Determinants and Outcomes of Hospice Utilization Among Patients with Advance-Staged Hepatocellular Carcinoma in a Veteran Affairs Population

Abstract

Background Hospice provides integrative palliative care for advance-staged hepatocellular carcinoma (HCC) patients, but hospice utilization in HCC patients in the United States is not clearly understood. Aims We examined hospice use and subsequent clinical course in advance-staged HCC patients. Methods We conducted a retrospective study on a national, Veterans Affairs cohort with stage C or D HCC. We evaluated demographics, clinical factors, treatment, and clinical course in relation to hospice use. Results We identified 814 patients with advanced HCC, of whom 597 (73.3%) used hospice. Oncologist management consistently predicted hospice use, irrespective of HCC treatment (no treatment: OR = 2.25 (1.18–4.3), treatment: OR = 1.80 (1.10–2.95)). Among patients who received HCC treatment, hospice users were less likely to have insurance beyond VA benefits (47.2% vs. 60.0%, p = 0.01). Among patients without HCC treatment, hospice users were older (62.2 [17.2] vs. 60.2 [14.0] years, p = 0.05), white (62.1% vs. 52.9%, p = 0.01), resided in the southern United States (39.5% vs. 31.8%, p = 0.05), and had a performance score ≥ 3 (41.9% vs. 31.8%, p = 0.01). The median time from hospice entry to death or end of study was 1.05 [2.96] months for stage C and 0.53 [1.18] months for stage D patients. Conclusions 26.7% advance-staged HCC patients never entered hospice, representing potential missed opportunities for improving end-of-life care. Age, race, location, performance, insurance, and managing specialty can predict hospice use. Differences in managing specialty and short-term hospice use suggest that interventions to optimize early palliative care are necessary.

National Trends in Location of Death in Patients With End‐Stage Liver Disease

“…Our analysis also compared ESLD with other major causes of death and found that although ESLD had the second highest proportion of deaths in hospice, it still substantially trailed malignancy. Based on previous studies in cancer populations, ( 29,44,45 ) we expected and found that patients who died with HCC and non‐HCC malignancy had significantly higher rates of death at hospice and home than other diseases. Death attributed to infection, on the other hand, occurred more often in an inpatient setting, which may be because infections are felt by many to require hospitalization.…”

Palliative care in hepatocellular carcinoma

“…Another study by Zou et al . of the United States Veteran Affairs database identified 814 patients with advanced ( n = 564) or terminal ( n = 250) stage HCC 61 . The authors found 40.8% of patients entered hospice care (and hence received palliative care involvement) directly after HCC diagnosis.…”

“…The implementation of palliative care for HCC is hindered by factors including lack of resources, stigmatization, and physician‐associated barriers 61,62,66,70,79 (Table 3). Several studies in the United States have also identified cultural, language, and insurance barriers to accessing palliative care in ESLD, with lower referral rates seen in non‐Caucasian and uninsured populations 68,69 …”

“…Closely entwined with stigmatization of palliative care services are the widespread misconceptions in the community regarding who should receive this service and what it is. Patients and families can perceive palliative care as “giving up,” resulting in refusal to engage with the service 61,66 . There have been attempts to address this by rebranding palliative care to “supportive care,” although this has not been uniformly adopted 79 .…”

“…There are also physician‐associated factors that serve as barriers to the implementation of palliative care. HCC is often managed by gastroenterologists rather than oncologists, who are proven to refer to palliative care less frequently than oncologists 61,74 . In addition to concerns regarding the aforementioned stigma, 91% of physicians cited insufficient time, and 81% felt they lacked adequate cultural awareness to initiate the referral 70 .…”