Cultural factors account for cost differences at the end of life

In the final year of life, men incur more healthcare costs than women on average. Dying is more expensive in the French and Italian speaking parts of Switzerland than in the German-speaking part. These are the findings of an analysis of health insurance data that was conducted as part of the National Research Programme "End of life" (NRP 67).

Between 2008 and 2010, 184,791 people died in Switzerland. Of these, 113,277 (or 61.3 per cent) adults were insured with one of six major health insurers who provided their – anonymised – data to the researchers at the Institute of Social and Preventive Medicine at the University of Bern. The scientists used this data to investigate the regional distribution of healthcare costs in the year before death as part of the National Research Programme "End of life" (NRP 67).

Their recently published analysis showed that the healthcare costs reimbursed by insurance rise sharply to an average of over 30,000 francs per individual in the last year of life. They account for many times the normal healthcare costs, which are estimated to be between 3,500 and 6,700 francs a year depending on the person's age.

The cost drivers are individual factors, including the cause of death, age and gender. Thus, the last 12 months for cancer patients (especially in cases of breast, lung and prostate cancer) involve the highest costs reimbursed by health insurers. On the other hand, the insurance companies have to pay less at the end of life in cases of accidental death or heart failure.

Dying women cost less

Compared with men, women die later and accumulate lower costs. The data cannot establish whether these reduced costs are associated with the fact that most women are widowed when they die. There are other possibilities, including that the healthcare system may not extend the same therapeutic efforts for women as it does for men. "Our results only indicate differences. We can only speculate as to how these differences arise," says Radoslaw Panczak, the lead author of the study.

Panczak and his colleagues have corrected for individual factors in their statistical models – but substantial differences still remain in the regional distribution of healthcare costs at the end of life: Individuals living in regions of French- and Italian-speaking Switzerland have, on average, around 20 per cent more cost in the year before death than in German-speaking Switzerland.

Dying at home thanks to Spitex

As one possible reason for these differences, the researchers point to a survey conducted by Swiss doctors showing that French-speaking specialists tend to treat pain rather more aggressively. On average, they were less willing than their German-speaking counterparts to refrain from therapeutic measures at the request of their relatives.

Another reason cited by the researchers for the cost differences is the fact that more people die in hospital (and fewer at home or in retirement or nursing homes) in French- and Italian-speaking Switzerland than in German-speaking Switzerland. Panczak states that the probability of dying in hospital rather than in a nursing home is lower in places where there are more doctors who provide treatment on an outpatient basis and more nursing homes. This is apparent, for example, when comparing the regions of Yverdon and Neuchâtel. Neuchâtel began developing community-based Spitex structures at an early stage. This may explain why the average costs at the end of life are only half as much as those in the immediately adjacent region of Yverdon.