Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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4049 — Concurrent Care for Veterans with Terminal Cancer: The Impact of Avoiding the "Terrible Choice"

Lead/Presenter: Emily Corneau, COIN - Providence
All Authors: Corneau EA (Providence VAMC) Wagner TH (Palo Alto VA Health Care System) Miller SC (Brown University) Levy CR (VA Eastern Colorado Health Care System) Ersek M (Corporal Michael J. Crescenz VAMC, Philadelphia) Gidwani RA (Palo Alto VA Health Care System) Faricy-Anderson KE (Providence VAMC) Lorenz KA (Palo Alto VA Health Care System) Shreve ST (VA Hospice and Palliative Care Program, Washington DC) Mor V (Providence VAMC)

Objectives:
Palliative care and hospice are associated with less aggressive treatment at the end of life but under Medicare, beneficiaries have to forego expensive treatment like radiation and chemotherapy. The VA does not require this of Veterans allowing us to ask whether the large increase in the availability of hospice in the VHA over the past decade without restrictions on the use of medical treatment has altered Veterans' experiences, particularly the "burdensome health care transitions" that often accompany patients receiving aggressive medical care at the end of life.

Methods:
VA and Medicare claims data were used to construct a monthly record of health utilization for all newly diagnosed stage 4 Non-Small Cell Lung Cancer (NSCLC) Veteran decedents who were diagnosed between 2006-2012. Using a facility fixed effect model and controlling for patient demographics and co-morbidities, we tested the effect of the facility level estimate of the changing proportion of cancer decedents receiving hospice in the last six months of life in a given facility year on the likelihood that NSCLC patients experienced burdensome transitions (3+ hospital admissions, Tube feeding, mechanical ventilation, ICU admission) in the last month of life.

Results:
There was a 50% increase in the VHA facility average percentage of NSCLC decedents to receive hospice care during the study period but no change in receipt of radiation or chemotherapy in the last 6 months of life. In the last month of life, 11.9% of NSCLC decedents experienced a burdensome transition. Controlling for patient demographics and co-morbidities, for every one percent increase in facility-level hospice use, the relative risk of a NSCLC patient experiencing a burdensome transition in the last month of life declined by almost 80% (AOR .23; 95% CI .08-.72). We observed no association between 6 month mortality and increasing hospice exposure.

Implications:
Increasing the facility-level availability and use of hospice among Veterans dying with advanced lung cancer was associated with lower rates of burdensome transitions without any change in the use of cancer treatments.

Impacts:
Our study demonstrates that investment in hospice has had positive effects for Veterans' end of life care.