Shi-Yi Wang1, Jane Hall2, Craig E Pollack3, Kerin Adelson4, Elizabeth H Bradley5, Jessica B Long2, Cary P Gross6. 1. Department of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, CT, USA; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA. Electronic address: shiyi.wang@yale.edu. 2. Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA. 3. Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 4. Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA; Section of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. 5. Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA. 6. Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
Abstract
OBJECTIVES: To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, >1 emergency department (ED) visit within 30 days of death, >1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors. RESULTS: The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P<.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P<.001), ICU admissions (16.2% vs. 21.3%; P<.001), and late hospice enrollment (11.2% vs. 12.9%; P<.001), whereas in-hospital death declined (23.5% vs. 20.9%; P<.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period. CONCLUSIONS: Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program.
OBJECTIVES: To examine contemporary trends in end-of-life cancer care and geographic variation of end-of-life care aggressiveness among Medicare beneficiaries. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare data, we identified 132,051 beneficiaries who died as a result of cancer in 2006-2011. Aggressiveness of end-of-life care was measured by chemotherapy received within 14 days of death, >1 emergency department (ED) visit within 30 days of death, >1 hospitalization within 30 days of death, ≥1 intensive care unit (ICU) admission within 30 days of death, in-hospital death, or hospice enrollment ≤3 days before death. Using hierarchical generalized linear models, we assessed potentially aggressive end-of-life care adjusting for patient demographics, tumor characteristics, and hospital referral region (HRR)-level market factors. RESULTS: The proportion of beneficiaries receiving at least one potentially aggressive end-of-life intervention increased from 48.6% in 2006 to 50.5% in 2011 (P<.001). From 2006 to 2011, increases were apparent in repeated hospitalization (14.1% vs. 14.8%; P=.01), repeated ED visits (34.3% vs. 36.6%; P<.001), ICU admissions (16.2% vs. 21.3%; P<.001), and late hospice enrollment (11.2% vs. 12.9%; P<.001), whereas in-hospital death declined (23.5% vs. 20.9%; P<.001). End-of-life chemotherapy use (4.4% vs. 4.5%) did not change significantly over time (P=.12). The use of potentially aggressive end-of-life care varied substantially across HRRs, ranging from 40.3% to 58.3%. Few HRRs had a decrease in aggressive end-of-life care during the study period. CONCLUSIONS: Despite growing focus on providing appropriate end-of-life care, there has not been an improvement in aggressive end-of-life cancer care in the Medicare program.
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