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This episode features\\xa0Dr Deokhee Yi\\xa0(Cicely Saunders Institute of Palliative Care, King's College London).\\xa0Large variation exists in the health service use near the end of life and a 10% of patients are especially high-cost users.\\xa0A high proportion of care costs in the last year of life occur in the last 3\\u2009months.\\xa0Patients nearing the end of life often prefer to be cared for at home, but habitually spend much time in hospital.\\xa0Our samples are from older patients with higher risks and more complex needs, having had contacts with specialist palliative care services in three countries where palliative care services are established and integrated into the health care system.\\xa0In the last 3\\u2009months of life, more than 80% of the total health and social costs were attributable to hospital care and the costs of palliative care were only ~10%, despite the fact that all patients had accessed specialist palliative care and reported high satisfaction with these services.\\xa0Uniquely, the authors were able to compare actual costs, based on utilization, therefore providing a more robust comparison between countries with different reimbursement systems.\\xa0Cost distributions in England were more homogeneous, and with lower mean costs, than in both the United States and Ireland.\\xa0Financial difficulties and poor experience with home care services were associated with being a high-cost patient, but having cancer or non-cancer, or having multimorbidity was not.

Implications for practice, theory or policy.\\xa0Increasing community palliative care services may help older patients at the end of life avoid unwanted hospital care and increase care quality, value and access, and it should be a policy priority.\\xa0People with poverty, increased age and receiving poor home care should be a target for future interventions to improve care at the end of life.\\xa0The lower and more homogeneous costs in England require investigation, including the effects of different payment/reimbursement systems for health care.

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