Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

Abstract

IMPORTANCE Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans’ end-of-life care is unknown. OBJECTIVE To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. DESIGN, SETTING, AND PARTICIPANTS A modified difference-in-difference study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. EXPOSURES Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. MAIN OUTCOMES AND MEASURES Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. RESULTS Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67–3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53–0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62–0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. CONCLUSIONS AND RELEVANCE Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

Cost and Utilization of Lung Cancer End-of-Life Care Among Racial-Ethnic Minority Groups in the United States

“…Moreover, these points of care, being indicators of greater intensity of care, are made more critical in that they likely affect quality of life during the patient's final month. A recent study showed that increasing hospice care was associated with less aggressive medical treatment and lower costs . Our results provide evidence that racial‐ethnic minority patients enrolled in hospice much less frequently than NH white patients.…”

Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014

“…[64][65][66][67] Of note, racial/ethnic minorities in the U.S. are also generally less likely to use palliative care and hospice services, compounding high end-of-life expenditures as hospital-based end-of-life care is more likely to be aggressive, and therefore costly, in comparison. [68][69][70][71] Our high terminal phase cost estimates for racial/ethnic minorities may reflect these realities. The end-of life period, however, is not the only point at which low…”

Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease

“…[19][20][21][22][23] Collectively, our findings argue for stronger efforts to meld curative and palliative approaches to care earlier in the illness trajectory for patients with advanced kidney disease and to foster more seamless and patient-and family-centered transitions to hospice. [24][25][26] Our study also offers useful insights about the unintended consequences of restricting access to concurrent dialysis and hospice care. Documentation in the EMRs of members of this cohort provides concrete evidence that being forced to choose between dialysis and hospice can cause undue suffering and discourage, delay, or prevent hospice enrollment.…”