Real-time assessment of resource utilization and subsequent cost analysis in cancer patients (pts) near the end of life (EOL).

Abstract

303 Background: Aggressive medical interventions and associated high costs of care for cancer pts near the EOL are common. Addressing this issue at the local level requires an accurate, automated process to merge real-time clinical EHR data with cost data for performance reporting. Methods: This was a single-center, observational cohort study of decedents treated with anticancer therapy (antiCT) in the last 6 months of life from January 2016 to October 2017. Pts were stratified by antiCT use in the last 30 days of life. The primary outcome measure was total cost of care. Secondary outcome measures (hospitalizations, ER and ICU utilization, antiCT use, and hospice referral) were obtained through Flatiron Health EHR-based automated data processing. Cost data were merged from the Value-Driven Outcomes analytics framework. Results: 650 pts were included. 228 (35.1%) received antiCT in the 30 days before death. Non-drug costs for pts who received antiCT in the last 30 days of life were higher than those who did not (p < 0.01, median 38X higher). A higher proportion of pts who received antiCT in the last 30 days of life had ≥1 ER visit (29.4% vs 9.5%, p < 0.01) and hospital admission (58.8% vs 27.3%, p < 0.01) during the last 30 days. In addition, more of these pts received ICU care (35.5% vs 11.4%, p < 0.01). AntiCT in the last 30 days was associated with shorter median time from first hospice referral to death (1.4 vs 4.7 weeks; IQR 0.7-2.0 vs 3.14-7.7 weeks, p < 0.01). Distribution of antiCT types administered to pts in the last 30 days versus those given antiCT > 30 days from the EOL was significantly different, with the most substantial difference seen in the proportion of pts receiving immunotherapy (20.2% vs 12.6%, p = 0.04). Conclusions: Real-time assessment of EOL outcomes shows antiCT in the last 30 days of life is associated with aggressive medical interventions and increased total cost of care. Future research should identify pts who are unlikely to benefit from aggressive care, and whether performance reporting to oncologists will reduce futile interventions near the EOL.

Systemic Anticancer Therapy at the End of Life—Changes in Usage Pattern in the Immunotherapy Era

“…One study suggests that any SACT at EOL, including immunotherapy, is associated with higher rates of downstream acute care, delayed hospice care, and higher costs . This finding requires future research to examine the association of immunotherapy at EOL with downstream acute care use and quality of life in a larger, more representative sample.…”

“…Use of systemic anticancer therapy (SACT) at end of life (EOL) is associated with increased acute care use, delayed goals-of-care conversations, late hospice enrollment, higher costs, and possibly adverse quality and duration of life . In 2012, the American Society of Clinical Oncology and the National Quality Forum developed the quality measure Proportion Receiving Chemotherapy in the Last 14 Days of Life to promote reduction in chemotherapy and earlier integration of palliative care at EOL.…”

End-of-Life Systemic Oncologic Treatment in the Immunotherapy Era: The Role of Race, Insurance, and Practice Setting

“…5,6 Two recent studies suggest that continuing CPI or targeted therapies past the point of futility is associated with higher rates of acute care utilization. 2,7 Thus, understanding the factors associated with this practice is critical to developing future interventions to curtail it. Patient factors included race, 8,9 insurance type, 9 and Eastern Cooperative Oncology Group (ECOG) PS.…”

“…Use of systemic treatment at the end of life (EOL) is by definition futile and is highly correlated with EOL emergency department, hospital and intensive care unit utilization, late transition to hospice, death in the acute care setting, and higher costs. 1,2 This pattern leads to distress among patients and caregivers. In 2012, ASCO and the National Quality Forum (NQF) developed a quality measure with the goal of reducing chemotherapy within 14 days of death.…”

End-of-Life Care Among Patients With Metastatic Renal Cell Carcinoma: Importance of a Patient-Centric Focus in Clinical Decision Making

“…1 Initially, the focus was to provide earlier palliative care (conversation around goals of care and hospice enrollment), as no benefit had been observed among patients receiving chemotherapy at the EOL. 2,3 Studies have shown that patients receiving palliative chemotherapy at the EOL do not live longer, and their quality of life was impaired because of unnecessary toxicities. 1-4 In early 2000s, indicators of quality EOL care were identified, including administration of systemic therapy, hospital admission, ICU admission, > 1 emergency department visit within the last 30 days of life, in-hospital death, and hospice initiation within the last 30 days of life.…”