Factors related to and economic implications of inhospital death in German lung cancer patients - results of a Nationwide health insurance claims data based study.

Background: When patients die in a hospital their quality of life is lower than when they die at home or in a hospice. Despite efforts to improve palliative care supply structures, still about 60% of lung cancer patients die in a hospital. Studies have examined factors related to inhospital death in lung cancer patients, yet none used data of a representative German population, additionally including economic aspects. This study aimed to identify factors related to inhospital death in German lung cancer patients and analysed resulting costs.Methods: We analysed a dataset of health insurance claims of 17,478 lung cancer patients (incident 2009) with 3 year individual follow-up. We grouped patients into inhospital death and death elsewhere. Studied factors were indicators of healthcare utilization, palliative care, comorbidities and disease spread. We used logistic regression models with LASSO selection method to identify relevant factors. We compared all-cause healthcare expenditures for the last 30 days of life between both groups using generalized linear models with gamma distribution.Results: Twelve thousand four hundred fifty-seven patients died in the observation period, thereof 6965 (55.9%) in a hospital. The key factors for increased likelihood of inhospital death were receipt of inpatient palliative care (OR = 1.85), chemotherapeutic treatments in the last 30 days of life (OR = 1.61) and comorbid Congestive Heart Failure (OR = 1.21), and Renal Disease (OR = 1.19). In contrast, higher care level (OR = 0.16), nursing home residency (OR = 0. 25) and receipt of outpatient palliative care (OR = 0.25) were associated with a reduced likelihood. All OR were significant (p-values< 0.05). Expenditures in the last 30 days of life were significantly higher for patients with inhospital death ((sic) 6852 vs. (sic) 33,254, p-value< 0.0001).Conclusion: Findings suggest that factors associated with inhospital death often relate to previous contact with hospitals like prior hospitalizations, and treatment of the tumour or comorbidities. Additionally, factors associated with dying elsewhere relate to access to care settings which are more focused on palliation than hospitals. From these results, we can derive that implementing tools like palliative care into tumour-directed therapy might help patients make self-determined decisions about their place of death. This can possibly be achieved at reduced economic burden for SHIs