Palliative care and hospice (a type of palliative care) 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 Veteran's Health Administration (VHA) does not require this of Veterans, whether receiving VA provided or Medicare reimbursed hospice, 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' end of life experiences, particularly the "burdensome health care transitions" that often accompany patients receiving aggressive medical care at the end of life.
The objectives of this study are to show the relationship between hospice and less aggressive treatment at the end of life for veterans newly diagnosed with non-small cell lung cancer (NSCLC). Specifically, we investigate if allowing veterans to access cancer treatment concurrently with hospice has altered veterans' end of life experiences, particularly burdensome events (i.e., burdensome health transitions and treatments) that often accompany patients receiving aggressive medical care at the end of life and whether this access results in higher overall medical care costs.
Using VA inpatient, outpatient and pharmacy claims matched with similar Medicare data, we created VA Medical Center level aggregates per year (2006-2012) characterizing all cancer decedents' use of hospice, cancer treatment and/or the simultaneous receipt of these two types of service. Using a facility fixed effect model and controlling for patient demographics, co-morbidities and pre-diagnosis hospital use, 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 non-small cell lung cancer (NSCLC) patients experienced burdensome transitions (3+ hospital admissions, Tube feeding, mechanical ventilation, ICU admission) in the last month of life and whether their overall medical care costs increased in relation to exposure to more concurrent care.
There was a 50% increase in the VHA facility average percentage of all cancer decedents to receive hospice care during the study period but no change in the proportion of all cancer patients who received radiation or chemotherapy in the last 6 months of life. Over the study period 11.9% of NSCLC decedents experienced a burdensome transition (9.0% ICU admission, 5.1% mechanical ventilation, 7.4% feeding tube and .5% 3+ hospital admissions) in the last month of life. 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 .22; 95% CI .07-.67), despite the fact that over the study period there was a 3 percentage point absolute increase in burdensome transitions in the newly diagnosed NSCLC patient population. We observed no association between 6 month mortality and increasing hospice exposure nor was there a statistically significant increase in VA plus Medicare health care costs.
Consistent with several small, single institution randomize trials, these findings suggest that allowing patients to simultaneously receive palliative care and anti-tumor treatment, concurrent care, actually reduces the aggressive end-of- life care associated with poor quality of life at no significant increase in medical care expenditures.
- Mor V, Wagner TH, Levy C, Ersek M, Miller SC, Gidwani-Marszowski R, Joyce N, Faricy-Anderson K, Corneau EA, Lorenz K, Kinosian B, Shreve S. Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer. JAMA oncology. 2019 Jun 1; 5(6):810-816.
- Haverhals LM, Manheim CE, Mor V, Ersek M, Kinosian B, Lorenz KA, Faricy-Anderson KE, Gidwani-Marszowski RA, Levy C. The experience of providing hospice care concurrent with cancer treatment in the VA. Supportive Care in Cancer : Official Journal of The Multinational Association of Supportive Care in Cancer. 2019 Apr 1; 27(4):1263-1270.
- Ersek M, Miller SC, Wagner TH, Thorpe JM, Smith D, Levy CR, Gidwani R, Faricy-Anderson K, Lorenz KA, Kinosian B, Mor V. Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer. 2017 Aug 15; 123(16):3186-3194.
- Hale-Gallardo J, Jia H, Delisle T, Levy CE, Osorio V, Smith JA, Hannold EM. Enhancing health and independent living for veterans with disabilities by leveraging community-based resources. Journal of multidisciplinary healthcare. 2017 Jan 20; 10:41-47.
- Gidwani R, Joyce N, Kinosian B, Faricy-Anderson K, Levy C, Miller SC, Ersek M, Wagner T, Mor V. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. Journal of palliative medicine. 2016 Sep 1; 19(9):957-63.
- Mor V, Joyce NR, Coté DL, Gidwani RA, Ersek M, Levy CR, Faricy-Anderson KE, Miller SC, Wagner TH, Kinosian BP, Lorenz KA, Shreve ST. The rise of concurrent care for veterans with advanced cancer at the end of life. Cancer. 2016 Mar 1; 122(5):782-90.
- Levy CR, Haverhals LM. Implementation Science Frameworks to Assess the VA Medical Foster Home Program. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2016 Nov 1; Denver, CO.
- Mor V. Concurrent Care for Veterans with Terminal Cancer: Avoiding the Terrible Choice. Paper presented at: VA Puget Sound Health Care System Palliative Care Grand Rounds; 2016 Mar 22; Seattle, WA.
- Joyce N, Cote D, Gidwani R, Youssef R, Lorenz K, Levy C, Kinosian B, Ersek MT, Miller SC, Faricy-Anderson K, Wagner T, Mor V. The rise of concurrent care for terminal cancer patients in the Veterans Health Administration. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.
- Joyce N, Cote D, Gidwani R, Youssef R, Lorenz KA, Levy CR, Kinsonian B, Ersek M, Miller SC, Faricy-Anderson K, Wagner T, Mor V. The rising use of hospice and palliative care among Veterans dying of cancer. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.
Health Systems, Cancer
Treatment - Comparative Effectiveness, Research Infrastructure
Cancer, Care Coordination, End-of-Life, Hospice, Outcomes - Patient, Predictive Modeling, Qualitative Methods, Statistical Methods, Symptom Management