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The association between palliative care team consultation and hospital costs for patients with advanced cancer: An observational study in 12 Dutch hospitals

2019; Wiley; Volume: 29; Issue: 3 Linguagem: Inglês

10.1111/ecc.13198

1365-2354

Arianne Brinkman‐Stoppelenburg, Suzanne Polinder, Branko F. Olij, Barbara den Berg, Nicolette Gunnink, Mathijs P. Hendriks, Yvette M. van der Linden, Daan Nieboer, Annemieke van der Padt‐Pruijsten, Liesbeth A. Peters, Brenda Roggeveen, Frederiek Terheggen, Sylvia Verhage, Maurice J. D. L. van der Vorst, Ingrid Willemen, Yvonne Vergouwe, Agnes van der Heide,

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European Journal of Cancer CareVolume 29, Issue 3 e13198 ORIGINAL ARTICLEOpen Access The association between palliative care team consultation and hospital costs for patients with advanced cancer: An observational study in 12 Dutch hospitals Arianne Brinkman-Stoppelenburg, Corresponding Author Arianne Brinkman-Stoppelenburg a.brinkman-stoppelenburg@erasmusmc.nl orcid.org/0000-0001-6377-1599 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Correspondence Arianne Brinkman-Stoppelenburg, Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Email: a.brinkman-stoppelenburg@erasmusmc.nlSearch for more papers by this authorSuzanne Polinder, Suzanne Polinder Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorBranko F. Olij, Branko F. Olij Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorBarbara van den Berg, Barbara van den Berg Department of Medical Oncology, Haga Hospital, The Hague, The NetherlandsSearch for more papers by this authorNicolette Gunnink, Nicolette Gunnink Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The NetherlandsSearch for more papers by this authorMathijs P. Hendriks, Mathijs P. Hendriks orcid.org/0000-0001-6687-5393 Department of Internal Medicine, Northwest Clinics, Alkmaar, The NetherlandsSearch for more papers by this authorYvette M. van der Linden, Yvette M. van der Linden Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The NetherlandsSearch for more papers by this authorDaan Nieboer, Daan Nieboer Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorAnnemieke van der Padt-Pruijsten, Annemieke van der Padt-Pruijsten Department of Medical Oncology, Maasstad Hospital, Rotterdam, The NetherlandsSearch for more papers by this authorLiesbeth A. Peters, Liesbeth A. Peters Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The NetherlandsSearch for more papers by this authorBrenda Roggeveen, Brenda Roggeveen Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The NetherlandsSearch for more papers by this authorFrederiek Terheggen, Frederiek Terheggen Department of Internal Medicine, Bravis Hospital, Bergen op Zoom, The NetherlandsSearch for more papers by this authorSylvia Verhage, Sylvia Verhage Breast Center, Jeroen Bosch Hospital, ’s-Hertogenbosch, The NetherlandsSearch for more papers by this authorMaurice J. van der Vorst, Maurice J. van der Vorst Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Internal Medicine, Rijnstate Hospital, Arnhem, The NetherlandsSearch for more papers by this authorIngrid Willemen, Ingrid Willemen Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The NetherlandsSearch for more papers by this authorYvonne Vergouwe, Yvonne Vergouwe Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorAgnes van der Heide, Agnes van der Heide orcid.org/0000-0001-5584-4305 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this author Arianne Brinkman-Stoppelenburg, Corresponding Author Arianne Brinkman-Stoppelenburg a.brinkman-stoppelenburg@erasmusmc.nl orcid.org/0000-0001-6377-1599 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Correspondence Arianne Brinkman-Stoppelenburg, Department of Public Health, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Email: a.brinkman-stoppelenburg@erasmusmc.nlSearch for more papers by this authorSuzanne Polinder, Suzanne Polinder Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorBranko F. Olij, Branko F. Olij Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorBarbara van den Berg, Barbara van den Berg Department of Medical Oncology, Haga Hospital, The Hague, The NetherlandsSearch for more papers by this authorNicolette Gunnink, Nicolette Gunnink Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The NetherlandsSearch for more papers by this authorMathijs P. Hendriks, Mathijs P. Hendriks orcid.org/0000-0001-6687-5393 Department of Internal Medicine, Northwest Clinics, Alkmaar, The NetherlandsSearch for more papers by this authorYvette M. van der Linden, Yvette M. van der Linden Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The NetherlandsSearch for more papers by this authorDaan Nieboer, Daan Nieboer Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorAnnemieke van der Padt-Pruijsten, Annemieke van der Padt-Pruijsten Department of Medical Oncology, Maasstad Hospital, Rotterdam, The NetherlandsSearch for more papers by this authorLiesbeth A. Peters, Liesbeth A. Peters Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The NetherlandsSearch for more papers by this authorBrenda Roggeveen, Brenda Roggeveen Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The NetherlandsSearch for more papers by this authorFrederiek Terheggen, Frederiek Terheggen Department of Internal Medicine, Bravis Hospital, Bergen op Zoom, The NetherlandsSearch for more papers by this authorSylvia Verhage, Sylvia Verhage Breast Center, Jeroen Bosch Hospital, ’s-Hertogenbosch, The NetherlandsSearch for more papers by this authorMaurice J. van der Vorst, Maurice J. van der Vorst Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands Department of Internal Medicine, Rijnstate Hospital, Arnhem, The NetherlandsSearch for more papers by this authorIngrid Willemen, Ingrid Willemen Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The NetherlandsSearch for more papers by this authorYvonne Vergouwe, Yvonne Vergouwe Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this authorAgnes van der Heide, Agnes van der Heide orcid.org/0000-0001-5584-4305 Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The NetherlandsSearch for more papers by this author First published: 11 December 2019 https://doi.org/10.1111/ecc.13198Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract Background Early palliative care team consultation has been shown to reduce costs of hospital care. The objective of this study was to investigate the association between palliative care team (PCT) consultation and the content and costs of hospital care in patients with advanced cancer. Material and Methods A prospective, observational study was conducted in 12 Dutch hospitals. Patients with advanced cancer and an estimated life expectancy of less than 1 year were included. We compared hospital care during 3 months of follow-up for patients with and without PCT involvement. Propensity score matching was used to estimate the effect of PCTs on costs of hospital care. Additionally, gamma regression models were estimated to assess predictors of hospital costs. Results We included 535 patients of whom 126 received PCT consultation. Patients with PCT had a worse life expectancy (life expectancy <3 months: 62% vs. 31%, p < .01) and performance status (p < .01, e.g., WHO status higher than 2:54% vs. 28%) and more often had no more options for anti-tumour therapy (57% vs. 30%, p < .01). Hospital length of stay, use of most diagnostic procedures, medication and other therapeutic interventions were similar. The total mean hospital costs were €8,393 for patients with and €8,631 for patients without PCT consultation. Analyses using propensity scores to control for observed confounding showed no significant difference in hospital costs. Conclusions PCT consultation for patients with cancer in Dutch hospitals often occurs late in the patients’ disease trajectories, which might explain why we found no effect of PCT consultation on costs of hospital care. Earlier consultation could be beneficial to patients and reduce costs of care. 1 INTRODUCTION In patients with incurable diseases for whom death is approaching, goals of care need to be realigned and typically include an emphasis on the relief of suffering and providing optimal quality of life (Sepulveda, Marlin, Yoshida, & Ullrich, 2002). However, burdensome medical interventions are sometimes prolonged at the end of life without any improvement in these outcomes (Bolt, Pasman, Willems, & Onwuteaka-Philipsen, 2016; Hales et al., 2014; McDermott et al., 2017; Teno et al., 1997; Veerbeek, van Zuylen, Swart, van der Maas, & van der Heide, 2007). Many hospitals have therefore started palliative care teams (PCTs) over the past decade (Brinkman-Stoppelenburg, Boddaert, Douma, & van der Heide, 2016; Davis, Strasser, & Cherny, 2015; Dumanovsky et al., 2016). PCTs constitute of professionals with expertise in palliative care and can be consulted by physicians or nurses working in the hospital. Several studies, mainly performed in the United States, have shown that consultation of PCTs in hospitals is associated with better patient quality of life, lower symptom burden and increased patient satisfaction with care (Gaertner et al., 2017; Kavalieratos et al., 2016; Temel et al., 2010; Zimmermann et al., 2014). Studies, mostly performed in the United States, have reported that the involvement of hospital PCTs was found to reduce the length of stay in hospital (Ciemins, Blum, Nunley, Lasher, & Newman, 2007; May et al., 2017) and to improve communication about goals of care, resulting in less diagnostic tests, less use of intensive care (Morrison et al., 2008; Penrod et al., 2006) and less aggressive care during the last weeks of life (Temel et al., 2010). Recently, a meta-analysis showed that involvement of a PCT within 3 days after hospital admission was associated with significant cost savings (May, Normand, et al., 2018). In the Netherlands, health care is characterised by a strong emphasis on home-based care, which is provided by general practitioners and community nurses (Kroneman et al., 2016). However, 77% of cancer patients of 65 years and older in the Netherlands were found to be admitted to the hospital at least once in the last 6 months of life (Bekelman et al., 2016). The Dutch Federation of Oncological Societies has stated that every hospital providing oncology care should have a PCT by January 2017. As a result, many Dutch hospitals have now established PCTs (Brinkman-Stoppelenburg et al., 2016). We studied the association between PCT consultation and use of hospital care for patients with advanced cancer. We also estimated the costs of hospital care for patients with and without PCT consultation, while taking into account baseline differences between both patient groups. 2 MATERIAL AND METHODS 2.1 Study design We performed a prospective observational study in inpatient wards of 12 hospitals, including general, teaching and university hospitals. Nine hospitals had a PCT facility. Patients with PCT consultation came from these nine hospitals. Patients without PCT consultation came from all twelve hospitals. Diagnostic and therapeutic interventions and hospital length of stay were compared for patients for whom a PCT was consulted during their stay in the hospital and control patients for whom no PCT was consulted. An extensive description of the study protocol has been published elsewhere (Brinkman-Stoppelenburg, Polinder, Vergouwe, & van der Heide, 2015). 2.2 Study population and setting Patients who were admitted to the hospital with incurable cancer, who were 18 years or over, for whom the physician answered “no” to the surprise question “Would you be surprised if this patient would die within the next year?” (Moss et al., 2010) and who were expected to stay in hospital for at least 3 days were eligible for this study. No sample size was calculated a priori as this was a secondary analysis of data from a study that had the primary aim to assess the effect of PCT consultation on patients’ quality of life. Patients were included sequentially (Brinkman-Stoppelenburg et al., 2015). All patients were followed during 3 months after their initial hospitalisation. 2.3 Intervention PCTs typically assess patients’ symptoms and physical, emotional, social and spiritual problems prioritize these and provide an advice to the attending healthcare professionals on how to address them. They also frequently advise on the coordination of care. Most PCTs consist of clinicians from different specialties, such as medical oncologists, neurologists, anesthesiologists, and nurses, nurse practitioners and psychosocial or spiritual caregivers (Brinkman-Stoppelenburg et al., 2016). Since 2014, the Dutch Federation of Oncological Societies (SONCOS) has stated criteria for PCTs in their “Multidisciplinary standards for oncological care in the Netherlands” (Dutch Federation of Oncological Societies, 2017). Criteria are for instance that PCTs should include at least two medical specialist and a nurse, and meet weekly. Members of the PCT should also have the possibility of consultation of other disciplines, all with expertise in palliative care, in so far as not already part of the PCT. However, it is known from other studies that PCTs in Dutch hospitals vary in the frequency of consultations, number of disciplines that are represented in the team and the procedures for consultations (Brinkman-Stoppelenburg et al., 2016). 2.4 Questionnaires and main outcomes The attending medical oncologist was asked to fill in a questionnaire about the patient's diagnosis, WHO performance status, co-morbidity, treatment status and life expectancy. Life expectancy was assessed using (modified versions) of the Surprise Question: “Would you be surprised if this patients died within 12/6/3/1 month(s)?” (Moss et al., 2010) Information about hospital length of stay, diagnostic procedures, in-hospital treatments such as chemotherapy, invasive procedures, medication and intensive care days was extracted from the patients’ medical file over a 3 month period using a standardised checklist. 2.5 Costs The economic evaluation was focused on hospital care. Costs of hospital care were calculated by multiplying volumes with the corresponding unit prices (see Attachment 1). We calculated costs of inpatient days in the hospital, costs of diagnostic procedures, costs of therapeutic interventions, including chemotherapy, medication and other types of treatment, and total hospital costs (May & Normand, 2016). Unit costs for medication were determined with information from the National Dutch Formulary (National Health Care Institute, 2016a, 2016b). The average costs per day for expensive and other medications were calculated, based on a random sample of 43 patients with and 43 patients without PCT consultation. Costs for inpatient days in hospitals were estimated as real, basic costs per day using detailed hospital administrative information. We distinguished costs in general and university hospitals. 2.6 Data analysis Propensity score matching was used to adjust for possible confounders of the association of PCT consultation and costs of hospital care (Austin, 2011). Within propensity score matching, patients who received and did not receive PCT consultation are matched based on the propensity score, which is the estimated probability that patients received PCT consultation based on their characteristics. Characteristics that were included in the propensity score model were age, gender, prognosis, WHO performance status, planned or unplanned hospital admission, treatment status, diagnosis, number of co-morbidities, type of hospital, time since primary diagnosis and number of hospital admissions. A 1:1 matching was performed using the nearest-neighbour algorithm with a caliper width of 0.1. The matching was performed using the MatchIT package in R. To assess the impact of the caliper width on the final results, we performed sensitivity analyses where we varied the caliper width. We fitted multivariable gamma regression models to investigate which determinants had a significant impact on hospital costs. A gamma regression model was used due to the expected skewed distribution of costs (Barber & Thompson, 2004). The exponentiated regression coefficients from this model can be interpreted as the relative difference of average costs between patients. Patient characteristics (age, gender, diagnosis and co-morbidity) and prognostic factors such as WHO performance status, treatment status, type of hospitalisation, time since primary diagnosis and number of hospitalisations were selected as potential determinants. A p-value < .05 was considered statistically significant. Gamma regression models were estimated for total hospital costs, costs of inpatient hospital stay, costs of diagnostic procedures and costs of therapeutic interventions. Each cost model used the same variables. Previous studies have found that the time between hospital admission and PCT consultation is an important factor in assessing the association between PCT consultation and hospital costs. We therefore also performed an analysis in which we restricted the consultation group to patients for whom consultations took place within 3 days of hospital admission. 2.7 Ethical considerations In three hospitals, data were collected anonymously. In nine other hospitals, the study included an assessment of patients’ quality of life, for which patients provided written informed consent. The results of this study are reported elsewhere. The research protocol was submitted to the Medical Ethical Research Committee of the Erasmus Medical Centre (MEC-2012–259). The committee stated that there were no objections to perform this study. 3 RESULTS 3.1 Baseline characteristics Between January 2013 and February 2015, 535 patients were included in the study. PCTs were consulted for 126 of these patients. Median time between hospital admission and PCT consultation was 4 days. At the time of their admission to the hospital, 62% of patients with PCT consultation had an estimated life expectancy of <3 months, compared to 31% of patients without PCT consultation (p < .01; Table 1). Hospitalisation was more often unplanned in patients with PCT consultation (88%) than in patients without PCT consultation (74%; p < .01). Baseline WHO performance status was also worse for patients with PCT consultation: 54% were only capable of limited self-care or completely disabled, compared to 28% of patients without PCT consultation (p < .01). Furthermore, at admission, patients with PCT consultation were less often receiving systemic anti-tumour treatment than patients without PCT consultation (26% vs. 56%, p < .01). Table 1. Baseline characteristics of patients with and without palliative care team consultation Patients with PCT consultation n = 126 Patients without PCT consultation n = 409 p-Value Mean (SD) Mean (SD) Age 66.4 (12.5) 64.9 (11.6) .20aa t Test. Number of hospital admissions due to current disease (median, IQR) 2 (1–3) 2 (1–4) .16bb Mann–Whitney test. Time since diagnosis (year, median, IQR) 2 (0–9) 1 (0–8) .29bb Mann–Whitney test. N (%) N (%) Female gender 73 (59) 215 (53) .22cc Chi-square test. Type of hospital <.01cc Chi-square test. General hospital 109 (86) 297 (73) Academic hospital 17 (14) 112 (27) Type of cancer .49cc Chi-square test. Gastrointestinal cancer 52 (42) 172 (43) Urogenital cancer 27 (22) 65 (16) Breast cancer 17 (14) 48 (12) Lung cancer 7 (6) 30 (8) Other 21 (17) 87 (22) Co-morbidities .97cc Chi-square test. No co-morbidities 48 (38) 152 (37) 1 co-morbidity 45 (36) 151 (37) > 1 co-morbidities 33 (26) 106 (26) Estimated life expectancy <.01cc Chi-square test. < 1 month 34 (27) 51 (13) 1–3 months 44 (35) 73 (18) 3–6 months 27 (21) 135 (33) 6–12 months 21 (17) 150 (37) WHO performance status <.01cc Chi-square test. 0 - Asymptomatic 9 (7) 67 (16) 1-Symptomatic but completely ambulatory 25 (20) 123 (30) 2-Symptomatic, 50% in bed, but not bedbound 45 (36) 87 (21) 4-Bedbound 22 (18) 29 (7) Hospital admission was: Planned 14 (12) 101 (26) <0.01cc Chi-square test. Unplanned 107 (88) 293 (74) Treatment status at time of admission: <0.01cc Chi-square test. Patient received anti-tumour therapy 33 (26) 226 (56) No further options for anti-tumour therapy 72 (57) 119 (30) Other 21 (17) 58 (14) a t Test. b Mann–Whitney test. c Chi-square test. 3.2 Discharge destination and survival Patients with PCT consultation were less often discharged to go home than patients without PCT consultation (62% vs. 80%, p < .01). There was a substantial difference in survival between the two groups (Table 2): 72% of patients with PCT consultation did not survive 3 months of follow-up, compared to 39% of patients without PCT consultation. Table 2. Discharge destination and survival of patients without and with palliative care team consultation Patients with PCT consultation N = 126 Patients without PCT consultation N = 409 p-Value N (%) N (%) Discharge destination <.01aa Chi-square test. Home 78 (62) 318 (80) Hospice 13 (10) 15 (4) Other 16 (13) 42 (11) Deceased during hospital admission 18 (14) 25 (6) Survival Deceased within 3 months after inclusion 91 (72) 160 (39) <.01aa Chi-square test. a Chi-square test. 3.3 Hospital care In Table 3, hospital care for patients with and without PCT consultation is presented. Patients with PCT consultation had a median length of stay in the hospital of 11 days (Interquartile range (IQR) 8–18), compared to 9 days (IQR 5–17) for patients without PCT consultation. The most common diagnostic procedures in both groups were blood tests (used in 94% of patients in both groups), X-rays (used in 52% of patients with and 50% of patients without PCT consultation), CT-scans (used in 54% and 39%, respectively) and urine tests (used in 42% and 28% respectively). Invasive therapeutic procedures were used in 14% and 19%, respectively, and chemotherapy in 4% and 20% respectively. Other therapeutic interventions were rare in both groups. Table 3. Hospital care and costs during 3 months of follow-up in patients with and without PCT consultation Patients with PCT consultation N = 126 Patients without PCT consultation N = 409 Length of hospital stay (days; median, IQR) 11 (8–18) 9 (5–17) Number of hospital admissions (median, IQR) 1 (1–1) 1 (1–2) N (%) N (%) Diagnostic procedures Ultrasound 27 (21) 90 (22) MRI 19 (15) 43 (11) CT-scan 68 (54) 161 (39) Endoscopy 7 (6) 41 (10) X-ray 66 (52) 204 (50) ECG 17 (14) 44 (11) Gastroscopy 3 (2) 21 (5) Blood test 119 (94) 384 (94) Urine test 53 (42) 113 (28) Therapeutic interventions Chemotherapy 5 (4) 80 (20) Invasive procedures 18 (14) 79 (19) Admission to ICU 0 (0) 11 (3) Tube feeding 5 (4) 16 (4) Artificial respiration 0 (0) 1 (0) Costs (€) Costs (€) Costs of hospital stay Mean (SD) 6,505 (4,546) 6,261 (6,263) Median (IQ) 5,136 (3,544–8,417) 4,494 (2,568–7,974) Diagnostic costs Mean (SD) 648 (656) 559 (726) Median (IQR) 455 (252–878) 374 (106–719) Costs for therapeutic interventionsaa Costs for therapeutic interventions include medication costs, costs for other/medical procedure and costs of PCT consultation. Mean (SD) 1,240 (2,351) 1812 (3,831) Median (IQR) 487 (414–726) 235 (103–2,529) Costs for chemotherapy Mean (SD) 119 (621) 856 (2,368) Median (IQR) 0 (0–0) 0 (0–0) Total hospital costsbb Costs of therapeutic interventions include costs of PCT consultation, costs of therapeutic procedures and medication costs. The average medication costs per day were estimated based on a random sample of 43 patients in both groups to be €15 per day for regular medication and €143 per day for expensive medication. We did not find a difference in costs between patients with and without PCT consultation. Mean (SD) 8,393 (6,358) 8,631 (8,572) Median (IQR) 6,296 (4,444–10,483) 5,647 (3,445–10,826) a Costs for therapeutic interventions include medication costs, costs for other/medical procedure and costs of PCT consultation. b Costs of therapeutic interventions include costs of PCT consultation, costs of therapeutic procedures and medication costs. The average medication costs per day were estimated based on a random sample of 43 patients in both groups to be €15 per day for regular medication and €143 per day for expensive medication. We did not find a difference in costs between patients with and without PCT consultation. 3.4 Costs of hospital care The total mean costs of hospital care during 3 months of follow-up were €8,393 for patients with PCT consultation and €8,631 for patients without PCT consultation (Table 3). The majority of these costs consisted of costs of inpatients days in the hospital. Whereas the proportion of patients who survived the 3 month follow-up period was lower among patients with PCT consultation, we also calculated the average costs per in-hospital day. The average daily costs for diagnostic procedures were €54 in both groups. The average daily costs for therapeutic procedures were €83 and €201 for patients with and without PCT consultation, respectively, for chemotherapy they were €6 and €131, and the average total daily hospital costs were €607 and €757. Analyses using propensity scores to control for observed confounding showed that PCT consultation had no effect on costs of hospital stay, costs of diagnostic procedures, costs of therapeutic interventions or total hospital costs. Varying the caliper width did not impact the results in a meaningful way. 3.5 Predictors of costs of hospital care Gamma regression models showed that the predictors varied between different types of costs (Table 4). The total costs of hospital care were predicted by patients’ prognosis: a prognosis of <1 month was associated with lower costs; and type of hospitalisation: unplanned admission was associated with lower costs. The total hospital care costs nor the costs per inpatient day were significantly associated with PCT consultation. Table 4. Determinants of costs of hospital care: generalised linear model Costs of hospital stay Costs of diagnostic procedures Costs of therapeutic interventionsaa Costs of therapeutic interventions include costs of PCT consultation, costs of therapeutic procedures and medication costs. The average medication costs per day were estimated based on a random sample of 43 patients in both groups to be €15 per day for regular medication and €143 per day for expensive medication. We did not find a difference in costs between patients with and without PCT consultation. Costs of chemotherapy Total hospital care costs Exp (B) 95% CI p-Value Exp (B) 95% CI p-Value Exp (B) 95% CI p-Value Exp (B) 95% CI p-Value Exp (B) 95% CI p-Value PCT consultation .34 .21 .89 .67 .48 Yes 1.09 0.92–1.29 1.18 0.91–1.52 0.98 0.72–1.33 0.85 0.41–1.78 1.06 0.90–1.26 No 1.