Resource utilization and provider variation in the care of patients with stage IV non-small cell lung cancer six months before death.

216 Background: Cost of care of cancer patients near the end of life is a focus for payers and others. The breakdown of costs during this period for patients with Stage IV non-small cell lung cancer (NSCLC) are shifting as therapeutic choices change. We measured and reported variation in utilization, by oncologist, aiming to improve standardization and reduce utilization while maintaining or increasing the quality of care. Methods: Within the University of Pennsylvania Health System (UPHS), we identified all deceased patients with Stage IV NSCLC with first contact of 1/3/2011 to date of death of 4/10/2016, at least 1 chemotherapy visit, and 6 months between first contact and death (N=175). We captured all inpatient and outpatient charges within 6 months of patient death. Results: The median gross total charge per patient was $209,637 (interquartile range, $121,517-$371,196), which consisted of 39% outpatient infusions, 23% radiation therapy, 18% inpatient medical admissions, 11% outpatient radiology, 4.5% professional charges, and <1% ED visits. Infusions of pemetrexed and bevacizumab accounted for 7.3% and 6.1% of the gross total charges, respectively. Only 13/175 (7.4%) of patients received infusions within 14 days of death. Primary oncologist was not found to be a significant driver of variation in total, outpatient, or inpatient gross charges per patient (p=0.097, 0.208, 0.297). However, we showed that professional charges and use of outpatient radiology differed by oncologist (p=0.039, 0.003). We also identified oncologist-driven differences in use of supportive care drugs pegfilgrastim, darbepoietin, and denosumab (p=0.002, <0.001, <0.001). We detected no differences in use of pemetrexed or bevacizumab (p=0.835, 0.521). The differences in number of infusion visits approached significance (p=0.058). Conclusions: Outpatient infusions and radiation therapy were the largest contributors to healthcare resource utilization in the care of Stage IV NSCLC patients in the last 6 months of life. Variation in utilization by primary oncologist was detected in professional charges, outpatient radiology, and the use of supportive care (but not chemotherapeutic) agents.