Veterans with Cancer Received Higher Quality, Lower Intensity End-of Life Care in VA Compared to Medicare

BACKGROUND:
Both the American Society of Clinical Oncology (ASCO) and National Quality Forum (NQF) recommend a reduction in intensive medical interventions in the last month of life for cancer patients. Despite these recommendations, care intensity remains high at end of life, and in the last four weeks of life, healthcare use and associated costs accelerate. This retrospective study evaluated the quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted ASCO and NQF quality-of-care metrics. Investigators also assessed whether palliative care was associated with higher-quality end-of-life care. The study cohort included Veterans (n=87,251) who died of solid neoplasms from FY2010 through FY2014. [About half of the cohort (52%) was Medicare-reliant.] Veterans were 66 years or older, and were continuously enrolled in FFS Medicare in the 12 months prior to death. Study outcomes included care in the last 30 days of life. Investigators evaluated quality of care as the proportion of patients who experienced: two or more emergency department (ED) visits, chemotherapy, an ICU stay, hospital admission, death in hospital, and number of days spent in hospital. Poor-quality care was indicated by higher proportions of patients receiving these services. The receipt of palliative care also was examined, as were rural vs. urban residence and racial disparities.

FINDINGS:

• Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Medicare-reliant patients were significantly less likely to have multiple ED visits.
• Palliative care penetration had no effect on patients' experience of chemotherapy, two or more ED visits, hospital stay, ICU admission, or days spent in the hospital. The effect of palliative care penetration on patient likelihood of dying in the hospital was not significant.
• 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 hospital.

IMPLICATIONS:

• Findings suggest VA should continue to track the quality of end-of-life care and bolster coordination efforts with non-VA providers to ensure the best care for Veterans dying of cancer.

LIMITATIONS:

• It is possible that unmeasured confounders remain for which investigators could not adjust, such as patient preferences or other patient characteristics.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 14-067 and SDR 02-237). Dr. Gidwani-Marszowski is part of HSR&D's Health Economics Resource Center (HERC) and the VA Palo Alto Health Care System.

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. January 2018;37(1):95-103.