Study Evaluates Timing and Duration of Hospice and Palliative Care across VA, Medicare, and VA-Purchased Care
The Institute of Medicine, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network recommend palliative care for cancer patients, advising that palliative care begin soon after diagnosis of advanced cancer and play a larger role in overall care as illness progresses. Despite the recent attention paid to palliative care from quality-of-care and specialty societies, actual practice of care is not well understood. This retrospective study examined the real-world timing of palliative care in VA, and how timing and duration of hospice care varied across Medicare, VA, and VA-purchased care. Using both VA and Medicare administrative data for 11,896 Veterans aged 65 or older who died with cancer in 2012, investigators assessed the likelihood of receiving palliative care; receiving hospice care; and receiving hospice care for at least three days across all three combinations of payment source and setting. Veterans were identified as having cancer if they had one inpatient or outpatient cancer diagnosis in the 365 days before death.
- Most Veterans received hospice care (71%; n=8,444), while fewer received palliative care (52%). Taken together, 86% of Veterans had some exposure to hospice or palliative care in the approximately 180 days before death.
- Median first exposure to hospice care was slowest in VA (more days before receipt of care) and fastest in VA-purchased environments (fewer days before receipt of care). Patients with VA hospice care first received it a median of 14 days before death, compared with VA-purchased hospice care (median of 28 days before death) and Medicare hospice care (median of 16 days before death).
- After adjusting for patient age and cancer type, Veterans who received VA hospice care were significantly less likely to receive it for at least three days compared with Veterans who received it through VA-purchased or Medicare environments.
- While VA has no Medicare-like restriction on the simultaneous use of hospice care and curative treatment, almost 70% of Veterans enrolled in VA hospice and more than 80% enrolled in VA-purchased hospice did so only after their cancer treatment ended. Thus, only 20-30% of Veterans with both hospice and cancer care received these services concurrently.
- Medicare was the largest payer of hospice care for Veterans (61%) followed by VA (44%) and VA-purchased care (10%). Numbers add up to more than 100% because 1,263 Veterans received hospice care through multiple environments.
- There remains a gap between recommended timing of supportive services and real-world practice of care. This is especially true for palliative care, which is recommended for all patients with advanced cancer regardless of terminal status.
- Investigators relied on VA administrative data to evaluate palliative care consults. However, as a non-revenue generating system, VA coding practices may not capture all care provided.
Gidwani R, Joyce N, Kinosian B, Faricy-Anderson K, Levy C, Miller S, Ersek M, Wagner T, and Mor V. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. Journal of Palliative Medicine. May 26, 2016;e-pub ahead of print.
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