The magnitude, share and determinants of unpaid care costs for home-based palliative care service provision in Toronto, Canada Huamin Chai PhD 1,2 , Denise N. Guerriere PhD 2 , Brandon Zagorski MSc 3 and Peter C. Coyte PhD 2 1 Department of Risk Management and Insurance, School of Economics, Nankai University, Tianjin, China, 2 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada and 3 BMZ Analytics, Toronto, ON, Canada Accepted for publication 12 April 2013 Correspondence Peter C. Coyte Institute of Health Policy, Management and Evaluation University of Toronto, 155 College Street, Suite 425, Toronto, ON M5T 3M6, Canada E-mail: peter.coyte@utoronto.ca What is known about the topic • Publicly financed palliative care programmes are effective in improving the quality of end-of-life care and significantly reducing caring costs. • Home-based palliative care resource utilisation and expenditures have traditionally measured publicly financed direct care costs and have not adopted a comprehensive societal approach to resource utilisation. What this paper adds • Evaluates home-based palliative care costs comprehensively from a societal perspective and examines the complete range of cost components attributed to different payers. • Provides insight into the magnitude and variations of Abstract With increasing emphasis on the provision of home-based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home-based unpaid care-giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home-based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty-nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home- based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care-giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care-giving costs were the largest component – $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out-of-pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients’ and caregivers’ sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care-giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home-based palliative care in future. Keywords: costs, home-based care, palliative care, unpaid care unpaid care-giving costs over the palliative care trajectory. • Devotes greater recognition to the magnitude of unpaid care-giving costs burdened by informal caregivers and identifies areas for intervention. Introduction With healthcare costs escalating and healthcare restructuring in North America, there is increasing attention on home-based care service provi- sion with palliative care as an area of emphasis. Research suggests that home-based care tends to place higher demands on family members, espe- cially when a patient is close to death (Aoun et al. 2005, Jo et al. 2007) and that between 75% and 90% of home-based care is provided by patients’ family members and friends (Dunbrack 2005). As a result, much of the costs that were previously incurred by the public sector have shifted to © 2013 John Wiley & Sons Ltd 30 Health and Social Care in the Community (2014) 22(1), 30–39 doi: 10.1111/hsc.12058