eCQ 11-3 Newsletter

Access to Hospice Concurrent with Active Cancer Therapy Decreases Aggressive Care, Costs

— i.e., the percentage of deceased lung cancer patients who received hospice care. OVERALL • In the top hospice-exposure quintile, 79%of patients received hospice care; in the bottom quintile, 55% used hospice. • During the six months following diag- nosis, 21.5% of patients were admitted to an ICU and 32% received any form of aggressive medical care (two or more hospital admissions within 30 days, ICU admission, tube feeding, or mechanical ventilation). • Less than half (44.1%) of patients had been hospitalized in the year prior to NSCLC diagnosis. • Those treated in the highest vs the low- est hospice-exposure quintile had lower rates of ICU use (19.3% vs 24.9%) and lower rates of aggressive medical care (28.3% vs 35.5%). KEY FINDINGS • In the six months following diagnosis, patients receiving treatment in the top- quintile facilities were one-third as likely to receive aggressive treatment compared with those treated in the bottom-quintile centers (adjusted odds ratio [AOR], 0.66; 95% confidence interval [CI], 0.53 to 0.81). • Top-quintile patients were 22% less likely to be admitted to an ICU during the six months after diagnosis (AOR, 0.78; 95% CI, 0.62 to 0.99) compared with bottom-quintile patients. • Following entry into hospice, rates of concurrent cancer treatment and che- motherapy or radiation therapy were more than twice as common among those in the highest-quintile facilities compared with those in the lowest (AOR, 2.28; 95% CI, 1.67 to 3.11). • In the last month of life, those treated in the highest-quintile medical centers vs those treated in the lowest had reduced odds of experiencing any form of ag-

A “both/and” program allowing vet- erans with advanced lung cancer access to hospice care while undergoing active disease-modifying treatment — rather than having to give up active treatment, as required by the “either/or” model of the Medicare hospice benefit — was found to lead to less aggressive care and lower costs in the six months following diagnosis, according to a report published in JAMA Oncology. These benefits were observed despite the finding that veterans treated in high hospice-exposure facilities were more than twice as likely to receive chemo- therapy or radiation therapy after initiating hospice services than were those treated in low hospice-exposure centers. The program, the Comprehensive End- of-Life Care Initiative, was launched by the U.S. Department of Veterans Affairs (VA) in 2009 to expand veterans’ access to hospice care by increasing the number of hospice units and trained staff in VA medical centers, as well as partnering with community hospices to provide services, while still allowing participants to receive disease-directed therapies. “We believe that this study offers a health system-level replication of [previ- ous] small randomized clinical trials of early concurrent care that also examined patients diagnosed with late-stage cancer,” write the authors. “As such, our results are very encouraging for those advocating concurrent care to allow for comprehen- sive end-of-life care earlier in the disease course, thereby reducing aggressive care at the end of life.” The investigators conducting the study analyzed VA claims merged with similar Medicare data for 13,085 veterans (male, 98.3%; white, 80.5%; aged < 65 years, 45.5%) newly diagnosed with stage IV non-small cell lung cancer (NSCLC) be- tween 2006 and 2012. The patients were cared for at 113VAmedical centers, which were ranked into quintiles according to each facility’s level of hospice exposure

gressive care (AOR, 0.55; 95%CI, 0.42 to 0.73). • The six-month costs for those in the top-quintile group were $266 per day lower (95% CI, $358 to $164) than for those in the bottom-quintile group. Their findings suggest that concur- rent care — the availability of hospice without having to forgo active treatment — reduces the likelihood of lung cancer patients receiving aggressive end-of-life treatment, while producing a net savings in medical care costs, the authors note. “The substantial reduction in healthcare costs suggests that the investment in hos- pice care that the VA made paid off and probably continues to pay off, without restricting veterans’ access to irradiation and chemotherapy,” they write. “This investment has contributed to high rates of hospice use: over 70% among veterans. Indeed, Medicare-enrolled veterans are more likely to use hospice than are general Medicare beneficiaries. “Whether this finding can be exported to Medicare is unclear, but the prospects are probably better under accountable care organizations or MedicareAdvantage plans than under Medicare fee-for-service care.” The author of an editorial on the study concludes, “Following the lead of [the founder of the first modern hospice, Dame Cicely] Saunders, we continue to study and forge novel care models to im- prove whole-person care for patients with terminal illness.” Source: “Association of Expanded VA Hospice Care with Aggressive Care and Cost for Veterans with Advanced Lung Cancer,” JAMA Oncology; Epub ahead of print, March 28, 2019. DOI: 10.1001/jamaoncol.2019.0081. Mor V, Wagner TH, Shreve S, et al; Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center; and Department of Health Services, Policy & Practice, Brown University School of Public Health, both in Providence, Rhode Island. Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California; Hospice and Palliative Care Program, U.S. Department of Veterans Affairs; and Penn State College of Medicine, Hershey, Pennsylvania.

Volume 11, Issue 3

Page 3

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