Hospital-Based End-of-Life Care and Costs for Older Patients With Malignant Brain Tumors

Abstract

Approximately half of patients with a diagnosis of primary malignant brain tumor (PMBT) or secondary malignant brain tumor (SMBT) are older than 65 years and experience disproportionate mortality and symptom burden. End-of-life care for patients with terminal cancer is often aggressive, costly, and discordant with patient preferences. 1 However, a lack of knowledge remains about patterns of end-of-life care for the growing population of elderly people with a malignant brain tumor. This study compares hospital-based care and costs in the last 30 days of life for older patients with PMBT and SMBT, identifies potential risk factors for aggressive care, and evaluates the association between aggressive care and cost. Methods | Medicare claims data, derived from a lay navigation program in the southeastern United States, were used to identify decedents from January 1, 2012, to December 31, 2015, who were 65 years or older with either PMBT (International Classification of Diseases, Ninth Revision [ICD-9] code 191.X) or SMBT (ICD-9 code 198.3). 2 Those with claims for both codes were excluded. Total costs to Medicare and hospital-based care (emergency department visits, intensive care unit admissions, and hospital admissions) in the 30 days prior to death, as described in Medicare core quality measures, were determined for each patient and compared using the Mann-Whitney test for continuous variables (cost) and χ 2 test for categorical variables (all others). 3 A 2-sided P = .05 indicated statistical significance. Regression analyses of risk for hospital-based care and costs were performed, with adjustment for sociodemographic factors (including self-reported race/ethnicity), Charlson comorbidity index score (excluding cancer), and receipt of chemotherapy, radiotherapy, and hospice care. Risks for hospital-based care were calculated by generalized log-linear models using Poisson distribution with robust variance estimates. Linear mixed-effect models accounting for random effects were constructed to assess costs. Analyses were performed from August 31, 2016, to February 16, 2017, using SAS software, version 9.4 (SAS Institute Inc). The University of Alabama at Birmingham institutional review board approved the study and the waiver of patient informed consent.

Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors

“…Total Medicare expenditure in the final 30 days life was previously reported and was similar between patients with PMBT and SMBT ($8592 vs $9964, P = 0.75; Table 2). 27 Sensitivity analyses that included the dual-coded cohort provided similar results for total Medicare expenditures. In the multivariable model, hospice…”

“…In our previous study, we reported that SMBT patients were more likely than PMBT patients to be hospitalized in the final month of life (50% vs 42%, P = 0.009), and hospitalizations were associated with a significant increase in Medicare expenditures. 27 The transition to hospice in SMBT patients may be more likely to occur following hospitalizations, which would curtail any cost savings potentially associated with hospice in that population.…”

“…[23][24][25][26] Hospital-based care was defined to include: emergency department visits (Healthcare Common Procedure Coding System [HCPCS] code G0380), intensive care unit admissions (HCPCS G9657), and hospital admissions as determined by Centers for Medicare & Medicaid Services inpatient admission claims. 27 Hospice Utilization, Cancer-Directed Therapy, and Medicare Expenditures Hospice care, utilization of cancer-directed therapies, and total Medicare expenditures were examined in the 30 days prior to death based on National Quality Forum endorsed quality measures. 6 Hospice care was defined as any use of outpatient, in-home, or inpatient hospice services (HCPCS Q50xx).…”

Disparities in Place of Death for Patients with Primary Brain Tumors and Brain Metastases in the United States

“…Increasing hospice utilization and reducing hospital deaths will reduce healthcare costs. One analysis found that hospice-based care in primary and metastatic brain tumor patients decreased Medicare costs by as much as $12,138 per patient whereas hospital-based care increased Medicare costs by as much $16,303 [41]. Future directions include prospective projects studying the implementation of standardized surveys and other tools to facilitate early, end-of-life discussion between providers, patients with brain tumors, and families, with a particular focus on at-risk populations.…”

End-of-Life Care Options and Decision Making for Older Patients With Malignant Brain Tumors

“…To the Editor We read with interest the report by Dover and colleagues regarding the costs of end-of-life care for older adults with malignant primary and secondary brain tumors. To be honest, we expected the numbers to be worse.…”