February 2018

In this Issue: Improving Cancer Care
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Enhancing the Value of End-of-Life Care for Veterans with Cancer

Feature Article

Specialty societies, including the American Society of Clinical Oncology (ASCO), recommend a reduction in the use of intensive medical services at the end of life for patients dying from cancer, noting these services are at odds with the focus on quality of life and pain and symptom management that would most benefit patients in their last days. Evidence indicates that many patients would also prefer less intensive services at the end of life. However, more than 25% of annual Medicare expenditures occur for persons in their last year of life, and approximately one-fifth of U.S. patients die in the hospital. This suggests that some end-of-life care may be low value, meaning it does not achieve an improvement in patient outcomes commensurate to its costs. Despite its importance, the value of end-of-life care has never before been evaluated.

This ongoing study (2016-2019) is evaluating the value of specific intensive end-of-life services provided to Veterans dying from cancer, using a patient-centered perspective. The first aim evaluated the quality of end-of-life care provided to Veterans dying of cancer, and evaluates care differences between those Veterans treated by Medicare and those treated by VA. Disparities that exist according to race, age, marital status, and rural status also were examined. The second aim evaluates the cost of end-of-life care for these Veterans, including their cost trajectories in the last year of life. The third aim investigates the relationship between intensive medical care provided in the last 30 days of life and Bereaved Family Survey outcomes of pain, desired medical management, and overall rating of care. Investigators will then evaluate the value (defined as cost relative to health outcomes) of each intensive service.

Findings: Findings from Aim 1 of this study have been published and include the following:  

• Veterans treated under traditional fee-for-service Medicare were more likely to get intensive care in the last 30 days of life compared to those treated by VA. Medicare-reliant Veterans were significantly more likely to receive chemotherapy, hospital stay, hospital days, ICU admission, and were more likely to die in the hospital. Conversely, Medicare-reliant patients were significantly less likely to have multiple ED visits.
• Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital.
• Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in the hospital.  

Impact: Results from this research can inform VA policymakers about the value of intensive end-of-life services, whether VA is providing Veterans with end-of-life care that matches their desires, and whether there exist any disparities in care according to sociodemographic variables (i.e., rurality, marital status, age, and race). Results also will provide actionable information about services to target in order promote high-value, patient-centered care for patients dying from cancer and reduce wasteful care and disparities in care. Additionally, as VA continues to purchase care in the community, findings can inform coordination efforts for the treatment of Veterans with advanced cancer.

Principal Investigator: Risha Gidwani-Marszowski, DrPH, VA Health Economics Resource Center (HERC) and HSR&D’s Center for Innovation to Implementation (Ci2i), Palo Alto, CA. 

Publications:

Gidwani-Marszowski R, Needleman J, Mor V et al.  Quality of end-of-life care is higher in the VA compared to care paid for by traditional Medicare.  Health Affairs.  Jan 2018; 37(1).

Enhancing the Value of End-of-Life Care for Veterans with Cancer project abstract