# Health Care Resource Use at End of Life in Patients with Advanced Lung Cancer
## 4 Discussion
Our results are in line with other similar studies across the world. In Japan, most EOL medical costs in lung cancer patients were inpatient costs, and EOL costs surpassed those for initial treatment [16]. Despite lower utilization in the US, inpatient hospitalization was still the main cost driver both in the US and Canada [17]. Among EU countries, inpatient care costs varied substantially from 30% in Slovakia to 67% in Ireland--accounting for an average of 56% of cancer-related health care costs for all cancer types combined [5]. Our study is unique in regard to the EOL data analysis depending on patients' eligibility for active oncology treatment. Next, we analysed the use of health care services by month before death. For all service types and for all months, the percentage of patients who used health care service was lower for the no-SACT arm than the SACT arm. Administration of SACT dropped as of the fifth month before death but was still nearly 20% during the last month of life. General practitioner visits increased from 40% in patients using the service in the 12 th month before death to 60% in SACT patients in the last month but remained below 20% in no-SACT patients regardless of time before death. The percentage of patients with inpatient care did not change significantly over time during the last year of life. In contrast, in the recent US study, patients receiving acute inpatient care increased from 12.2% in the sixth month before death to 43.8% in the last month [6]. Similarly, the percentage of patients who received hospice care increased from 0.7% in the sixth month to 35.6% in the last month. In the current study, although the average cost per person-month for nursing care was higher in the no-SACT arm, the frequency of service use per person-month was much lower than in the SACT arm (Tables 2 and 3). Approximately 20% of patients in the SACT arm, compared with only 7% in the no-SACT arm, received nursing care in the final month of life in our study. This clearly demonstrates a deficiency in the organization of hospice care. In developed countries, approximately one-third of lung cancer cases are diagnosed via an ED visit [18; 19]. Unplanned ED visits are related to significant clinical and economic burden due to the need for out-of-hours radiologist and specialist care services. In the recent UK study, lung cancer patients diagnosed during ED admission incurred greater costs during the first month and had a worse prognosis compared with outpatient diagnoses [18; 19]. Although we were not able to discern whether the initial diagnosis was made via ED, the higher than average costs per person-month for intensive care and hospital bed stays in the no-SACT arm indicate that our results are similar to the UK. To exclude costs related to the initial lung cancer diagnosis, costs per person-month were calculated from the day after the multidisciplinary tumour board until death. Our ED claims contained data on whether patients were discharged or admitted to the hospital. Patients may have a CT scan performed during ED admission, but procedures leading to the histology and treatment decision are generally carried out in an outpatient setting. Both the significant proportion of patients who died in acute care hospital admitted via ED and the high frequency of ED service use indicate a need for better organization of out-of-hours oncology care and hospice care covered by the health insurance fund. In our study, costs related to the administration of SACT accounted for 30% of total health care costs in the SACT arm. Across the EU, drug expenditure accounted for more than $13.5 billion, i.e., 27% of cancer-related health care costs in 2013, for all cancer types combined [5]. Drug expenditure as a proportion of overall cancer-related health care costs was lowest in Lithuania (15%) and highest in Cyprus (61%). At the time of the study,immunotherapy and targeted treatment, except first generation EGFR tyrosine kinase inhibitors, were not reimbursed in Estonia.