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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2018-026309 on 20 March 2019. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-026309 on 20 March 2019. Downloaded from End-of-life cost and its determinants for patients with malignant neoplasms in urban China: A population-based retrospective study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2018-026309 Article Type: Research Date Submitted by the Author: 29-Aug-2018 Complete List of Authors: Li, Zhong; Huazhong University of Science and Technology Tongji Medical College, School of Medicine and Health Management Pan, Zijin; Huazhong University of Science and Technology Tongji Medical College, School of Medicine and Health Management ZHANG, LIANG; Huazhong University of Science and Technology Tongji Medical College He, Ruibo; Huazhong University of Science and Technology Tongji Medical College, Jiang, Shan; Nanjing Medical University, School of Health Policy and Management Xu, Chengzhong; Yichang Center for Disease Control and Prevention Lu, Fangfang ; Yichang Center for Disease Control and Prevention Zhang, Pei; Yichang Center for Disease Control and Prevention, Yichang http://bmjopen.bmj.com/ Li, Boyang; Huazhong University of Science and Technology Tongji Medical College, School of Medicine and Health Management cancer patients, end-of-life, utilisation, expenditure, retrospective study, Keywords: urban China on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-026309 on 20 March 2019. Downloaded from 1 2 3 1 End-of-life cost and its determinants for patients with malignant neoplasms in 4 5 2 urban China: A population-based retrospective study 6 1# 1# 1 1 2 3 7 3 Zhong Li , Zijing Pan , Liang Zhang , Ruibo He , Shan Jiang , Chengzhong Xu , 8 3 3 1* 9 4 Fangfang Lu , Pei Zhang , Boyang Li 10 5 11 1. School of Medicine and Health Management, Huazhong University of Science and 12 6 Technology, Wuhan, Hubei, 430030, China; 2. School of Health Policy and 13 14 7 Management, Nanjing Medical University; 3. Yichang Center for Disease Control and 15 16 8 Prevention, Yichang,For Hubei,peer 443000, review China only 17 18 9 # Zhong Li and Zijin Pan contributed equally. 19 20 10 * Corresponding author: Boyang Li, E-mail: [email protected] 21 11 22 Address for correspondence: No.13 Hangkong Road, Qiaokou District, School of 23 12 Medicine and Health Management, Tongji Medical College, Huazhong University of 24 25 13 Science and Technology, Wuhan, Hubei, 430030, China 26 27 14 Abstract 28 29 15 Objective This study aimed to define end-of-life (EOL)healthcare utilisation and its 30 31 16 cost and determinants for patients with malignant neoplasms (PMNs) and to 32 17 http://bmjopen.bmj.com/ 33 proactively provide reference for related strategies in mainland China. 34 18 Design A population-based retrospective study. 35 36 19 Setting and Participants Data of 894 patients with PMNs were collected in the urban 37 38 20 Yichang, China from 1 July 2015 to 30 June 2017. 39 40 21 Outcome measures Emergency department (ED) visits, hospitalisation, intensive on September 29, 2021 by guest. Protected copyright. 41 42 22 care unit (ICU) admission and total costs were used as the main outcomes. 43 44 23 Results 66.78% of 894 patients were male, and the average age was 60.4 years. 45 24 Among these patients, 37.58% died at home with an average of 4.86 outpatient 46 47 25 services, 2.23 inpatient services and 1.44 ED visits. Additionally, 8.2% of these 48 49 26 patients who died at home once visited of ICU. During the EOL periods, the costs in 50 51 27 last 6 months, last 3 months, last 1 month and last 1 week were $18235, $13043, 52 53 28 $6349 and $2085, respectively. The cost increased dramatically as death approached. 54 29 55 The estimation results of generalised linear regression model showed that aggressive 56 30 care substantially affects expenditure. Patients with Urban Employee Basic Medical 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 17 BMJ Open: first published as 10.1136/bmjopen-2018-026309 on 20 March 2019. Downloaded from 1 2 3 1 Insurance spent more than those with Urban Resident-based Basic Medical Insurance 4 5 2 and New Rural Cooperative Medical Scheme. Place of death and survival time are 6 7 3 also the risk factors for the increased EOL cost. 8 9 4 Conclusion The findings suggested that the health expenditure for PMNs is 10 5 11 associated with aggressive care, insurance type and survival time. Timing palliative 12 6 care is urgently needed to deal with the irrational healthcare utilisation and reduce the 13 14 7 cost. 15 16 8 Trial registrationFor This peer study was reviewapproved by the onlyethics committee of Tongji 17 18 9 Medical College, Huazhong University of Science and Technology (IORG no. 19 20 10 2018S291). All the data used in this study were de-identified. 21 22 11 Keywords 23 12 cancer patients, end-of-life, utilisation, expenditure, retrospective study, urban China 24 25 13 Strengths and limitations 26 27 14 This population-based study was the first to systematically estimate the EOL health 28 29 15 expenditure for patients with cancer in mainland China. Estimating the palliative care 30 31 16 demand and guiding its system-building are important. 32 17 http://bmjopen.bmj.com/ 33 This study introduced EOL healthcare and cost in China and quantified the 34 18 relationship between them. 35 36 19 This study will guide health policy regarding the delivery of high-quality, 37 38 20 cost-effective cancer care system. 39 40 21 Given the anonymity of the data, we cannot obtain the health records from primary on September 29, 2021 by guest. Protected copyright. 41 42 22 care facilities. Thus, the EOL healthcare cost might have been underestimated. 43 23 44 The unique socioeconomic status of the selected cohort population may reduce the 45 24 generalisability of our findings. Further studies on the provincial or national level are 46 47 25 essential to provide systematic evidence for policy makers. 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 17 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2018-026309 on 20 March 2019. Downloaded from 1 2 3 1 Introduction 4 5 2 Cancer is the leading cause of mortality and accounts for 14.1 million new cancer 6 7 3 cases and 8.2 million deaths worldwide, thereby resulting in 32.6 million individuals 8 9 4 living with cancer in 2012 [1]. Cancer greatly affects low- and middle-income 10 5 11 countries and is expected to account for 70% of the newly reported cancer by 2030 [2]. 12 6 Given the considerable share of the total health expenditure on cancer (approximately 13 14 7 6% in European countries [3], 9.2% in Taiwan) [4 5]) and the staging 5/80 cancer 15 16 8 disequilibriumFor between peer developed and review developing countries[2], only evaluating end-of-life 17 18 9 (EOL) cost and identifying its key determinants have been a worldwide concern [6]. 19 20 10 Several systematic reviews pointed out that EOL in-home care can improve patient 21 11 22 satisfaction, thereby reducing hospital care utilisation and death [7 8]. These reviews 23 12 also indicated that aggressive procedures do not improve the quality of life [9 10]. 24 25 13 However, the health expenditure and utilisation show large geographic variations 26 27 14 among patients in the USA with high medical care intensity at the EOL, thereby 28 29 15 producing poor outcomes and confusing the patients’ preference [11-13]. EOL 30 31 16 hospitalisation relatively lacks value worldwide with unsustainable expenditure [14 32 17 http://bmjopen.bmj.com/ 33 15], and palliative care is relatively underutilised though is proven to save cost [16]. 34 18 These phenomena thereby aggravate the inequality among patients with different 35 36 19 economic levels or health insurance types and decrease the overall efficacy [17-19]. 37 38 20 According to the Fifth Chinese National Health Services Survey in 2013, the 39 40 21 incidences of malignant neoplasms in China reached 0.35% and 0.23% in the urban on September 29, 2021 by guest.
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