L. Marcia1, Z. W. Ashman2, E. B. Pillado1, C. Hines1, D. S. Plurad2, D. Y. Kim2 1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2Harbor-UCLA Medical Center,Surgery,Torrance, CALIFORNIA, USA
Introduction: Advance directive (AD) and do-not-resuscitate (DNR) orders are expected to improve end-of-life care in a cost-effective manner. Our objective was to describe the relationship between cost of care and timing of DNR orders among stage IV cancer patients with Acute Care Surgery (ACS) consultations.
Methods: Single institution retrospective review of all ACS consultations over an 8-year period in stage IV cancer patients with ACS consultation. Cost estimates were calculated from the Healthcare Cost and Utilization Project (the Nationwide Inpatient Sample), Centers for Medicare and Medicaid Services in California and other published cost estimates. Statistical analysis included univariate analysis to characterize data, ANOVA and chi-square tests to assess correlation
Results: Two hundred three patients were identified; mean age was 55.3 ± 11.4 years old, 48.8% were male. Fifty patients (24.6%) underwent exploratory laparotomy for gastrointestinal obstruction and/or perforation and 26 (12.8%) underwent other types of surgery. Twenty-one patients (10.3%) had a DNR order on-admission, 54 (26.6%) became DNR post-admission and 128 patients (63.1%) remained full-code. DNR post-admission was associated with longer mean length of stay (LOS) (19.6 days) vs DNR on admission (7.0 days) and full code (10.5 days; p<0.01). This was similar for ICU LOS: 7.7days in the DNR post-admission, 1.7 in the full code and 0.9 days in the DNR on-admission groups (p<0.01). DNR post-admission was associated with higher total cost of hospitalization ($76,133) compared to DNR on-admission ($25,114) and patients that remained full code ($36,857; p<0.01). DNR post-admission was associated with higher cost for ICU stay compared to DNR on-admission and full-code groups ($11,747 vs $1,304 vs $2,520, p<0.01). Procedural/surgical costs were higher for DNR post-admission compared to DNR on-admission and full-code groups ($610 vs $381 vs $535; p = 0.34). Hospital mortality was higher in the post-admission DNR group (82.1%) in comparison to the DNR on-admission (10.7%) and full code groups (7.1%, p< 0.01). The mean estimated cost after inpatient death was $88,662. The full-code group had the lowest cost after inpatient death followed by DNR on-admission and DNR post-admission groups ($6,351 vs $10,491 vs $106,016, p<0.01). In the post-admission DNR group, the mean interval between admission and DNR was 19 days and from post-admission DNR to in-hospital death was 4 days.
Conclusion: DNR post-admission is associated with higher cost-of-care than DNR on-admission and full-code groups. This group experiences prolonged hospital and ICU LOS, which are the primary drivers of cost in all groups. These patients elect for aggressive (and costly) care at the end-of-life despite a known life-limiting diagnosis and poor immediate prognosis. These interventions may not extend length of life meaningfully and may worsen the quality of life before death. Improvements should be made to identify such patients, with the goal of providing high quality care sensitive to the context of a terminal diagnosis.