Trends in end-of-life cancer care in the Medicare program

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.