# Health Care Resource Use at End of Life in Patients with Advanced Lung Cancer
###### Abstract  
We aimed to study differences in the use of health care resources in relation to time before death in patients with advanced lung cancer who either received systemic anti-cancer treatment (SACT) or were ineligible for SACT. A retrospective cohort of lung cancer patients (\(N=778\)) diagnosed with advanced disease at North Estonia Medical Centre from 2015-2017 was linked to population-based health care data. We calculated a composite measure of cumulative resource use, comprised from the following: outpatient care, emergency department (ED) visit, inpatient care, admission to intensive care unit, nursing care and prescriptions. Costs were highest in patients who received SACT in the last month before death and decreased in parallel with the time elapsed from the last SACT. Only 20% of SACT patients received nursing care in the final month of life. The no-SACT patients had less time covered by health care services per month, and large differences were seen in the type of service received by the study groups. The largest contributor of health care costs at end of life was acute inpatient care, including approximately 10% of patients who died on the same day as or day following the emergency department visit. These results demonstrate the low nursing care and hospice utilization rates in Estonia. resource use; health care; end of life care; advanced lung cancer 2021 11 9  
followed by breast cancer (12%), colorectal cancer (10%) and prostate cancer (7%) [5]. With regard to the type of cost, inpatient care was the major component in lung cancer (\(\ell\)2.87 billion, 68%) and colorectal cancer (\(\ell\)4.04 billion, 73%), whereas drugs were the major component in breast cancer (46%) and prostate cancer (57%) across the EU. Substantial differences were observed between EU countries in absolute costs per citizen, and the costs varied by type of health care service. The mortality of lung cancer is high, accounting for nearly 20% of all cancer deaths in 2018 globally [4]. In addition to tumour type, total cancer-related costs vary by stage, with the highest costs incurred in the final year of life. In a retrospective cohort study, [PERSON] et al. evaluated direct medical expenditures in patients with lung cancer in South Korea [3]. Surgically treated patients had the highest absolute expenditure ($36,013) due to the high cost in the initial phases of the disease, but the monthly average expenditure was the lowest. In advanced lung cancer, monthly medical expenditure was highest for the last three months of life, with anti-cancer treatment being the greatest cost driver in this period. In the United States, cancer end-of-life (EOL) costs are burdensome, the 5-6% of Medicare beneficiaries who died consumed 27-30% of the annual cancer payments and 78% of costs accrued from acute care in the final 30 days of life [6; 7]. [PERSON] et al. demonstrated that aggressive care, as well as hospitalization costs due to intensive care unit (ICU) admissions, chemotherapy and radiotherapy at EOL, has steadily increased from 1998 to 2014 in the United States [8]. Nearly half of new lung cancer cases are in advanced stage, and approximately half of patients will develop distant metastases after treatment for local disease. Systemic anti-cancer treatment (SACT) is the primary treatment option for these patients. Platinum-based combination chemotherapy has been cornerstone in lung cancer for decades. Recent developments include immunotherapy and targeted treatment in carriers of specific genetic alterations, particularly in EGFR and ALK gene. In Estonia, approximately 800 people annually are newly diagnosed with lung cancer [9]. The five-year overall survival (OS) of lung cancer is estimated at 10-15% worldwide [10]. The poor prognosis means that there is an ultimate need for EOL care services. Estonia has universal insurance coverage and oncology care is delivered only by the national health care system.