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Accounting for the Scarcity of Time as Patients Approach End of Life: The Construction of End-Weighted Time Toxicity

Jacobsen, Juliet LU ; Mahajan, Sanjoy LU ; Ekstrand, Joakim LU ; Boo Hammas, Karin LU ; May, Peter and Klintman, Jenny LU (2025) In Value in Health
Abstract
Objectives
People with serious illness approaching end of life often end up in emergency and hospital care, frequently against expressed preferences. Consequently, oncology trials record care days as a measure of treatment burden called “time toxicity.” However, this measure ignores the diminishing marginal utility of time: that the value of a day is higher when fewer remain. We aimed to incorporate this relationship into time toxicity.
Methods
We derived a preference-independent time-toxicity metric sensitive to time remaining, end-weighted time toxicity. It has units of toxiles and is based on the fraction of the patient’s remaining time taken up by a care visit. We trialed this metric in a cohort of Swedish cancer patients... (More)
Objectives
People with serious illness approaching end of life often end up in emergency and hospital care, frequently against expressed preferences. Consequently, oncology trials record care days as a measure of treatment burden called “time toxicity.” However, this measure ignores the diminishing marginal utility of time: that the value of a day is higher when fewer remain. We aimed to incorporate this relationship into time toxicity.
Methods
We derived a preference-independent time-toxicity metric sensitive to time remaining, end-weighted time toxicity. It has units of toxiles and is based on the fraction of the patient’s remaining time taken up by a care visit. We trialed this metric in a cohort of Swedish cancer patients referred to palliative care.
Results
There were 192 patients in the cohort; 146 (76%) eventually enrolled in palliative care. In the cohort, mean (SD, skewness) and median (IQR) end-weighted time toxicities were 0.63 (0.89, 1.77) and 0.23 (0.03-0.81) toxiles. End-weighted time toxicity was significantly less for the group eventually enrolled in palliative care (0.52 [0.75] and 0.22 [0.04-0.63] toxiles) than for the never enrolled group (0.97 [1.18] and 0.27 [0.27-1.76] toxiles) (P = .024). A time-series analysis showed that total toxicity in never- or not-yet-enrolled patients was 120.2 toxiles, whereas total toxicity in already-enrolled patients was 1.0 toxiles.
Conclusions
A healthcare metric that incorporates diminishing marginal utility of time can highlight the effect of palliative care and could improve resource allocation and patient satisfaction with care near end of life. Further research should explore stakeholder perspectives and practical applications. (Less)
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organization
publishing date
type
Contribution to journal
publication status
epub
subject
in
Value in Health
publisher
Elsevier
external identifiers
  • pmid:41456816
  • scopus:105027698826
ISSN
1098-3015
DOI
10.1016/j.jval.2025.12.010
language
English
LU publication?
yes
id
df8c6c0e-0e50-44e1-81c7-5b2fcdc351ec
date added to LUP
2026-02-28 07:30:00
date last changed
2026-03-02 08:51:08
@article{df8c6c0e-0e50-44e1-81c7-5b2fcdc351ec,
  abstract     = {{Objectives<br/>People with serious illness approaching end of life often end up in emergency and hospital care, frequently against expressed preferences. Consequently, oncology trials record care days as a measure of treatment burden called “time toxicity.” However, this measure ignores the diminishing marginal utility of time: that the value of a day is higher when fewer remain. We aimed to incorporate this relationship into time toxicity.<br/>Methods<br/>We derived a preference-independent time-toxicity metric sensitive to time remaining, end-weighted time toxicity. It has units of toxiles and is based on the fraction of the patient’s remaining time taken up by a care visit. We trialed this metric in a cohort of Swedish cancer patients referred to palliative care.<br/>Results<br/>There were 192 patients in the cohort; 146 (76%) eventually enrolled in palliative care. In the cohort, mean (SD, skewness) and median (IQR) end-weighted time toxicities were 0.63 (0.89, 1.77) and 0.23 (0.03-0.81) toxiles. End-weighted time toxicity was significantly less for the group eventually enrolled in palliative care (0.52 [0.75] and 0.22 [0.04-0.63] toxiles) than for the never enrolled group (0.97 [1.18] and 0.27 [0.27-1.76] toxiles) (P = .024). A time-series analysis showed that total toxicity in never- or not-yet-enrolled patients was 120.2 toxiles, whereas total toxicity in already-enrolled patients was 1.0 toxiles.<br/>Conclusions<br/>A healthcare metric that incorporates diminishing marginal utility of time can highlight the effect of palliative care and could improve resource allocation and patient satisfaction with care near end of life. Further research should explore stakeholder perspectives and practical applications.}},
  author       = {{Jacobsen, Juliet and Mahajan, Sanjoy and Ekstrand, Joakim and Boo Hammas, Karin and May, Peter and Klintman, Jenny}},
  issn         = {{1098-3015}},
  language     = {{eng}},
  month        = {{12}},
  publisher    = {{Elsevier}},
  series       = {{Value in Health}},
  title        = {{Accounting for the Scarcity of Time as Patients Approach End of Life: The Construction of End-Weighted Time Toxicity}},
  url          = {{http://dx.doi.org/10.1016/j.jval.2025.12.010}},
  doi          = {{10.1016/j.jval.2025.12.010}},
  year         = {{2025}},
}