or chronic and can be caused by the tumor growing in tissues and organs, such as the liver or bone, or can be caused by treatments for the cancer, such as chemotherapy, radiotherapy, or surgery. Table 1 outlines the many ways that unrelieved cancer pain affects the lives of patients and their families. Decreased quality of life, functionality, activity, appetite and productivity can result in the patient’s unwillingness to continue antineoplastic treatment. The most disturbing result of unrelieved pain is the movement to legalize euthanasia for terminally ill patients. A reported 69 percent of the general public surveyed indicated that they would consider suicide if pain became intolerable.2 The clinical problem of unrelieved pain has received much attention in the last decade with an emphasis on medical community education, national clinical practice guidelines, and new pharmacotherapeutic options for treatment. In fact, for the vast majority of cancer patients with pain, the use of analgesic medications is the mainstay of treatment. When pain is relieved at home, patients and their families incur only the costs associated with treatment, usually pharmacotherapy. When pain is unrelieved at home, patients frequently require emergency department visits, which may result in expensive inpatient admissions. In these pain crisis situations, direct medical costs, direct and indirect non-medical costs to patients, and intangible pain and suffering costs are high (Table 2). Evaluations of the costs of unrelieved cancer pain have shown that the most expensive therapies are the ones that don’t work. Economic reports from two cancer centers confirmed the significance of hospital costs for unscheduled hospital admissions for unrelieved pain (Table 3). 3,4 During the evaluation period, each hospital spent about $5 million annually for patients admitted for pain management with longer than average hospital lengths of stay. City of Hope National Medical Center in Duarte, California, instituted a quality assurance program in pain management to educate the medical community on appropriate opioid administration, side effect management, and identification of high-risk patients for referral to the hospital’s Pain & Symptom Management Consultation Service. These efforts resulted in a $1 million savings to the hospital.5 There is a tendency in health care to overlook out-of-pocket costs for direct and indirect costs borne by the patient and family in managing cancer pain. Stommel6 quantified these costs for a three-month period and annualized the family cost to $12,532 (79 percent for lost wages). In a separate evaluation these investigators calculated the cost of family care by multiplying the hourly cost of home health by an estimate of the direct patient care hours. The average annual family cost of direct care hours was $18,284, slightly less than the cost for a one-year