Has There Been a Shift in Use of Subacute Rehabilitation Instead of Hospice Referral Since Immunotherapy Has Become Available?

Abstract

PURPOSE: Immunotherapy has rapidly become the mainstream treatment of multiple cancer types. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice and an increase in referrals to subacute rehabilitation (SAR) facilities, possibly with the aim of getting strong enough for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice use. METHODS: We performed an electronic chart review of patients discharged from our inpatient oncology units to SAR facilities from 2009 to 2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. RESULTS: Three hundred fifty-eight patients were referred to SAR 413 times. One hundred seventy-four patients (49%) returned to the oncology clinic before readmission or death, and only 117 (33%) ever received additional cancer-directed treatment (chemotherapy, radiation, or immunotherapy). Among all discharges, 28% led to readmissions within 30 days. Seventy-four patients (21%) were deceased within 30 days, only 31% of whom were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate code status, documented goals of care discussions, and electronic advance directives. CONCLUSION: A growing number of oncology inpatients are being discharged to SAR, but two thirds do not receive additional cancer therapy at any point, including a substantial fraction who are readmitted or deceased within 1 month. These data can help guide decision making and hospital discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.

Utilization of Systemic Therapy in Patients With Cancer Near the End of Life in the Pre- Versus Postimmune Checkpoint Inhibitor Eras

“…6 More frequent use of subacute rehabilitation, delays in hospice referrals, and an increase in in-hospital deaths have also been reported. 6,9,10 Immune-related toxicities associated with ICIs are also likely more common outside of clinical trials 11 and can lead to unnecessary medical and financial burdens for patients and the health care system.…”

Prognostic Communication in the Era of Targeted Therapy and Immunotherapy

“…These factors in combination with the hope for durable responses have resulted in a shift in referral patterns for patients with advanced and metastatic disease. In a 2019 study, a trend toward fewer hospice referrals and increased subacute rehab referrals from inpatient oncology units was noted with nearly two-thirds of patients never receiving additional cancer therapy [27]. In another retrospective study of deceased patients who had received immunotherapy, two-thirds had received immunotherapy in the last 90 days of life [28].…”

Immunotherapy in Patients With Poor Performance Status: The Jury Is Still Out on This Special Population

“…13,[18][19][20][21] The promise of ICIs also leads patients with debility from cancer or other comorbidities to pursue rehabilitation near the end of life and hold on to hope for further therapy, although few successfully reach this goal. 22 These findings suggest that in pursuing ICI therapy with uncertain or low likelihood of benefit, patients and clinicians may defer important discussions about prognosis and patient preferences for end-of-life care and results in higher health care utilization. Although ICIs do not have side effects that are as toxic as chemotherapy, ICI use near the end of life is still not benign and its effect on burdensome end-of-life care suggests that this may also be a low-value practice.…”