Increased Hospice Care for Veterans Associated with Less Aggressive Medical Treatment and Lower Medical Costs

BACKGROUND:
Aggressive end-of-life care is prevalent for individuals with advanced cancer, and multiple clinical trials show that patients with terminal cancer benefit from concurrent care – treatment for cancer in addition to palliative end-of-life care. VA provides hospice care for Veterans, who can also choose to receive concurrent antineoplastic (e.g., used in chemotherapy to kill cancer cells) and other disease-modifying treatments. However, Medicare beneficiaries are forced to choose between hospice care or active cancer treatment. This study sought to determine if increased availability of hospice for Veterans is associated with reduced aggressive treatments and medical care costs at the end of life. Investigators evaluated 13,085 Veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs between 2006 and 2012 (and who died between 1/1/2006 and 12/31/2012). Data analyses were conducted between January 2017 and July 2018. The primary outcomes were receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first six months after diagnosis.

FINDINGS:

• Veterans with newly diagnosed end-stage lung cancer treated at VAMCs with the most expansion in hospice use had a significantly greater likelihood of receiving chemotherapy or radiation therapy after hospice enrollment – but a lower likelihood of having aggressive treatment or intensive care unit use, compared with similar Veterans treated in VAMCs with low hospice growth. Thus, increasing hospice availability – without restricting treatment access for Veterans with advanced lung cancer – was associated with less aggressive medical treatment and significantly lower medical costs, while still enabling Veterans to receive cancer treatment.
• Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care. Radiation therapy was more common than chemotherapy.
• The six-month costs were lower by an estimated $266 per day for the high-quintile group vs. the low-quintile group. There was no survival difference through 180 days post-diagnosis.

IMPLICATIONS:

• The substantial reduction in healthcare costs suggests that the investment in hospice care that VA made has paid off, and will likely continue to pay off without restricting Veterans' access to radiation and chemotherapy. Whether this finding can be exported to Medicare is unclear.

LIMITATIONS:

• VAMCs that offered more hospice care likely differed in other respects from those that offered less access to hospice care.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 12-121). Dr. Mor is part of HSR&Ds Center of Innovation in Long-Term Services and Supports, and Dr. Wagner directs HSR&D's Health Economics Resource Center (HERC).

Mor V, Wagner T, Levy C, et al. Association of Expanded VA Hospice Care with Aggressive Care and Cost for Veterans with Advanced Lung Cancer. JAMA Oncology. March 28,2019; Epub ahead of print.