Support Care Cancer (2014) 22:1907–1914
DOI 10.1007/s00520-014-2168-5
ORIGINAL ARTICLE
Hospice shared-care saved medical expenditure and reduced
the likelihood of intensive medical utilization among advanced
cancer patients in Taiwan—a nationwide survey
Wen-Yuan Lin & Tai-Yuan Chiu & Chih-Te Ho & Lance E. Davidson &
Hua-Shui Hsu & Chiu-Shong Liu & Chang-Fang Chiu & Ching-Tien Peng &
Chih-Yi Chen & Wen-Yu Hu & Ling-Nu Hsu & Chia-Ing Li &
Tsai-Chung Li & Chin-Yu Lin & Ching-Yu Chen & Cheng-Chieh Lin
Received: 24 October 2013 / Accepted: 5 February 2014 / Published online: 26 February 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Hospice shared care (HSC) is a new care model that
has been adopted to treat inpatient advanced cancer patients in
Taiwan since 2005. Our aim was to assess the effect of HSC
on medical expenditure and the likelihood of intensive med-
ical utilization by advanced cancer patients.
Methods This is a nationwide retrospective study. HSC was
defined as using “Hospice palliative care (HPC) teams to
W.<Y. Lin : C.<T. Ho : H.<S. Hsu : C.<S. Liu : C.<C. Lin (*)
Department of Family Medicine, China Medical University Hospital,
Taichung, Taiwan
e-mail: cclin@mail.cmuh.org.tw
W.<Y. Lin : C.<Y. Chen
Department of Family Medicine, National Taiwan University
Hospital, Taipei, Taiwan
W.<Y. Lin : C.<S. Liu : C.<C. Lin
School of Medicine, China Medical University, Taichung, Taiwan
W.<Y. Lin : C.<C. Lin
Graduate Institute of Clinical Medicine Science, China Medical
University, Taichung, Taiwan
T.<Y. Chiu : C.<T. Peng
Department of Pediatrics, China Medical University Hospital,
Taichung, Taiwan
L. E. Davidson
Department of Exercise Sciences, Brigham Young University, Provo,
UT, USA
C.<F. Chiu
Division of Hematology/Oncology, Department of Internal
Medicine, China Medical University Hospital, Taichung, Taiwan
provide consultation and service to advanced cancer patients
admitted in the nonhospice care ward.” There were 120,481
deaths due to cancer between 2006 and 2008 in Taiwan.
Patients receiving HSC were matched by propensity score to
patients receiving usual care. Of the 120,481 cancer deaths,
12,137 paired subjects were matched. Medical expenditures
for 1 year before death were assessed between groups using a
database from the Bureau of National Health Insurance.
C.<Y. Chen
Department of Surgical Medicine, China Medical University
Hospital, Taichung, Taiwan
W.<Y. Hu
Department of Nursing, National Taiwan University Hospital, Taipei,
Taiwan
L.<N. Hsu : C.<Y. Lin
Department of Nursing, China Medical University Hospital,
Taichung, Taiwan
C.<I. Li
Department of Medical Research, China Medical University
Hospital, Taichung, Taiwan
T.<C. Li
Graduate Institute of Biostatistics, China Medical University,
Taichung, Taiwan
C.<C. Lin
Institute of Health Care Administration, College of Health Science,
Asia University, Taichung, Taiwan
1908
Paired t and McNemar’s tests were applied for comparing the
medical expenditure and intensive medical utilization before
death between paired groups.
Results Compared to the non-HSC group, subjects receiving
HSC had a lower average medical expenditure per person
(US$3,939 vs. US$4,664; p<0.001). The HSC group had an
adjusted net savings of US$557 (13.3 %; p<0.001) in inpa-
tient medical expenditure per person compared with the non-
HSC group. Subjects that received different types of HPC had
15.4–44.9 % less average medical expenditure per person and
significantly lower likelihood of intensive medical utilization
than those that did not receive HPC.
Conclusions HSC is associated with significant medical ex-
penditure savings and reduced likelihood of intensive medical
utilization. All types of HPC are associated with medical
expenditure savings.
Keywords Hospice shared care . Palliative care . Medical
expenditure . Advanced cancer
Introduction
Cancer incidence and mortality have risen dramatically in past
decades worldwide [11]. A similarly rapid increase has made
cancer the leading cause of death in Taiwan since 1982 [7]. In
2009 alone, 39,917 (28.1 % of total deaths) Taiwanese died of
cancer [7]. Numerous screening tools and anticancer therapies
have been developed for early detection and treatment, but
many cancer patients are diagnosed as incurable. Hospice
palliative care (HPC) has been recognized as one of the best
care models for advanced cancer patients [12, 17]. HPC
systems have been shown to spare medical expenditures and
increase quality of life compared to usual care among ad-
vanced cancer patients [8, 13, 16, 20, 22].
HPC has been established for more than 20 years in
Taiwan. Both the Bureau of National Health Insurance and
the Bureau of Health Promotion in Taiwan provide payments
or subsidies for hospice palliative hospitalization and home
care service. However, the percentage of advanced cancer
patients that accepted hospice palliative services was only
17 % in 2005 [6]. Since that time, the Bureau of Health
Promotion in Taiwan has subsidized hospitals to provide a
“Hospice Shared Care (HSC) Program” for advanced cancer
patients [23, 24]. The program allows hospitalized advanced
cancer patients to receive hospice palliative service by spe-
cialized HSC teams without leaving their original medical
care team and environment [6]. The program, together with
hospice palliative hospitalization and home care services, has
already increased the usage of hospice palliative services
among advanced cancer patients to 38 % in 2008. Previous
work has demonstrated that the HSC program significantly
improves the quality of life among advanced cancer patients
Support Care Cancer (2014) 22:1907–1914
[18]. It has also been found that both the HSC and hospice
ward care (HWC) programs among advanced cancer patients
can significantly and effectively relieve physical symptoms,
spiritual distress, and improve psychosocial burden during the
final stage of life [18]. An important question to ask is whether
HSC can save medical costs and reduce unnecessary medical
utilization, such as the use of an intensive care unit (ICU),
before death for advanced cancer patients. Therefore, we
conducted a nationwide study using propensity score-
matched controls to assess the effect of HSC on medical
expenditure among advanced cancer patients using a database
from the Bureau of National Health Insurance in Taiwan. We
also evaluated the medical expenditure savings and intensive
medical care utilization among different types of hospice
palliative services.
Patients and methods
Study subjects
This study was a two-group comparison of an interdisciplin-
ary HSC service in Taiwan. Our sample includes patients from
the linked National Health Insurance (NHI) dataset, National
Cancer Registry, death certification profiles, and Taiwan HSC
dataset, who died with a primary diagnosis of cancer between
2006 and 2008. Taiwan’s NHI dataset contained health care
data from 99 % of the population receiving health care in 1997
and has continued that breadth of coverage ever since [3]. The
primary diagnosis of cancer was defined by an International
Classification of Disease, 9th revision, clinical modification
(ICD-9-CM) code of 140 through 239. There were 120,481
deaths due to cancer between 2006 and 2008 in Taiwan. We
excluded patients whose records contained dates of interdis-
ciplinary HSC services after the date of death (n=8), and
patients without utilization of medical care in 1 year before
death (n=262). A total of 120,211 patients were included in
the matching procedure. Of these, 37,080 patients were in the
ever-received HPC group and 83,131 patients were in the
never-received HPC group.
Patient demographics and clinical characteristics
Age and gender were captured from claims data. Baseline
clinical characteristics included initial cancer stage, category
of initial cancer type, and type of medical care use. The initial
cancer type was categorized into 12 groups: liver cancer,
gastric and esophageal cancer, colon and intestinal cancer,
lung and bronchial cancer, head and neck cancer, pancreatic
and gallbladder cancer, reproductive cancer, breast cancer,
genitourinary cancer, hematologic cancer, and others. For
patients who ever received HPC, the medical care group
classification was determined by the type of medical care they
Support Care Cancer (2014) 22:1907–1914 1909

received at their first outpatient visit or hospitalization.
Durations from their first date of receiving HPC to date of
death were calculated and divided into 10-day intervals. The
interval of the first use of HPC was identified for further
informing the matching process. For patients who never re-
ceived HPC, the intervals with the use of outpatient visit or
hospitalization admission prior to death were identified. Only
intervals with medical use were considered in the matching
procedure.
Matching procedure
According to the type of HPC, patients who ever received
HPC were divided into seven groups: only received HSC
(n = 14,303), only received hospice home care (HHC;
n = 1,951), only received hospice ward care (HWC;
n=8,297), received HSC and HWC (n=6,220), received
HSC and HHC (n=1,484), and received HSC, HHC, and
HWC (n=2,045) (Fig. 1).
In order to improve comparability of the characteristics of
patients including age, gender, initial cancer stage, and cate-
gory of initial cancer type between patients who ever received
HPC and who never received HPC, we used an individual
2006/1/1~2008/12/31 Mortality due to cancer
n=120,481
Excluded due to information
error or no medical care use
Ever-received hospice
palliative care
n =37,080
Seven type of service
Only received HSC, n =14,303
Only received HHC, n =1,951
Only received HWC, n =8,297
Received HSC, HHC and HWC, n =2,045
Received HSC and HWC, n =6,220
Received HSC and HHC, n =1,484
Received HHC and HWC, n =2,780
matching method by propensity score to control for potential
confounding effects. Patients who had ever received HPC
were matched in a 1:1 ratio to those who had never received
HPC on the basis of the propensity score matching method
without replacement. Conditional on the features of this pro-
pensity score matching method, matched pairs of patients
have similar distribution, but are not necessarily equal to the
category in gender, initial cancer type, and the interval used to
determine outpatient visits or hospitalization admission. In
order to have equal categories in these factors between pa-
tients with ever-received HPC and with never-received HPC,
an individual’s likelihood of receiving HPC (propensity score)
applied by logistic regression with age and initial cancer stage
as independent predictors was calculated by using these fac-
tors as stratified factors. The fitted probability from this model
(i.e., the propensity score), which reflected a patient’s estimat-
ed propensity to receive HPC rather than not to receive it, was
assigned to each patient. The nearest available pair-matching
method with a greedy algorithm was applied [19]. In greedy
matching, a patient with ever-received HPC was selected and
matching was attempted with the nearest patient with never-
received HPC. When two or more patients with never-
received HPC had the same propensity score match, the match
for the analysis was chosen randomly. This process was
repeated until matches had been attempted for all patients with
ever-received HPC. A total of 30,903 matched pairs were
obtained for data analysis. The number of matched pairs in
seven types or combinations of HPC services are presented in
within one year prior to Fig. 1 as follows: 12,137 pairs in patients who only received
death
n =270 HSC; 1,542 pairs in those who only received HHC; 6,645
Never-received hospice pairs in those who only received HWC; 5,546 pairs in those
palliative care who received HSC and HWC; 1,322 pairs in those who
n =83,131
received HSC and HHC; 2,489 pairs in those who received
HHC and HWC; and 1,222 pairs in those who received HSC,
HHC, and HWC (Fig. 1). The China Medical University
Hospital Institutional Review Board approved this study.
Medical expenditure measurement

Propensity score matching-method was applied For patients with ever-received HPC, the start date of their first
by using age and initial cancer stage as instance of receiving HPC from the claims data was defined as
matching factors in logistic regression model
stratified by gender, initial cancer type, and the index date. For patients with never-received HPC, the
interval for the use of outpatient visit or
hospitalization admission index dates were assigned depending on the index date of
the individual’s propensity score-matched, ever-received HPC
Excluded without matching, Excluded without matching,
n =6,177 n =52,228 patient. All medical expenditures and utilization for these
patients were calculated from the index date to the date of
Number of matched-pairs
Only received HSC, n =12,137 death.
Only received HHC, n =1,542 Each patient’s medical expenditure was summarized as
*Abbreviation: Only received HWC, n =6,645
HSC, hospice shared-care
inpatient service, outpatient service, emergency room service,
Received HSC, HHC and HWC, n =1,222
HHC, hospice home care Received HSC and HWC, n =5,546 and grand total expenditure from the index date to the date of
HWC, hospice ward care Received HSC and HHC, n =1,322 death. The expenditure of inpatient service was categorized
Received HHC and HWC, n =2,489 into six domains as previously reported [13]: (1) diagnosis
Fig. 1 Flowchart and individually matched schedule in this study fees; (2) laboratory/X-ray fees; (3) therapeutic fees (including
1910 Support Care Cancer (2014) 22:1907–1914

therapeutic procedures, rehabilitation, special materials, psy- Results

chiatric treatment, and injection services fees); (4) drug fees
(including drugs and dispensing services fees); (5) ward fees
(including wards and tube feeding fees); and (6) other fees
(such as surgery, hemodialysis, and blood/plasma analysis
fees). All medical expenditures were presented in US$.
Intensive medical unitization before death
We derived three indicators for intensive medical utilization
before death: utilization of ICU, cardiopulmonary resuscitation
(CPR), and endotracheal tube (ETT) insertion. Any patient who
received these services from index date to date of death from
claim data was classified by these indicators in a binary (with or
without receiving services before death) fashion.
Statistical analysis
Descriptive statistics were used to characterize the medical
utilization. The data are presented as means and standard
deviation unless otherwise indicated. The log-transformation
of medical expenditure was done for normal distribution in
inferential statistics. The paired t test was used to test signif-
icant differences for continuous data between matched pairs.
The McNemar’s test was applied for comparisons of intensive
medical utilization between two groups. All statistical tests
were two-sided at the 0.05 significance level. These statistical
analyses were performed using SAS software version 9.2
(SAS Institute, Cary, NC, USA).
Table 1 shows the average medical expenditure per person
between HSC and non-HSC groups. The average medical
expenditures per person among inpatient, outpatient, and
emergency room services on HSC group were significantly
lower than non-HSC groups (all p<0.001). The grand total
medical expenditure per person was US$4,664 and US$3,939
for non-HSC and HSC groups, respectively. The largest med-
ical expenditure savings was found in inpatient service.
The analyzed medical expenditures in this subgroup are
shown in Table 2, including a non-HSC versus HSC compar-
ison within types of medical costs associated with the inpa-
tient care setting. The average medical expenditure per person
was lower in the HSC group compared to the non-HSC
groups. A similar relationship was found for all expenditure
subgroups except diagnosis fee.
A comparison of medical expenditure between groups who
did or did not receive any form of HPC is displayed in Table 3.
Regardless of care type, inclusion of HPC was associated with
a reduction in medical expenditure. The medical expenditure
savings per person among those who received various com-
binations of HSC, HHC, and/or HWC ranged between 15.4 %
and 44.9 % (Table 3).
Table 4 shows the intensive medical utilization (ICU, CPR,
or ETT insertion) between patients who ever-received or
never-received HPC (HSC, HHC, and/or HWC). Patients with
any type of HPC have significantly decreased likelihood of
ICU, CPR, or ETT use except for the HSC group, which has
an incidence of ICU utilization that is not significantly lower
than the non-HSC group.

Table 1 Average medical expenditure per person between patients with and without HSC

Without HSC (N=12,137) With HSC (N=12,137) p Valuesb

Inpatient service
Total times 1.5(1.4) 1.5 (1.4) <0.001
Length of stay (days) 16.0 (21.6) 19.0 (27.0) <0.001
Total expenditure (US$)a US$4,183 (6,434) US$3,626 (5,872) <0.001
Outpatient service
Total times 2.7 (7.1) 1.9 (6.5) <0.001
Total expenditure (US$)a US$339 (1410) US$253 (1,359) <0.001
ER service
Total times 0.7 (1.2) 0.4 (1.3) <0.001
Total expenditure (US$)a US$142 (335) US$61 (198) <0.001
Grand total expenditure (US$)a US$4,664 (6,921) US$3,939 (6,379) <0.001

Present with mean (SD) or N (%) as indicated. Patients with or without HSC were matched for age, gender, initial diagnosis of cancer stage, cause of
death, and type of hospital category.
HSC hospice shared care, ER emergency room
a
Log transformation was done for normal distribution
b
Paired t test for continuous variables
Support Care Cancer (2014) 22:1907–1914 1911

Table 2 Average inpatient expenditure per person between patients with and without related HSC

Medical expenditure per person (US$) Without HSC (N=12,137) With HSC (N=12,137) p Values*

Diagnosis fees US$205 (265) US$209 (285) <0.001

Laboratory/X-ray fees US$780 (887) US$586 (822) <0.001
Therapeutic fees US$684 (828) US$578 (851) <0.001
Drug fees US$1,119 (2,115) US$1,079 (2,195) <0.001
Ward fees US$954 (1,513) US$874 (1,306) <0.001
Others US$446 (860) US$305 (688) <0.001
Grand total US$4,183 (6,434) US$3,626 (5,872) <0.001

Present with mean (SD). Patients with or without HSC were matched for age, gender, initial diagnosis of cancer stage, cause of death, and type of hospital
category
HSC hospice shared-care
*
p Values were calculated by paired t test

Discussion hospital cost). Pyenson and colleagues [22] reported that

Using a nationwide survey in Taiwan, we have demonstrated
that cancer patients who receive HSC can effectively reduce
medical expenditure and decrease the incidence of intensive
medical utilization. To our knowledge, this is the first nation-
wide study not only to provide a useful solution to reduce
medical expenditure and unnecessary intensive medical utili-
zation but also to increase the coverage of HPC among ad-
vanced cancer patients. In an era of steadily increasing med-
ical costs, our finding that HSC is associated with significant
reductions in medical expenditure has important implications
for policy makers in Taiwan as well as for other countries that
could benefit from implementing this treatment model.
Previous studies have reported that a palliative care pro-
gram can reduce hospital cost and health care utilization
[9, 15, 16, 21]. Emanuel [9] summarized data showing that
HPC can save 25–40 %, 10–17 %, and up to 10 % of health
care costs during the last month, 6 months, and 12 months of
life, respectively. Morrison and colleagues [16] also estimated
the hospital cost from eight different hospitals in the USA and
found that HPC consultation teams are associated with signif-
icant hospital cost savings (saving 13.6–18.4 % of total
patients who receive hospice care have lower mean and me-
dian Medicare costs than nonhospice care patients and that the
lower cost is not associated with shorter time until death.
Penrod and colleagues [20, 21] also reported that, compared
to usual care, palliative care was associated with significantly
lower inpatient costs and lower likelihood of ICU use.
Compared to previous studies, the current study has a number
of strengths. First, our sample size is sufficiently large to allow
for propensity score matching and thus minimize potential
confounders. Second, this is a nationwide study which can
represent the true medical condition among advanced cancer
patients living in a developed country. Third, we collected
medical expenditure from our NHI, a single third payment
party which covers all the residents in Taiwan’s health care
system, and thus our results reflect actual total medical costs
(including inpatient, outpatient, ER, and other costs) rather
than only hospital cost. Finally, we compared the medical
expenditure not only on HSC but also on HHC and HWC,
representing all medical expenditures among patients with or
without HPC.
Spector and Mor [25] reported that medical expenditures
increase markedly near time of death among advanced ill

Table 3 Average medical expenditure per person between patients with and without related HPC (HSC, HHC, and/or HWC)

Care type No of patients in each group Grand total expenditure (US$)a Difference (%) p Valuesa

Without related HPC With related HPC

Received HSC or HHC or HWC 30,903 US$5,099 US$4,314 -15.4 <0.001

Only received HSC 12,137 US$4,664 US$3,939 -15.6 <0.001
Only received HHC 1,542 US$4,914 US$2,709 -44.9 <0.001
Only received HWC 6,645 US$3,845 US$3,220 -16.2 <0.001
Received HSC, HHC, and HWC 1,222 US$8,526 US$6,708 -19.0 <0.001

HPC, hospice palliative care, HSC hospice shared care, HHC, hospice home care, HWC hospice ward care
a
Log transformation was done for normal distribution, and then evaluated by paired t test
1912 Support Care Cancer (2014) 22:1907–1914

Table 4 Intensive medical utilization (ICU, CPR, and ETT) before death between patients with and without related HPC (HHC, HHC, and/or HWC)

Hospice type Used No of patients in each group Intensive medical utilization before death, n (%)

ICU CPR ETT

Received HSC or HHC or HWC Yes 30,903 4,295 (13.9 %) 772 (2.5 %) 3,430 (11.1 %)
No 30,903 6,767 (21.9 %) 2,626 (8.5 %) 7,231 (23.4 %)
p<0.001 p<0.001 p<0.001
Only received HSC Yes 12,137 2,451 (20.2 %) 570 (4.7 %) 2,221 (18.3 %)
No 12,137 2,475 (20.4 %) 995 (8.2 %) 2,682 (22.1 %)
p=0.699 p<0.001 p<0.001
Only received HHC Yes 1,542 109 (7.1 %) 9 (0.6 %) 74 (4.8 %)
No 1,542 362 (23.5 %) 126 (8.2 %) 366 (23.8 %)
p<0.001 p<0.001 p<0.001
Only received HWC Yes 6,645 179 (2.7 %) 239 (3.6 %) 511 (7.7 %)
No 6,645 651 (9.8 %) 651 (9.8 %) 1,667 (25.1 %)
p<0.001 p<0.001 p<0.001
Received HSC, HHC, and HWC Yes 1,222 189 (15.5 %) 23 (1.9 %) 113 (9.3 %)
No 1,222 314 (25.7 %) 120 (9.9 %) 333 (27.3 %)
p<0.001 p<0.001 p<0.001

HPC, hospice palliative care, HSC hospice shared care, HHC, hospice home care, HWC hospice ward care, ICU, utilization of intensive care unit; CPR,
cardiopulmonary resuscitation, ETT endotracheal tube insertion
p Values were calculated by McNemar’s test

patients. Barnato and colleagues [1] reported that 30 % of
medical expenditures are spent by 5 % of beneficiaries who
die within the year. The Congressional Budget Office in the
USA reported that 5 % of beneficiaries enrolled in Medicare
accounted for 43 % of total spending [4]. Carlson and col-
leagues [2] also found that individuals with cancer who
unenrolled from hospice incurred higher medical expenditures
across all categories of care than patients who remained with
hospice until death. One of the possible reasons for the in-
crease of medical expenditure before death is the unnecessary
use of intensive medical care. In this study, we found that
individuals with advanced cancers who received HSC had
lower medical expenditures from inpatient, outpatient, and
ER services than those without HSC. The largest medical
expenditure savings among these two groups appeared in
subjects who received inpatient services including fees for
laboratory/X-ray analyses, therapeutic treatment, drugs, ward
use, and other fees. In the SUPPORT study, physicians had a
tendency to use high-cost tests and intensive medical utiliza-
tion (such as ICU facilities) to prolong seriously ill patients’
survival [26]. Based on the lower likelihood of intensive
medical utilization among advanced cancer patients who
underwent HPC in our study, the significant overall cost
reduction among these patients was due, in part, to the reduced
use of intensive medical care.
The types of cancer care and associated costs vary by
cancer site and cancer stage. According to the projections of
the cost of cancer care in USA, the average annualized net
costs of care in the last year of life varied by cancer site,
gender, and age [14]. Therefore, we estimated the expenditure
of HCS by using the propensity score paired matching method
with consideration for confounding variables including gen-
der, age, initial cancer type, initial cancer stage, and interval
for the use of outpatient visit or hospitalization admission. For
the propensity score matching method, whether one-to-one
matching is done “with replacement” or “without replace-
ment” is frequently debated in the literature [5, 10]. One-to-
one matching with replacement (meaning that a control sub-
ject may be included in more than one matched pair) can
reduce sample bias and is more versatile when the treatment
group is bigger than the control group [5]. In the present study,
however, we have a large number of patients without HCS,
which minimizes sample bias and renders one-to-one
matching without replacement, a more logical and clinically
relevant option.
For policymakers, our findings have important implica-
tions. First, this is a newly developed palliative care program
designed to increase the coverage of hospice palliative ser-
vices and to enhance the quality of life among advanced
cancer patients. Evidence of its success makes this an enticing
option that may be applied to other countries to improve
patients’ quality of life at the end-of-life stage. Second, HPC
services (HSC, HHC, and HWC) are associated with consid-
erable medical expenditure savings among advanced cancer
patients. As the mean age of society increases alongside an
ever-increasing prevalence of cancer, the burden of rising
Support Care Cancer (2014) 22:1907–1914
medical care costs will continue to plague national agendas.
The effective incorporation of palliative care into the end-of-
life care model responds to the concomitant need for cost
reduction and improved quality of life. Our findings highlight
the success of an HSC program to increase the use of HPC
among inpatient advanced cancer patients. Both a savings of
medical expenditures and a decrease in burdensome intensive
medical utilization can be accomplished through the HSC
program. For advanced cancer patients who refuse to accept
HWC or HHC, the HSC program provides a viable treatment
option to reduce end-of-life suffering. To expand an effective
HSC program in other countries for the benefit of patients who
are seriously ill or have advanced cancer should become a
national priority.
Although this study has a host of strengths, there are some
notable limitations. First, the decision to choose HSC was
based on physicians and patient/families preferences, which
opens the study to inherent outcome bias. However, because
the study was conducted nationwide during the same period,
this effect could be reduced to minimal and caused unidirec-
tional bias. Second, our study subjects focused on advanced
cancer patients who received HPC in Taiwan. Therefore, it
may not be generalizable to individuals with terminal diagno-
ses other than cancer or to countries with a widely different
health care system than is available in Taiwan.
Conclusion
In conclusion, this study found that HSC was associated with
a reduction in all medical expenditures including inpatient,
outpatient, and ER fees. Compared to usual care, various types
of HPC produced a medical expenditure savings of 15.4 % to
44.9 % among advanced cancer patients. With soaring med-
ical expenditures and increasing cancer prevalence, a program
that effectively incorporates palliative care into the standard
medical care model has the potential for improved end-of-life
care with an added benefit of medical cost savings worldwide.
For patients, family, and/or physicians hesitant to accept a
complete transition to HHC or HWC, this new HSC program
may increase HPC coverage and effectively reduce medical
expenditure while providing high-quality services among ad-
vanced cancer patients.
Acknowledgments We thank the medical staff in hospice palliative
medicine throughout Taiwan for their assistance in completing this study.
This study was financially supported by grants from the Bureau of Health
Promotion, Department of Health, Executive Yuan, Taiwan (DOH96-HP-
1502, DOH97-HP-1503), from China Medical University Hospital
(DMR-99-109), and from Taiwan Department of Health, China Medical
University Hospital Cancer Research Center of Excellence (DOH102-
TD-B-111-004).
1913
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