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Publication Briefs

Study Shows Hospice Enrollment for Veterans with Advanced Stage Lung Cancer Increases

Early enrollment in hospice care maximizes potential benefits and should be emphasized; however, hospice referrals often occur too late to improve quality of life for patients with cancer. In addition, considerable variability exists in hospice use by U.S. geographic region, even among academic and National Cancer Institute designated medical centers. VA has developed several programs and initiatives to improve hospice use, including a Hospice and Palliative Care Program Office, and VA's Comprehensive End-of-Life Care Initiative – designed to increase access to palliative care services and collaboration with community hospice programs. This study examined the use of hospice care by Veterans enrolled in VA healthcare. Using data from the VA Central Cancer Registry (VACCR), investigators identified 21,860 decedents with advanced stage lung cancer who were diagnosed between January 2007 and June 2013. [Lung cancer is the leading cause of cancer death among both men and women in the U.S.] VA and Medicare data were used to assess the timing of hospice enrollment, as well as disease staging and treatments received in hospice. Policy experts recommend that patients spend 2-3 months in hospice, with late enrollment defined as within the last 3 days of life.


  • Overall, hospice enrollment among VA patients with advanced stage lung cancer increased from 65% in 2007 to 71% in 2013. Early hospice enrollment also increased, with time from cancer diagnosis to hospice enrollment decreasing by 65 days (32% relative decrease).
  • There was statistically significant regional variability in overall hospice enrollment across the VA healthcare system, ranging from 64% in the Northeast to 77% in the Southeast. Regional variability in the timing of hospice enrollment also was significant; for example, enrollment in the last 3 days of life ranged from 18% in the Northeast to 12% in the Southeast.
  • Hospice enrollment was associated with older age, moderate compared to low income, a higher FCI (Functional Comorbidity Index – a measure of physical function limitations) score, white race, being married, and stage IV lung cancer.


  • Significant regional variability in hospice enrollment and patient characteristics associated with the use and timing of enrollment suggest a framework for focused efforts to enhance utilization. Also, the authors suggest future studies should focus on identifying elements within integrated healthcare systems (i.e., financial and service models) that contribute to timely hospice use.


  • The VACCR is limited to Veterans who are diagnosed with or receive cancer care within VA, excluding those who receive care elsewhere.
  • Regional differences in hospice use may be impacted by availability, which was not explored.

Drs. Sullivan and Ganzini are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

PubMed Logo Sullivan D, Ganzini L, Lapidus J, et al. Improvements in Hospice Utilization among Patients with Advanced Stage Lung Cancer in an Integrated Health Care System. Cancer. October 10, 2017; Epub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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