Health Care Contact Days Among Older Cancer Survivors

Health Care Contact Days, Care Experience, and Out-of-Pocket Spending Among Traditional Medicare Patients

This cross-sectional study examines the level of satisfaction in care, ease of managing care, and out-of-pocket expenses among patients enrolled in traditional Medicare.

Health Care Contact Days for Older Adults Enrolled in Cancer Clinical Trials

Importance

Contact days-days with health care contact outside the home-are a measure of how much of a patient's life is consumed by health care. Clinical trials, with a more uniform patient mix and protocolized care, provide a unique opportunity to assess whether burdens differ by individuals' sociodemographic backgrounds.

Objective

To characterize patterns of contact days for older adults with cancer participating in clinical trials.

Design, Setting, and Participants

In this cohort study, data from 6 SWOG Cancer Research Network trials across prostate, lung, and pancreatic cancers that recruited patients aged 65 years or older from 1999 to 2014 were linked with Medicare claims data. Data were analyzed from December 14, 2023, to September 26, 2024.

Exposures

Demographic variables, including age, sex, self-reported race and ethnicity, and insurance status; clinical factors, such as cancer type and study-specific prognostic risk score; and social factors, such as neighborhood socioeconomic deprivation.

Main Outcomes and Measures

Number of contact days, defined as number of days with contact with the health care system, percentage of health care contact days (number of contact days divided by follow-up), and sources of contact days (eg, ambulatory or inpatient) in the first 12 months after trial enrollment. Sociodemographic and clinical factors associated with contact days were examined using negative binomial regression, including an offset variable for duration of observation.

Results

The study included 1429 patients (median age, 71 years [range, 65-91 years]; 1123 men [78.6%]; and 332 patients [23.5%] with rural residence). The median number of contact days was 48 (IQR, 26-71), of a median of 350 days (IQR, 178-365 days) of observation; the median percentage of contact days was 19% (IQR, 13%-29%). The most common sources of contact days were ambulatory clinician visits (median, 17 [IQR, 7-25]), tests (median, 12 [IQR, 3-24]), and treatments (median, 11 [IQR, 3-22]). A median of 70% (IQR, 50%-88%) of ambulatory contact days had only a single service performed on that day (eg, only tests). In multivariable regression, factors associated with increased contact days included age (relative risk [RR] per year, 1.02 [95% CI, 1.01-1.02]), insurance type (Medicare alone or with Medicaid or private insurance vs other: RR, 2.47 [95% CI, 2.16-2.83]), prognostic risk score (above the median vs at or below the median: RR, 1.14 [95% CI, 1.04-1.25]), and type of cancer (pancreatic vs prostate cancer: RR, 1.69 [95% CI, 1.51-1.89]; lung vs prostate cancer: RR, 1.69 [95% CI, 1.54-1.85]).

Conclusions and Relevance

In this cohort study of older adults with advanced stage cancer participating in phase 3 randomized clinical trials, patients spent nearly 1 in 5 days with health care contact. These findings highlight the need to simplify trial requirements to minimize participant burden.

"The biggest challenge is there's never a routine": a qualitative study of the time burdens of cancer care at home

PURPOSE

As cancer care is increasingly delivered in the home, more tasks and responsibilities fall on patients and their informal care partners. These time costs can present significant mental, physical, and financial burdens, and are undercounted in current measures of time toxicity that only consider care received in formal healthcare settings.

METHODS

Semi-structured qualitative interviews were conducted with patients with gastrointestinal cancer and informal care partners at a single tertiary cancer center between March and October 2023. Interviews explored cancer care tasks conducted when home, associated time burdens, how these time burdens compared to facility-based care, and whether home-based care should be included in objective measures of time toxicity. Two coders transcribed interviews and analyzed data using a grounded theory approach.

RESULTS

A single interviewer conducted semi-structured interviews with 15 patients and 18 care partners, and identified five major themes: (1) unexpected home-based care activities are time burdensome; (2) other burdens interact with and impact time burdens; (3) time burdens evolve over the disease course and differentially impact patients and care partners; (4) several factors influence the choice of home-based versus in-facility care; and (5) home-based care is generally perceived as less time-burdensome than in-facility care. Overall, 12 of 33 (36%) participants recommended including days with home-based care in the current contact days measure of time toxicity.

CONCLUSION

In addition to characterizing time burdens associated with home-based cancer care, this study builds on existing literature to explore if and how to incorporate days with home-based care into the contact days measure.

Estimating financial and health burden by initial Medicare plan choice and history of cancer

Understanding the downstream consequences of initial Medicare plan selection is necessary to ensure access to and affordability of health care services, especially for older adults with serious illness. We used 2008-2020 data from the Health and Retirement Study to estimate financial and health burden by initial Medicare plan selection (traditional Medicare without supplemental coverage, traditional Medicare plus supplemental coverage, or Medicare Advantage) and self-reported history of cancer. Initially choosing benefits with greater financial protections (either traditional Medicare plus supplemental coverage or Medicare Advantage) relative to traditional Medicare without supplemental coverage was associated with lower levels of out-of-pocket spending and a lower likelihood of reporting cost-related medication nonadherence and fair or poor health. Policymakers should consider improving the adequacy of traditional Medicare coverage to ensure the affordability of health care services and reduce the burden of serious illness among older adults, especially those with a history of cancer.

Time's up: the urgency to investigate time toxicity in patients with genitourinary malignancies

Patients with genitourinary (GU) malignancies have seen the development of multiple life-prolonging treatments in the past decade. As patients and clinicians consider their treatment options along the cancer journey, time spent with healthcare contact, or "time toxicity," has emerged as a new outcome measure that comprehensively considers time receiving cancer care, including planned visits for evaluation and treatment as well as unplanned urgent care addressing complications. Despite its rising study across cancer populations, there has been a surprising lack of work evaluating time toxicity in patients with GU cancers. This narrative review aims to summarize the available studies on time toxicity in cancer, with a deeper dive into the methodology, strengths and limitations, and future directions of the field. A dedicated section focused on scenarios and best practices to measure and collect data on time toxicity can serve to spark interest in evaluating this novel health outcome on GU cancer survivors. Ultimately, time toxicity is a relevant patient-centered metric that can be incorporated into clinical trial design and routine clinical care to influence clinical decision-making.

Patient, Caregiver, and Clinician Perspectives on the Time Burdens of Cancer Care

Importance

Cancer and its care impose significant time commitments on patients and care partners. The oncology community has only recently conceptualized these commitments and the associated burden as the "time toxicity" of cancer care. As the concept gains traction, there is a critical need to fundamentally understand the perspectives of multiple stakeholders on the time burdens of cancer care.

Objectives

To explore time-consuming aspects of cancer care that were perceived as burdensome, identify the individuals most affected by time burdens of cancer care, and evaluate the consequences of these time burdens.

Design, Setting, and Participants

Participants in this qualitative analysis were recruited from a National Cancer Institute-designated cancer center in Minnesota, where semistructured qualitative interviews were conducted from February 1 to October 31, 2023. Purposive and criterion sampling methods were used to recruit patients (adults with advanced stage gastrointestinal cancer receiving systemic cancer-directed treatment), care partners (patient-identified informal [unpaid] partners), and clinicians (physicians, physician assistants, nurse practitioners, nurses, social workers, and schedulers). Data were analyzed from February 2023 to February 2024.

Main Outcomes and Measures

Thematic analysis was conducted with a hybrid (inductive and deductive methods) approach. Themes, subthemes, and illustrative quotations are presented.

Results

Interviews included 47 participants (16 patients [8 aged ≤60 years; 12 women (75.0%)], 15 care partners [12 aged ≤60 years; 9 women (60.0%)], and 16 clinicians [11 women (68.7%)]). A total of 31 subthemes were identified that were grouped into 5 themes. Theme 1 captured time burdens due to health care outside the home (eg, travel, parking, and waiting time), while theme 2 identified the often invisible tasks performed at home (eg, handling insurance and medical bills, receiving formal home-based care). Theme 3 explored how care partners are affected alongside patients (eg, burdens extending to the wider network of family, friends, and community) and theme 4 represented the consequences of time burdens (eg, demoralization, seemingly short visits turned into all-day affairs). Finally, theme 5 referenced positive time spent in clinical interactions and hope for change (eg, patients value meaningful care, the "time toxicity" label is a spark for change).

Conclusions and Relevance

This qualitative analysis identifies key sources and effects of time toxicity, as well as the populations affected. The results of this study will guide the oncology community to map, measure, and address future time burdens.

The association of health-care contact days with physical function and survival in CCTG/AGITG CO.17

INTRODUCTION

Although contact days-days with health-care contact outside home-are increasingly adopted as a measure of time toxicity and treatment burden, they could also serve as a surrogate of treatment-related harm. We sought to assess the association between contact days and patient-reported outcomes and the prognostic ability of contact days.

METHODS

We conducted a secondary analysis of CO.17 that evaluated cetuximab vs supportive care in patients with advanced colorectal cancer. CO.17 collected European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 instrument data. We assessed the association between number of contact days in a window and changes in physical function and global health status and the association between number of contact days in the first 4 weeks with overall survival.

RESULTS

There was a negative association between the number of contact days and change in physical function (per each additional contact day: at 4 weeks, 1.50-point decrease; 8 weeks, 1.06-point decrease; P < .0001 for both) but not with global health status. This negative association was seen in patients receiving cetuximab but not supportive care. More contact days in the first 4 weeks was associated with worse overall survival for all participants and patients receiving cetuximab (per each additional contact day: all participants, adjusted hazard ratio [HR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10; and cetuximab, adjusted HR = 1.08, 95% CI = 1.05 to 1.11; P < .0001 for both).

CONCLUSIONS

In this secondary analysis of a clinical trial, more contact days early in the course were associated with declines in physical function and worse survival in all participants and in participants receiving cancer-directed treatment.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT00079066.

Trajectories of Health Care Contact Days for Patients With Stage IV Non-Small Cell Lung Cancer

Importance

Patients with stage IV non-small cell lung cancer (NSCLC) experience substantial morbidity and mortality. Contact days (ie, the number of days with health care contact outside the home) measure how much of a person's life is consumed by health care, yet little is known about patterns of contact days for patients with NSCLC.

Objective

To describe the trajectories of contact days in patients with stage IV NSCLC and how trajectories vary by receipt of cancer-directed treatment in routine practice.

Design, Setting, and Participants

A retrospective, population-based decedent cohort study was conducted in Ontario, Canada. Participants included adults aged 20 years or older who were diagnosed with stage IV NSCLC (January 1, 2014, to December 31, 2017) and died (January 1, 2014, to December 31, 2019); there was a maximum 2-year follow-up. Data analysis was conducted from February 22 to August 16, 2023.

Exposure

Systemic cancer-directed therapy (yes or no) and type of therapy (chemotherapy vs immunotherapy vs targeted therapy).

Main Outcomes and Measures

Contact days (days with health care contact, outpatient or institution-based, outside the home) were identified through administrative data. The weekly percentage of contact days and fitted models with cubic splines were quantified to describe trajectories from diagnosis until death.

Results

A total of 5785 decedents with stage IV NSCLC were included (median age, 70 [IQR 62-77] years; 3108 [53.7%] were male, and 1985 [34.3%] received systemic therapy). The median overall survival was 108 (IQR, 49-426) days, median contact days were 36 (IQR, 21-62), and the median percentage that were contact days was 33.3%. A median of 5 (IQR, 2-10) days were spent with specialty palliative care. Patients who did not receive systemic therapy had a median overall survival of 66 (IQR, 34-130) days and median contact days of 28 (IQR, 17-44), of which a median of 5 (IQR, 2-9) days were spent with specialty palliative care. Overall and for subgroups, normalized trajectories followed a U-shaped distribution: contact days were most frequent immediately after diagnosis and before death. Patients who received targeted therapy had the lowest contact day rate during the trough (10.6%; vs immunotherapy, 15.4%; vs chemotherapy, 17.7%).

Conclusions and Relevance

In this cohort study, decedents with stage IV NSCLC had a median survival in the order of 3.5 months and spent 1 in every 3 days alive interacting with the health care system outside the home. These results highlight the need to better support patients and care partners, benchmark appropriateness, and improve care delivery.