Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care

Estimating the Costs of End-of-Life Care in Patients With Advanced Cancer From the Perspective of an Insurance Organization: A Cross-Sectional Study in Iran

OBJECTIVES

Cancers are significant medical conditions that contribute to the rising costs of healthcare systems and chronic diseases. This study aimed to estimate the average costs of medical services provided to patients with advanced cancers at the end of life (EOL).

METHODS

We analyzed data from the Sata insurance claim database and the Health Information System of Baqiyatallah hospital in Iran. The study included all adult decedents who had advanced cancer without comorbidities, died between March 2020 and September 2020, and had a history of hospitalization in the hospital. We calculated the average total cost of healthcare services per patient during the EOL period, including both cancer-related and noncancer-related costs.

RESULTS

A total of 220 patients met the inclusion criteria. The average duration of the EOL period for these patients was 178 days, with an average total cost of $8278 (SD $5698) for men and $9396 (SD $6593) for women. Cancer-related costs accounted for 64.42% of the total costs, including inpatient and outpatient services. Among these costs, hospitalization was the primary cost driver and had the greatest impact on EOL costs. This observation was supported by the multiple linear regression model, which suggested that hospitalization in the final days of life could potentially drive costs in these patients. Notably, no specialized palliative care was provided to the patients included in this study.

CONCLUSIONS

The results demonstrate that there is a significant rise in costs of care in patients receiving routine cancer care rather than optimized EOL care.

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

IMPORTANCE

Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer.

OBJECTIVE

To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022.

EXPOSURES

Nursing home status.

MAIN OUTCOMES AND MEASURES

Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death.

RESULTS

The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]).

CONCLUSIONS AND RELEVANCE

Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Intensity of end-of-life care for dual-eligible beneficiaries with cancer and the impact of delivery system affiliation

BACKGROUND

Dual-eligible beneficiaries, who qualify for Medicare and Medicaid, are a vulnerable population with much to gain from efforts to improve quality. Integrated delivery networks and cancer centers, with their emphasis on care coordination and communication, may improve quality of care for dual-eligible patients with cancer at the end of life.

METHODS

This study used Surveillance, Epidemiology, and End Results registry data linked with Medicare claims to evaluate quality for beneficiaries who died of cancer and were diagnosed from 2009 to 2014. High-intensity care was evaluated with 7 end-of-life quality measures according to dual-eligible status with multivariable logistic regression models. Regression-based techniques were used to assess the effect of delivery system affiliation (ie, cancer center or integrated delivery network vs no affiliation).

RESULTS

Among 100,549 beneficiaries who died during the study interval, 22% were dually eligible. Inferior outcomes were identified for dual-eligible beneficiaries in comparison with nondual beneficiaries across nearly every quality measure assessed, including >1 hospitalization in the last 30 days (12.6% vs 11.3%; P < .001) and a greater proportion of deaths occurring in a hospital setting (30.2% vs 26.2%; P < .001). Receipt of care in an affiliated delivery system was associated with reduced deaths in a hospital setting and increased hospice utilization for dual-eligible beneficiaries.

CONCLUSIONS

Dual-eligible status is associated with higher intensity care at the end of life. Delivery system affiliation has a modest impact on quality at the end of life, and this suggests that targeted efforts may be needed to optimize quality for this group of vulnerable patients.

The Impact of Health Delivery Integration on Cancer Outcomes

Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.