Impact of Hospice on Spending and Utilization Among Patients With Lung Cancer in Medicare

Abstract

Objectives: To compare patterns and understand drivers of spending and utilization by month in the last 6 months of life between patients with lung cancer who used hospice versus those who did not. Study Design: Retrospective cohort analysis using 2009 to 2013 Medicare claims. Methods: We used a 10% random sample of Medicare fee-for-service beneficiaries with lung cancer who died between 2010 and 2013 (43 789 beneficiaries). Patients were assigned to 2 groups depending on whether they used hospice care in the last 6 months of life. The following outcomes were constructed by month: (1) all-cause Medicare spending, (2) indicator of hospitalization, (3) indicator of emergency department (ED) visit, (4) number of part B chemotherapy claims, and (5) number of radiation therapy sessions. We used a combination of propensity score matching and regression analysis to compare outcomes between the 2 groups. Results: Patients who used hospice had significantly lower spending in the last month of life compared to nonusers (US$16 907 vs US$26 906, P < .00). The spending differences in the last month of life between the 2 groups were largely driven by lower likelihood of hospitalization (54% vs 80%, P < .01) and ED visits (15% vs 22%, P < .01) and fewer chemotherapy (0.12 vs 0.32, P < .01) and radiation therapy sessions (0.80 vs 1.26, P < .01). During the other months in the 6-month period, spending was similar between the 2 groups. Conclusions: Timely hospice enrollment of patients with lung cancer—the group suffering from high morbidity and mortality among patients with cancer—may lead to significant cost savings.

Impact of Length of Hospice on Spending and Utilization Among Medicare Beneficiaries With Lung Cancer

“…3 A recent study by Kalidindi et al found that Medicare decedents with lung cancer who used hospice had significantly lower health-care spending than nonusers in the last 6 months of life, with most of the difference occurring in the final month of life. 4 This finding was consistent with studies of hospice use among patients with other conditions. 5,6 However, one limitation of these prior studies was that that they did not distinguish between patients with different lengths of hospice enrollment; instead, they lumped together patients who used hospice for 6 months or more with those enrolled for less than a week.…”

“…5,6 However, one limitation of these prior studies was that that they did not distinguish between patients with different lengths of hospice enrollment; instead, they lumped together patients who used hospice for 6 months or more with those enrolled for less than a week. A second limitation of prior work was that cost savings were estimated over long time intervals-such as last year of life, 5,6 last 6 months, 4 or last month, 7 while the median length of hospice use was only 17 days, and the average length of stay was around 88.2 days. 8 Given the variation in length of hospice enrollments, useful assessments of hospice savings must: (1) consider the patient's actual length of hospice stay, and (2) use the period during which hospice is actually used for cost comparisons.…”

“…Next, we examined spending and utilization differences during the target enrollment period between hospice users and nonusers. Similar to the study by Kalidindi et al, 4 we examined a comprehensive set of utilization measures including hospitalizations, emergency department (ED) visits, and use of select outpatient services including chemotherapy and radiation therapy sessions.…”

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis

“…Patients with terminal cancer were more likely to present to ED in the evenings, overnight or at the weekends, outwith usual business hours 19,28 . There was consistent evidence (5 studies) demonstrating that cancer decedents who were close to death were significantly more likely to use unscheduled care than those who were not close to death 9,16,30,34,35 .…”

“…There was a significant amount of consistent evidence supporting the association between hospice enrolment and unscheduled care use by cancer decedents (12 studies). Being enrolled in a hospice programme was consistently associated with a lower use of unscheduled care 5,7,15,18,34,[37][38][39] . Some studies found that hospice enrolment was involved in a 1.5-2 fold decrease in ED attendances 13,37,38 .…”