Characteristics associated with in-hospital death in commercially insured decedent.

Abstract

35 Background: A majority of patients with poor-prognosis cancer express a preference for in-home death, however, in-hospital deaths are common. We sought to identify characteristics associated with in-hospital death among commercially-insured decedents. Methods: Building on a data-sharing project between our institution and Blue Cross/Blue Shield of MA, we obtained health care claims records for a sample of commercially insured decedents who died between July 2010 and December 2013. All patients received cancer care at Dana-Farber. In-hospital vs. out-of-hospital death was ascertained from hospital claims. Odds ratios (OR) and 95% confidence intervals (CI) were used to evaluate the association of in-hospital death with patient characteristics and established retrospective measures of end-of-life (EOL) care quality. Results: 904 commercially insured decedents were included in our sample, and 537 decedents (59%) enrolled in hospice prior to death. There were 254 in-hospital deaths (28% of all deaths), and 79 in-hospital deaths (31%) occurred at unaffiliated hospitals. Three measures of EOL care quality were found to be associated with in-hospital death, including chemotherapy within 14 days (OR 4.0 [95% CI 2.6-6.2]) or 15-30 days (OR 2.1 [1.4-3.1]) of death, 2 or more ED visits within the last 30 days of life (OR 3.0 [2.1-4.3]), and non-enrollment in hospice (OR 28.8 [18.7-44.3]). Hematologic malignancy, but not other cancer types, was significantly associated with in-hospital death (OR 5.09 [3.1-8.5]). Age at death, sex, marital status, race/ethnicity, and distance of residence from the cancer center were not significantly associated with in-hospital death, though sample sizes for some comparison groups were small. Conclusions: In-hospital deaths are common among commercially insured cancer patients, and data sharing identified nearly 1/3 of in-hospital deaths that occurred at unaffiliated hospitals. Retrospective measures of intensive EOL care quality were significantly associated with in-hospital death, and patients enrolled in hospice were dramatically less likely to experience an in-hospital death.