Assessment of Guideline-Nonconcordant Radiotherapy in Medicare Beneficiaries With Metastatic Cancer Near the End of Life, 2015-2017

Purpose An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to ASCO's membership following publication or presentation of potentially practice-changing data from major studies. This PCO addresses the integration of palliative care services into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. Clinical Context Palliative care is frequently misconstrued as synonymous with end-of-life care. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. Although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services. By potentially improving quality of life (QOL), cost of care, and even survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available. Recent Data Seven published RCTs form the basis of this PCO. Provisional Clinical Opinion Based on strong evidence from a phase III RCT, patients with metastatic non–small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care—when combined with standard cancer care or as the main focus of care—leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research. NOTE. ASCO's provisional clinical opinions (PCOs) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical trials and cannot be assumed to apply to the use of these interventions in the context of clinical practice. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO's PCOs, or for any errors or omissions.

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Determinants of total end-of-life healthcare costs of Medicare beneficiaries: A quantile regression forests analysis

The Journals of Gerontology Series A ◽

10.1093/gerona/glab176 ◽

2021 ◽

Author(s):

Lihua Li ◽

Liangyuan Hu ◽

Jiayi Ji ◽

Karen Mckendrick ◽

Jaison Moreno ◽

...

Keyword(s):

Quantile Regression ◽

End Of Life ◽

Healthcare Costs ◽

Health Maintenance Organizations ◽

Medicare Beneficiaries ◽

Health Maintenance ◽

Regional Characteristics ◽

Hospital Referral Region ◽

High Quantiles ◽

Hospital Referral

Abstract Background To identify and rank the importance of key determinants of end-of-life (EOL) healthcare costs, and to understand how the key factors impact different percentiles of the distribution of healthcare costs. Methods We applied a principled, machine learning based variable selection algorithm, using Quantile Regression Forests, to identify key determinants for predicting the 10 th (low), 50 th (median) and 90 th (high) quantiles of EOL healthcare costs, including costs paid for by Medicare, Medicaid, Medicare Health Maintenance Organizations (HMO), private HMO, and patient’s out-of-pocket expenditures. Results Our sample included 7,539 Medicare beneficiaries who died between 2002 and 2017. The 10 th, 50 th and 90 th quantiles of EOL healthcare cost are $5,244, $35,466 and $87,241 respectively. Regional characteristics, specifically, the EOL-expenditure index, a measure for regional variation in Medicare spending driven by physician practice, and the number of total specialists in the hospital referral region, were the top two influential determinants for predicting the 50 th and 90 th quantiles of EOL costs, but were not determinants of the 10 th quantile. Black race and Hispanic ethnicity were associated with lower EOL healthcare costs among decedents with lower total EOL healthcare costs but were associated with higher costs among decedents with the highest total EOL healthcare costs. Conclusions Factors associated with EOL healthcare costs varied across different percentiles of the cost distribution. Regional characteristics and decedent race/ethnicity exemplified factors that did not impact EOL costs uniformly across its distribution, suggesting the need to use a “higher-resolution” analysis for examining the association between risk factors and healthcare costs.

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Active treatment near the end-of-life in metastatic cancer patients

Annals of Oncology ◽

10.1093/annonc/mdv346.03 ◽

2015 ◽

Vol 26 ◽

pp. vi114

Author(s):

S. Bolzonello ◽

E. Poletto ◽

L. Gerratana ◽

M. Bonotto ◽

M. Cinausero ◽

...

Keyword(s):

End Of Life ◽

Cancer Patients ◽

Active Treatment ◽

Metastatic Cancer

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Palliative Tracheostomy at the End of Life: Utilization in a Patient with Metastatic Cancer

Journal of Palliative Medicine ◽

10.1089/jpm.2017.0255 ◽

2017 ◽

Vol 20 (10) ◽

pp. 1052-1053

Author(s):

Carleen Risaliti ◽

Jillian Gustin

Keyword(s):

End Of Life ◽

Metastatic Cancer

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Hospice Use And End-Of-Life Spending Trajectories In Medicare Beneficiaries On Hemodialysis

Health Affairs ◽

10.1377/hlthaff.2017.1181 ◽

2018 ◽

Vol 37 (6) ◽

pp. 980-987 ◽

Cited By ~ 9

Author(s):

Ann M. O’Hare ◽

Susan M. Hailpern ◽

Melissa Wachterman ◽

William Kreuter ◽

Ronit Katz ◽

...

Keyword(s):

End Of Life ◽

Medicare Beneficiaries ◽

Hospice Use

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Disparities in end-of-life inpatient care received by patients with metastatic cancer, 2010 to 2017.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.12008 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 12008-12008

Author(s):

Stephanie Deeb ◽

Fumiko Chino ◽

Lisa Diamond ◽

Anna Tao ◽

Abraham Aragones ◽

...

Keyword(s):

End Of Life ◽

Systemic Therapy ◽

Minority Groups ◽

Metastatic Cancer ◽

Cohort Analysis ◽

Population Based ◽

Teaching Hospitals ◽

Patients Âgés ◽

Logistic Regression Models ◽

Total Charges

12008 Background: Many patients with metastatic cancer receive high-cost, low-value care near the end of life. We examined interventions during terminal hospitalizations for patients with metastatic cancer to identify those with high likelihood of receiving futile care. Methods: A retrospective population-based cohort analysis of encounter-level data from the National Inpatient Sample was conducted, including records from 2010-2017 for patients ages ≥18 with metastatic cancer who died during hospitalization. We fit multivariable binomial logistic regression models to examine associations between exposures, including patient demographics, and the main outcome of aggressive, low-value, and high-cost medical care (Table). Results: Out of 321,898 hospitalizations among patients with metastatic cancer, 21,335 (6.6%) were terminal. Of these, 65.9% were white, 14.1% Black, 7.5% Hispanic, 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% were admitted from the Emergency Department (ED), 4.6% received systemic therapy, and 19.2% received invasive ventilation. Median total charges were $43,681. Black patients and publicly insured patients had higher likelihoods of admission from the ED and receiving ventilation, as well as higher total charges; similar trends emerged among patients of Asian race and Hispanic ethnicity. Patients hospitalized at urban teaching hospitals had higher likelihoods of receiving systemic therapy, ventilation, and incurring higher total charges (Table). Conclusions: Metastatic cancer patients of racial and ethnic minority groups and those with Medicare or Medicaid were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to determine the underlying causes of these disparities in order to implement prospective interventions and advance appropriate end-of-life care.[Table: see text]

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Abstract P72: Pattern of Deactivation of Implantable Cardioverter Defibrillator in Inpatient Hospice Units

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.ap72 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Umashankar Lakshmanadoss ◽

Lohith Reddy ◽

Saadia Sherazi ◽

Abeer Anabtawi ◽

Michael DiSalle ◽

...

Keyword(s):

End Of Life ◽

Hospice Care ◽

Metastatic Cancer ◽

Care Center ◽

Sudden Cardiac Arrest ◽

Shock Therapy ◽

Implantable Cardioverter Defibrillators ◽

Icd Implantation ◽

Number Of Patients ◽

Icd Shock

Background: There have been an increasing number of patients receiving implantable cardioverter defibrillators (ICDs) over the last decade. Although ICDs prevent arrhythmic death, patients may still develop other terminal illnesses, or progression of underlying heart failure. ICD- delivered shocks are associated with significant pain, anxiety and reduced quality of life. Therefore for this population of patients, it may become undesirable to receive shock therapy nearing the end of life. We reviewed the practices for ICD deactivation on a series of patients admitted to a hospice center. We hypothesized that for patients with ICDs, the frequency for ICD deactivation at end of life would be low. Methods: In this retrospective study we reviewed records of patients with ICDs who were admitted to the Hildebrandt Hospice Care Center, an inpatient hospice facility, in Rochester NY from January 2005 to December 2009. Information regarding patient's demographics, indications for ICD implantation, deactivation of ICD (frequency, location) and history of shock in hospice care was recorded. Results: We identified 32 patients who were admitted to inpatient hospice with ICDs for primary prevention of sudden cardiac arrest. The mean age was 78 + 9 years and 23 out of 32 (72%) were male. Sixteen patients had metastatic cancer, 8 patients had sepsis, 4 patients had stroke, 3 patients had renal disease and one patient had liver disease. Twenty (62%) patients had their ICD deactivated in the hospital before transferring to inpatient hospice. Nine (28%) patients were transferred to the center without ICD deactivation. Among these patients, 3 (10%) received ICD shock while in hospice and subsequently died in the center (average 2 days after receiving the shock). Three (10%) patients refused to have their ICD deactivated. Out of these three patients, two died in the hospice center while one patient was discharged home and none of them had ICD shock during hospice admission. Conclusion: The discussion about ICD deactivation should be initiated in terminally ill patients who are opting for hospice care for end of life care. Deactivating the device allows patients to die without the discomfort of electric shocks.

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Use of a computer model and care coaches to increase advance care planning conversations for patients with metastatic cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.8 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 8-8

Author(s):

Divya Gupta ◽

Touran Fardeen ◽

Winifred Teuteberg ◽

Briththa Seevaratnam ◽

Mary Khay Asuncion ◽

...

Keyword(s):

End Of Life ◽

Cancer Patients ◽

Advance Care Planning ◽

Computer Model ◽

Metastatic Cancer ◽

Life Quality ◽

Care Planning ◽

Survival Prognosis ◽

Advance Care ◽

Lay Care

8 Background: Patients with metastatic cancer benefit from advance care planning (ACP) conversations. Despite initiatives which train providers to have ACP conversations using the serious illness care program (SICP) conversation guide, few patients have a documented prognosis discussion due to busy clinic schedules and difficulty in deciding the right times to have such conversations. We designed an intervention to improve ACP by incorporating a validated computer model to identify patients at high risk for mortality in combination with lay care coaches. We investigated whether this would improve end of life quality measures. Methods: Four Stanford clinics were included in this pilot; all received SICP training. Two clinics (thoracic and genitourinary) underwent the intervention (computer model + care coach), and two clinics (sarcoma and cutaneous) served as the control. For providers in the intervention, an email was sent every Sunday listing the metastatic cancer patients who would be seen in clinic the following week and a predicted prognosis generated by the model. A lay care coach contacted patients with a predicted survival ≤2 years to have an ACP conversation with them. After, the care coach notified the provider to suggest discussion regarding prognosis with the patient. Criteria for a patient visit to be included in the analysis were: age ≥18, established patient, has sufficient EMR data for computer model, and no prior prognosis documentation. The primary outcome was documentation of prognosis in the ACP form by the end of the week following the clinic visit. Results: 5330 visits in 1298 unique patients met the inclusion criteria. Median age was 67 (range 19-97); 790 male, 508 female. 1970 visits were with patients with ≤2 year predicted survival. Prognosis discussion was documented by providers in the ACP form for 8.1% of intervention visits compared to 0.07% of control visits (p=0.001 in mixed effects model). Of the 1298 unique patients, 84 were deceased by December 2020. 41.7% died in the hospital. 59.5% were enrolled in hospice prior to death, and 19.0% were hospitalized in the ICU ≤14 days prior to death. Of deceased patients with ACP form prognosis documentation, 5.0% had ≥2 hospitalizations in the 30 days before death compared to 23.4% of deceased patients with no prognosis documented (p=0.10). For ≥ 2 ER visits in the 30 days before death, the proportions were 5.0% and 20.3% (p=0.17). Conclusions: This pilot study supports that our intervention is associated with higher rates of prognosis discussions and documentation. There was a trend towards better quality of end of life care as noted by higher rates of hospice enrollment and less intensive care at end of life. These results merit further investigation as a means to improve goal-concordant care and ensure appropriate care for cancer patients at the end of life.

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Assessing Quality of Life of Patients with Advanced Chronic Obstructive Pulmonary Disease in the End of Life

Journal of Palliative Care ◽

10.1177/082585970502100311 ◽

2005 ◽

Vol 21 (3) ◽

pp. 180-187 ◽

Cited By ~ 22

Author(s):

Samantha M.C. Pang ◽

Kin-Sang Chan ◽

Betty P.M. Chung ◽

Kam-Shing Lau ◽

Edward M.F. Leung ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Obstructive Pulmonary Disease ◽

End Of Life ◽

Pulmonary Disease ◽

Metastatic Cancer ◽

Chinese Patients ◽

Chronic Obstructive ◽

Life Questionnaire ◽

Obstructive Pulmonary Disease

Given the limitations of existing health-related quality-of-life (QOL) measures in capturing the end-of-life experience of patients with advanced chronic diseases, an empirically grounded instrument, the quality-of-life concerns in the end of life questionnaire (QOLC-E), was developed. Though it was built on the McGill quality of life questionnaire (MQOL), its sphere is more holistic and culturally specific for the Chinese patients in Hong Kong. One hundred and forty-nine patients with advanced chronic obstructive pulmonary disease (COPD) or metastatic cancer completed the questionnaire. Seven factors (28 items) which emerged from the factor analysis were grouped into four positive (support, value of life, food-related concerns, and healthcare concerns) and four negative (physical discomfort, negative emotions, sense of alienation, and existential distress) subscales. Good internal consistency and concurrent validity were shown. The results also revealed that these two groups of patients had similar QOL concerns. The validity of applying QOLC-E as an outcome measure to evaluate the effectiveness of palliative and psychoexistential interventions has yet to be tested.

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