# Health Care Resource Use at End of Life in Patients with Advanced Lung Cancer
## 4 Discussion  
Advanced stage lung cancer inevitably leads to death. Up to 60% of patients develop brain metastases, 40% develop bone metastases and nearly all have breathing difficulties, making early palliative and supportive care particularly important [12]. Timely initiation of palliative care paves the way for planned hospice care and improved quality of life at EOL [13; 14]. This study focused on health care services reimbursed by the national insurer in Estonia in patients with advanced lung cancer. Use of the resources was analysed in relation to time before death in patients who received SACT compared with those who were ineligible for SACT, e.g., amenable to supportive care only. An international study of place of death reported that in most of the 40 populations studied covering all deaths, the median percentage of all deaths occurring in hospitals was 54%, in residential homes 18% and other locations 28% [15]. In Estonia, the respective figures for 2010 were 54%, 11% and 35%, i.e., very close to the international average. In the current study, the available data did not allow to discriminate between residential and private homes, and the category out-of-hospital includes both residential care and private home deaths. We found that 62% of deaths in the SACT group occurred in a hospital, close to the average of 55% of all deaths in Estonia (Table 4). Only 22% of deaths in the no-SACT group occurred in a hospital setting. This can be interpreted as less medical attention being given to lung cancer patients who are ineligible for SACT and other modalities of active oncological care. Patients who died early after SACT (EOL-SACT) likely died in an acute \begin{table}
\begin{tabular}{c c c c c} \hline  & **No-SACT** & **SACT \textgreater{} 100** & **SACT 31–100** & **EOL-SACT** \\  & **(N = 278)** & **(N = 162)** & **(N = 142)** & **(N = 72)** \\ \hline Time covered with & 0.07 & 0.27 & 0.32 & 0.26 \\ services (95\% CI) * & (0.07–0.08) & (0.26–0.27) & (0.31–0.33) & (0.25–0.28) \\ \hline Intensity index (95\% CI) & 8.3 & 30.1 & 38.0 & 30.2 \\ per FU month & (8.0–8.6) & (29.6–30.6) & (37.4–38.6) & (29.3–31.0) \\ \hline Intensity of service use & 0.27 & 0.99 & 1.24 & 0.99 \\ per person-day (95\% CI) & (0.26–0.28) & (0.97–1.00) & (1.23–1.26) & (0.96–1.02) \\ \hline \end{tabular}  
* Averaged for the last 100 days of life; FU—follow-up; SACT, systemic anti-cancer treatment; EOL, end of life; EOL-SACT, patients received SACT within last 30 days of life; >100 SACT, patients received SACT > 100 days before death; SACT 31–100, patients received SACT 31–100 days before death.  
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Table 6: Proportion of time covered by health care services per month, and intensity of service use per person-month. \begin{table}
\begin{tabular}{c c c} \hline  & **Actual Average Cost (EUR)** & **Resource Use Weight** \\ \hline Outpatient visit, incl. diagnostics & 50 & 1 \\ \hline Home nurse visit, incl. disposables & 50 & 1 \\ \hline ED visit, incl. diagnostics & 150 & 3 \\ \hline Hospital bed-day, incl. diagnostics and procedures & 250 & 5 \\ \hline ICU bed-day, incl. procedures and treatments & 500 & 10 \\ \hline ED, emergency department; ICU, intensive care unit. & \\ \end{tabular}
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Table 5: Average cost and resource use weight of health care service at the end of life care. care hospital due to treatment related complications and/or rapidly progressing disease. The likelihood of dying out-of-hospital increased as the time from the last SACT until death was prolonged. Still, we observed a substantial difference in the place of death between the no-SACT arm and patients who died >100 days after the last SACT. Hence, EOL care is affected by the receipt of previous active oncology treatment. Inpatient care accounted for the largest proportion of health care services used in our study. Nearly all patients in the SACT group had at least one inpatient hospital stay, whereas only 11% of patients in the no-SACT arm were hospitalized during the course of their disease (Table 1).