Original Article

Palliative Medicine
23(8) 708–717
Costs associated with resource utilization ! The Author(s) 2009
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during the palliative phase of care: sagepub.co.uk/journalsPermissions.nav

DOI: 10.1177/0269216309346546
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a Canadian perspective

Serge Dumont School of Social Work, Laval University; Laval University Cancer Research Center, Quebec, Quebec, Canada
Philip Jacobs Department of Medicine (Gastroenterology), University of Alberta, Edmonton, Alberta, Canada
Konrad Fassbender Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
Donna Anderson School of Social Work, Laval University; Laval University Cancer Research Center, Quebec, Quebec, Canada; Centre for
Interdisciplinary Research in Rehabilitation and Social Integration, Rehabilitation Institute of Quebec City and Rehabilitation Department, Quebec, Quebec, Canada
Véronique Turcotte Laval University Cancer Research Center, Quebec, Quebec, Canada
François Harel Laval University Cancer Research Center, Quebec, Quebec, Canada

Abstract
Objective: This study aimed to evaluate prospectively the resource utilization and related costs during the palliative phase
of care in five regions across Canada. Subjects: A cohort of 248 patients registered in a palliative care program and their
main informal caregivers were consecutively recruited. Research Design: A prospective research design with repeated
measures was adopted. Interviews were conducted at two-week intervals until the patient s passing or up to a maximum of
6 months. Measures: The survey questions prompted participants to provide information on the types and number of
goods and services they used, and who paid for these goods and services. Results: The largest cost component for study
participants was inpatient hospital care stays, followed by home care and informal caregiving time. In regard to cost sharing,
the public health care system (PHCS), the family, and not-for-profit organizations (NFPO) sustained respectively 71.3%,
26.6%, and 1.6% of the mean total cost per patient. Conclusion: Such results provide a comprehensive picture of costs
related to palliative care in Canada, by specifying the cost sharing between the PHCS, the family, and NFPO.

Keywords
Palliative care, cost analysis, resource utilization, informal caregiving, economic burden

programs reported that none of the studies examined

Introduction
Following the recent health care reforms in Canada a
trend towards the deinstitutionalization of palliative
care is increasing. Indeed, in the last 10 years, some
regions of Canada have implemented regional palliative
care programs to coordinate community and hospital
resources. Therefore, the role of informal caregivers in
providing ongoing care and assistance to end-of-life
patients is on the rise.1,2
Despite the growing number of studies assessing
palliative care costs, the sharing of these costs between
the public health care system (PHCS), families, and
not-for-profit organizations (NFPO) remains unclear.
Fassbender et al.3 who systematically reviewed 38 arti-
cles providing evidence of the costs of 47 palliative care
described who pays. Methodological obstacles are cited
in the literature as a continuing reason for inconclusive
evidence.4–6 Regarding provider costs, most studies uti-
lized administrative data. Unfortunately, from region
to region, and country to country, databases are usually
fragmented, inconsistent and poorly compatible.
Regarding family costs, there are no uniform methods
used in the literature, nor are there uniform measures of
family caregiving time. Also, most studies adopted a
retrospective research design. Retrospective studies
lack reliability regarding the information about per-
sonal expenses (although people will tend to remember
the length of their hospital stays 3 or 4 months after
it occurred, they often cannot accurately remember
how much they spent on medications or supplies 3 or

Corresponding author:
Serge Dumont, School of Social Work, Pavillon Charles-De Koninck, 1030 avenue des Sciences Humaines, Laval University, Quebec, Quebec, Canada
G1V 0A6. Email: Serge.Dumont@svs.ulaval.ca
S Dumont et al.
4 weeks earlier). Consequently, a prospective study
design seems to be more appropriate in this area.
The main purpose of this study was to provide infor-
mation regarding the resource utilization and related
costs during the palliative phase of care in five regions
across Canada. The specific objectives were: (a) identify
and measure prospectively the goods and services used;
(b) estimate their costs; and (c) determine who paid.
Methods
Study design
A prospective study with repeated measures was per-
formed in five urban Canadian sites: Halifax, Montreal,
Winnipeg, Edmonton, and Victoria. Regional programs
at each of these sites provide community-based models of
palliative care. Ethics approval was obtained from the
Laval University Research Ethics Committee (Quebec),
and from each participating site ethics boards.
Sampling
Data were obtained from a consecutively recruited
cohort of patients enrolled in a palliative care program
and from their main informal caregivers. Patients had
to be over 18 years old, able to understand and speak
English or French, affected by terminal disease, a new
participant in a regional palliative care program, still
living at home, and constantly receiving care and assis-
tance from at least one informal caregiver. The infor-
mal caregiver had to be over 18 years old, and able to
understand and speak English or French, and could be
a family member or a friend.
Data collection
The study questionnaire was developed through the
Delphi procedure. An initial list of goods and services,
based on the work of Jacobs et al.7 and of Grunfeld
et al.,8 was submitted to a group of Canadians who had
recently been involved in the care of a close relative
who had subsequently died of cancer. The final list of
goods and services was refined and then integrated into
the survey questions in line with validated questions
from The Canadian Community Health Survey per-
formed by Statistics Canada in 2000–2001.9 Survey
development and data collection procedures were
defined according to the guidelines provided in Health
Technology Assessment.10
The survey questions prompted participants to pro-
vide information on the types and number of goods and
services they used, and to identify who paid for these
goods and services.
Interviews were completed between January 2005
and December 2006. The first interview was performed
709
in the patient’s home. Subsequent phone interviews
were conducted at 2-week intervals until the patient’s
death or for up to a maximum of 6 months.
Costing
Consistent with the recommendations of the Canadian
Coordinating Office for Health Technology
Assessment11 and of Drummond et al.,12 the costing
of goods and services included two elements: (a) quan-
tities used; and (b) unit costs.
Quantities used were measured as follows. The
number of days of stay in hospital or long-term care
facilities was calculated by comparing the discharge
and admission dates. The length of time spent on out-
patient visits, home care visits, and phone calls was
reported by participants. When length of time was miss-
ing, the average time provided by other participants for
the same visit or call was used. For medical equipment
or aids rented or borrowed the length of use was calcu-
lated from the first time the items were reported to the
time of death or the last follow-up. Regarding transpor-
tation to and from services, the distance traveled on each
trip was obtained using Google Maps. The amount of
time spent by informal caregivers in providing care and
assistance to patients was calculated as follows. At base-
line, caregivers were asked how much time they spent on
a typical day prior to the patient’s illness on household
chores, errands and personal care for the patient. Then,
at baseline and every follow-up, caregivers were asked to
repeat this exercise in reference to a typical day in the
previous 2 weeks. The difference between time spent on
each task in the previous 2 weeks and time spent on the
same task prior to the patient’s illness was calculated to
obtain the additional time spent on each task on a typ-
ical day as a result of the patient’s illness. Caregiving
time was obtained by adding together the additional
time spent on all of these tasks.
The next step involved assigning a unit cost to each
resource used. Owing to their availability and comple-
teness, Alberta unit costs were used as standard costs,
except for personal expenses, which were obtained by
asking participants to provide these costs. Details
about each costing option are provided in Appendix 1.
Statistical analyses of costs
Statistical analyses were performed with SAS 9.1 (Cary,
NC) software. The key variables were: physical mea-
sures of goods and services used, their costs and the
sharing of costs (who paid and by what percentage);
missing paid percentages were replaced by medians.
For each resource category, the mean total cost per
patient for the 6-month period was calculated using the
non-parametric estimator method of Lin et al.13 to adjust
710
for censored cost data. Indeed, as patients were followed
for a fixed period of time, some of them did not die
during the study period and, therefore, the subsequent
costs occurred by these patients are unknown; in other
words, a part of cost data is censored. Numerous authors
have shown that ignoring censoring when estimating
patient-level medical care costs may lead to biased
results.13–16 In order to minimize the bias induced by cen-
soring, many methods have been proposed in the litera-
ture. In the presence of end-of-study censoring, with the
availability of detailed patients’ cost histories and interval
cost data, Lin et al.’s method appears to perform well.16,17
In line with Lin et al.’s method,13 the entire time
period was divided into 26-week intervals. For each
time interval, costs for all patients were weighted by
the Kaplan–Meier survival probability of being alive
at the beginning of the interval. The mean total cost
for the entire study period is then obtained by summing
the weighted costs of the 26-week intervals. The mean
total cost obtained with Lin et al.’s method was divided
by the Kaplan–Meier median survival time to estimate
the mean daily cost per patient. The bootstrapping
technique was used to provide 95% confidence interval
of all of the mean cost estimates.
Results
Study description and participant characteristics
Of the 2970 patients screened, 684 met the eligibility
criteria and were contacted and informed about
100%
90%
80%
70%
60%
Survival (%)
50%
40%
30%
20%
10%
0%
0 1 2 3
At risk 248 202 153
Figure 1. Kaplan-Meier survival curve.
Palliative Medicine 23(8)
the study. Of these 684, 248 agreed to participate and
were met for the baseline interview, which represents a
36% response rate.
Some participants (13%) died after the baseline
interview. The others were followed for a median
length of 11  9 weeks. The first interview took on
average 42  26 minutes with patients and 46  22 min-
utes with caregivers to complete. Each follow-up call
took on average 11  7 minutes with patients
and 13  7 minutes with caregivers to complete.
The Kaplan–Meier survival estimate at the end of the
6-month follow-up was of 30.3% (95% CI 24.4–36.3%)
(Figure 1).
Sociodemographic characteristics of patients and
main caregivers are displayed in Table 1. The sample
of patients consisted of an equal number of men (50%)
and women, with a mean age of 67  13 years. About
67% of caregivers were females, with a mean age of
58  13 years. Most of patients and caregivers were
married (65% and 73%, respectively). Almost half of
participants (48% of patients and 50% of caregivers)
lived with their spouse only. Most of caregivers were a
spouse (61%). About 22% of participants had an
annual household income of CAD$20,000 or less, and
21% had incomes of CAD$61,000 and more. At the
time of the first interview, just over half (53%) of
patients were classified as grade 3 on the ECOG
Performance Status scale,18 which means that these
patients were capable of only limited self-care, and
were confined to bed or chair more than 50% of their
waking hours.
4 5 6
Months
114 90 78 63
S Dumont et al. 711

Table 1. Sociodemographic characteristics of patients and their main caregiver

Patient (n ¼ 248) Caregiver 1 (n ¼ 243)

Variable Level n (%) n (%)

Site Edmonton 90 (36.3) 87 (35.8)

Montreal 50 (20.2) 49 (20.2)
Winnipeg 25 (10.1) 25 (10.3)
Victoria 33 (13.3) 32 (13.2)
Halifax 50 (20.2) 50 (20.6)
Age Mean (SD) 67 (12.83) 58 (13.15)
Gender Female 123 (49.6) 162 (66.7)
Male 123 (49.6) 79 (32.5)
Missing 2 (0.8) 2 (0.8)
Marital status Married 162 (65.3) 178 (73.3)
Common law 11 (4.4) 16 (6.6)
Separated 5 (2.0) 3 (1.2)
Divorced 19 (7.7) 11 (4.5)
Widowed 34 (13.7) 8 (3.3)
Single 17 (6.9) 18 (7.4)
Missing – – 9 (3.7)
Living situation Lives alone 34 (13.7) 14 (5.8)
With spouse only 120 (48.4) 122 (50.2)
With spouse and others 50 (20.2) 75 (30.9)
With others only 43 (17.3) 26 (10.7)
Missing 1 (0.4) 6 (2.5)
Relationship to the patient Spouse – – 148 (60.9)
Child – – 64 (26.3)
Sibling – – 8 (3.3)
Friend – – 8 (3.3)
Other – – 14 (5.8)
Missing – – 1 (0.4)
Household income* 20 000 55 (22.2) – –
21 000–30 000 43 (17.3) – –
31 000–40 000 41 (16.5) – –
41 000–50 000 21 (8.5) – –
51 000–60 000 18 (7.3) – –
61 000 51 (20.6) – –
Missing 19 (7.7) – –
ECOG Performance Status** 0 1 (0.4) – –
1 25 (10.1) – –
2 63 (25.4) – –
3 131 (52.8) – –
4 27 (10.9) – –
Missing 1 (0.4) – –
*Household income is the sum of all the incomes for everyone living in the patient’s home, expressed in Canadian dollar.
**At the time of the first interview.
712 Palliative Medicine 23(8)

33.2

18.7

17.6
100 18446  1223 (16048–20844) 100
7.9

3.8
1.6
6.5
6.0
4.6
%
Cost profile
Mean total costs and mean daily costs per patient

6125  778 (4600–7650)

1466  127 (1218–1714)
3456  705 (2075–4838)

3251  277 (2709–3793)

incurred by each part and for each resource category

1197  125 (953–1442)

1115  101 (918–1312)
703  201 (310–1096)

842  118 (610–1073)

are depicted in Tables 2 and 3. The largest cost compo-

Mean  SE (95% Cl)

291  36 (221–361)
nent for study participants was inpatient hospital stays,
which accounted on average for 33.2% of the mean total
cost per patient. Over the course of the study about 42%
of patients were hospitalized. These patients had on aver-

Total
age 1.5  1.1 hospital admissions, and the mean length of
stay was 12.0  11.3 days. Home care and informal

11.7

83.2
0.0
3.4

0.0
0.0
0.0

1.7
0.0
caregiving time were the next most important cost com-

Mean  SE (95% Cl) %

ponents. Each accounted for an average of 18.7% and
17.6% of the mean total cost per patient, respectively.

82  25 (34–131)

13146  1111 (10969–15323) 100 4898  369 (4175–5621) 100 303  58 (190–416) 100 99  26 (49–149)
Ambulatory care accounted for an average of 7.9%

12  4 (4–19)
0  0 (0–0)
3  2 (0–7)

0  0 (0–0)
0  0 (0–0)
0  0 (0–0)

2  1 (0–3)
0  0 (0–0)
of the mean total cost per patient. Prescription medica-
tions and medical equipment or aids used at home

Others
accounted for an average of 6.5% and 6.0% of the
mean total cost per patient, respectively. Although

98.9
out-of-pocket expenditures were incurred by almost

0.0
0.1
0.4
0.0
0.0
0.0

0.5
0.0
Mean  SE (95% Cl) %
all participants (97%), these costs accounted for 4.6%

299  57 (187–411)
of the mean total cost per patient. Few patients (10%)
used long-term-care services. This cost component

0  0 (0–0)
0  0 (0–1)
1  1 (0–3)
0  0 (0–0)
0  0 (0–0)
0  0 (0–0)

2  1 (0–5)
0  0 (0–0)
accounted, on average, for 3.8% of the mean total
cost per patient. Transportation accounted on average
NFPO

for 1.6% of the mean total cost per patient.

17.0
66.4
Table 2. Mean total cost per patient incurred by each part for each resource category*

0.0
0.9
4.4
1.2
2.0
1.4
6.7
Cost sharing
%

3251  277 (2709–3793)

Table 2 indicates that the most important cost compo-

835  118 (604–1065)

Mean  SE (95% Cl)

All costs are expressed in Canadian dollar and have been rounded to the nearest number.
329  42 (247–411)
nent supported by the PHCS was inpatient hospital
216  90 (40–393)
60  25 (11–108)
97  10 (76–117)
68  26 (17–120)

care (46.6%), followed by home care (24.5%), and

42  14 (14–70)

ambulatory care (10.8%). A large part (66.4%) of

0  0 (0–0)

costs supported by the family was attributable to car-

egiving time. The family also absorbed out-of-pocket
Family

cost (17.0%), and a part of costs related to home med-

ical equipment or aids (6.7%), and home care (4.4%).
46.6
10.8
24.5
4.9
1.5
8.6
3.1
0.0
0.0

Almost all costs assumed by NFPO and other payers

%

(98.9% and 83.2%, respectively) were for home medical

equipment or aids.
6125  778 (4600–7650)
1420  124 (1177–1664)
3227  698 (1860–4594)

1129  124 (885–1372)

The sharing of all costs incurred by participants over

643  191 (268–1017)
Mean  SE (95% Cl)

194  30 (136–252)

404  61 (285–523)

the course of the study was as follows: 71.3% by the

PHCS; 26.6% by the family; 1.6% by NFPO; and 0.5%
by other payers (Figure 2).
4  1 (1–6)
0  0 (0–0)

In particular the PHCS sustained 100.0% of the

inpatient care costs and almost all of the ambulatory
PHCS

care costs (96.9%), and the long-term care costs

(91.5%). As the majority of participants benefited
Medical equipment/Aids
Prescription medication
Inpatient hospital care

from the provincial drug plan, the PHCS also sup-

Caregiving time costs
Out-of-pocket costs
Resource category

ported a large part of the outpatient prescription med-

Ambulatory care

Long-term care

ication costs (94.3%). The costs related to the patient

Transportation

transportation were shared between the PHCS and the

Home care

family (66.7% and 33.3%, respectively). With regards

to costs of care received by the patient at home
Total

(including formal and informal caregiving) these costs

S Dumont et al. 713

203.2  20.5 (163.0–243.4)

1.6%

67.6  10.6 (46.8–88.3)

0.5%

16.1  1.6 (13.1–19.2)

38.0  8.2 (22.0–54.1)

13.2  1.4 (10.4–15.9)

35.8  4.0 (28.0–43.6)

12.3  1.4 (9.5–15.0)
Mean  SE (95% Cl)

7.8  2.3 (3.2–12.3)

9.3  1.6 (6.2–12.4)

3.2  0.5 (2.3–4.1)
26.6%
PHCS
Family
NFPO
Total

Others

71.3%
Mean  SE (95% Cl)

(0.0–0.0)
(0.0–0.1)
(0.0–0.2)
(0.0–0.0)
(0.0–0.0)
(0.0–0.0)
(0.3–1.5)
(0.0–0.0)
(0.0–0.0)
1.1  0.3 (0.5–1.7)
Figure 2. Sharing of all costs incurred by participants between
0.0  0.0
0.0  0.0
0.1  0.0
0.0  0.0
0.0  0.0
0.0  0.0
0.9  0.3
0.0  0.0
0.0  0.0
the PHCS, the family, NFPO, and others.
Others

were almost equally shared among the PHCS and the

family (48.1% and 51.7%, respectively). Out-of-pocket
costs were almost completely absorbed by the family
Mean  SE (95% Cl)

(99.2%). Costs related to home medical equipment or

(0.0–0.0)
(0.0–0.0)
(0.0–0.0)
(0.0–0.0)
(0.0–0.0)
(0.0–0.0)
(2.0–4.6)
(0.0–0.0)
(0.0–0.0)
3.3  0.7 (2.0–4.6)

aids were shared between the PHCS, the family and

NFPO (36.2%, 29.5%, and 26.8%, respectively).
0.0  0.0
0.0  0.0
0.0  0.0
0.0  0.0
0.0  0.0
0.0  0.0
3.3  0.7
0.0  0.0
0.0  0.0
NFPO

Discussion
To the best of the authors’ knowledge, only one other
study, by Penrod et al.19 published in 2001, has per-
Table 3. Mean daily cost* per patient incurred by each part for each resource category**

formed an evaluation of palliative care costs in

35.8  4.0 (28.0–43.6)
53.9  5.7 (42.8–65.1)

Canada. This study only took into account the costs

Mean  SE (95% Cl)

9.2  1.6 (6.1–12.3)

0.0  0.0 (0.0–0.0)
0.5  0.2 (0.2–0.8)
2.4  1.0 (0.4–4.3)
0.7  0.3 (0.1–1.2)
1.1  0.1 (0.8–1.3)
0.8  0.3 (0.2–1.3)
3.6  0.5 (2.6–4.7)

assumed by the PHCS. The results obtained in the pre-

**All costs are expressed in Canadian dollar and have been rounded to the nearest number.
*Mean daily cost was obtained by dividing the mean total cost by the median survival time.

sent study were somewhat similar to those of the study

by Penrod et al. Both studies found that about 47% of
the mean total cost per patient enrolled in the palliative
Family

care program incurred by the PHCS over the course of

the study was for hospitalization. Penrod et al. found
that 43% of the costs incurred by the PHCS were for
home services, while the present study found that costs
144.8  16.6 (112.3–177.3)

related to home care represented 24.5% of the mean

67.6  10.6 (46.8–88.3)

total cost per patient incurred by the PHCS. Penrod

15.6  1.5 (12.6–18.6)
35.5  8.1 (19.7–51.3)

12.4  1.4 (9.7–15.1)

Mean  SE (95% Cl)

7.1  2.2 (2.7–11.5)

et al. also found that 10% of costs incurred by the

2.1  0.4 (1.4–2.9)

4.5  0.8 (3.0–5.9)

0.0  0.0 (0.0–0.1)
0.0  0.0 (0.0–0.0)

PHCS were for ambulatory care (including medication)

while, in the present study, 10.8% and 8.6% of costs
incurred by the PHCS were for ambulatory care and
outpatient prescription medication, respectively.
PHCS

With the growing trend, in many developed coun-

tries, towards palliative care delivery away from public
institutions and into community settings, which is com-
patible with the wish of a large part of patients to spend
Medical equipment/Aids
Prescription medication
Inpatient hospital care

their last days of life at home,21–23 many of the costs

Caregiving time costs
Out-of-pocket costs
Resource category

previously incurred by the PHCS seem to be shifted to

Ambulatory care

Long-term care

patients and their families. Indeed, a growing body of

Transportation

literature supports the claim that programs largely

Home care

based on home care, including palliative care programs,

provide cost savings for the PHCS.24–29 Were these sav-
Total

ings the result of such transfers, then the question

714
should be addressed as to whether or not this burdening
of the families is ‘socially’ acceptable.
The present study does not pretend to answer this
question. However, it does portray the magnitude of
palliative care costs and of how these costs are shared
between the PHCS, the family, and NFPO, which is
essential information if the question raised is to be
answered.
The societal obligation to meet patient–family health
care needs derives from the more general obligation to
guarantee ‘fair equality of opportunity’.30 In the
Canadian health system context, fairness means equita-
ble access to an appropriate set of health care services
according to the patient’s medical condition.31
Policymakers’ views and Canadian families’ wishes
seem to converge on the preference for dying at home
when the context is favorable to do so. However, such a
decision should not have as a consequence an unfair
shift of the financial burden over the family.
Study limitations
In the current paper the differences between social
programs and policies in place in the five Canadian
provinces under study are not taken into account.
Only patients enrolled in palliative care programs
Appendix 1. Cost estimation of individual resources
Resource Description
Inpatient hospital Visits to hospital or emergency
care room with overnight stay.
Ambulatory care Day surgery, emergency room visits $313 per visit
(without overnight stay) and
outpatient hospital visits.
Family physician or specialist office
visits.
Tests and treatments performed in
an ambulatory setting.
Professional services dispensed by
professionals other than family
physicians and specialists in an
ambulatory setting.
Palliative Medicine 23(8)
were targeted in this study. Patients who have access
to palliative care programs are mainly cancer patients.
In addition, the study sample was adult patients. As the
profile or type of costs may vary depending on the type
of illness or on the patient’s lifespan stage, future
research should focus on these factors.
Conclusion
The present study has provided a comprehensive pic-
ture of costs occurred by palliative care patients and
their families in five Canadian regions. How these
costs were shared between the PHCS, the family and
the NFPO has also been specified. The knowledge
gained from this study would be useful in guiding finan-
cial support programs for the families taking care of a
loved one at home during the palliative phase of care.
Acknowledgements
We gratefully thank the patients and their caregivers who
offered their time to participate in the study. We also thank
the regional co-investigators who coordinated the study at the
five participating sites including: Grace Johnston, Frederick
Burge, Michèle Deschamps, Robert Marchand, Lorena
McManus, Mike Harlos, Robin Fainsinger, Carleen
Brenneis, and Kelli Stajduhar. This study was funded by a
grant from the Canadian Institutes of Health Research.
Cost per unit Sources of data
$1044 per day Based on the acute hospital cost per day for Alberta
palliative care patients in 2000/2001,32 adjusted for
Alberta Consumer Price Index (CPI) to 2005/2006.33
Includes a physician fee per day ($26.86).34
Based on the total (direct and indirect) cost of an
emergency room visit for Capital Health Region,
Alberta in 2005/2006 ($268).35 Includes a physician/
specialist fee
per visit ($35.65),36 and some diagnostic test costs
(e.g. bloodwork).
$98 per visit Based on the fee per visit for palliative patients in
2000/200132 adjusted for Alberta CPI to 2005/2006.33
cost per Average costs in 2004–2005 from Health Costing in
test/treatment Alberta – 2006 Annual Report.37
cost per hour Based on national hourly wage by occupation in 2001,38
adjusted by the CPI for 2005/2006.33 An indirect factor to
account for indirect time was based on Penrod (2001)19
and added to the direct time estimate. A factor of 1.43
was used for missing estimates, based on data from
the Canadian National Physician Survey performed
in 2004.39 An overhead factor to allow for facility
resources associated with the visit was estimated at
27.5%, based on Fassbender (2005)32 and Institute for
Public Economics (2006).40
(continued)
S Dumont et al. 715

Appendix 1. Continued

Resource Description Cost per unit Sources of data

Home care Health care or homemaker services cost per hour Based on national hourly wage by occupation in 2001,38
received at home. adjusted by the CPI for 2005/2006.33 An indirect factor
Examples: nursing care, help with to account for indirect time was based on Penrod19 and
bathing, meal delivery. added to the direct time estimate. A factor of 1.43 was
Phone calls established with a cost per minute used for missing estimates, based on data from the
professional. Canadian National Physician Survey performed in
2004.39 An overhead factor to allow for facility
resources associated with the visit was estimated at
27.5%, based on Fassbender32 and Institute for Public
Economics.40
Diagnostic tests performed at cost per test AHW, Schedule of medical benefits. Item E-l
home. Hematology ‘‘complete blood count’’.41
Long-term care Stays in hospices, nursing homes or cost per day Because programs are not standard across the country,
any other types of assisted living estimates were used for each province (obtained direct
arrangements. from hospice program).
Transportation Any means of transportation used Ambulance: Because programs are not standard across the country,
for the purpose of receiving health cost per trip separate estimates were used for each province
care services. Walking and other (obtained direct from each program).
sources of non motorized trans- Other means of Based on rates of vehicle expense from Canada Revenue
portation were not accounted for. transportation: Agency.42 The mean of the average cents/km rate of
$0.47 per km each of the 5 province under study in effect in 2005 and
that in effect in 2006 was used ((46.2 + 47.9)/2 ¼ 47.05).
Prescription Any drug used in an ambulatory cost per To avoid discrepancies related to the huge variation in
medication setting requiring a prescription by a prescription that area, unit costs were established in accordance with
physician before it can be obtained the Alberta price list contained in the Alberta Health
in a local pharmacy. and Wellness Drug benefit list.43 When cost units were
not available from this list a list from the Régie de
l’Assurance Maladie du Québec44 was used. As unit
costs from these lists consisted of wholesale costs, a
mark-up (5%) and a pharmacist dispensing fee (25%)
were added to obtain the retail price to the consumer.45
Medical equip- Any medical equipment or aids Purchase: cost Costs reported by participants. When costs were
ment/Aids purchased, rented, or borrowed per item missing, costs from the Alberta Aids to Daily Living
used at home. (AADL) Program Manual46 were used.
Rental or loan: Rental costs obtained from Health Care Solutions or
cost per week Shopper Home HealthCare (retailers of home health
care products and services in Canada).
Out-of-pocket Any extra cost, such as non- cost per item Costs reported by participants. When costs were
costs prescription medication, and missing, costs were obtained by taking the average cost
personal care supplies. of the same item of which costs were provided by other
participants.
Informal Time spent providing care or $13.47 per hour Based on the value of household work in Canada, in
caregiving time assistance to the patient. 1992,47 adjusted for the flat rate of 2005–2006 (Bank of
Canada). A mean of the weighted average cost for
activities which women spend most of their time
(e.g. meal preparation, and cleaning) and the weighted
average cost for activities in which men spend most of
theirs (e.g. travelling for shopping, and maintenance)
was used ($12.39 (women’s activities) + $14.55
(men’s activities)  2 ¼ $13.47).
716
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