Escalation of Oncology Services at End of Life May Be Moderated by Coordinated Care

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“Use of oncology-related services is increasingly scrutinized, yet precisely which services are actually rendered to patients, particularly at the end of life, is unknown,” noted an article in the Journal of Oncology Practice. To address this knowledge gap, Eijean Wu, MD, of the Los Angeles County and University of Southern California Healthcare Network, and colleagues catalogued the end-of-life use of medical services by patients with gynecologic cancer at a large, urban safety-net hospital.

Study Details

The investigators retrospectively reviewed medical and hospital records to systematically identify all registrants in their hospital-based gynecologic oncology clinic with documented deaths between December 2006 and February 2012.

“The clinic is part of a 600-bed, publicly funded teaching hospital that serves a mid to low socioeconomic status population within a major metropolitan area,” the authors stated. “The core population serviced by this institution is 71% Hispanic, 7% white/non-Hispanic, 8% black, and 11% Asian. A total of 83% and 80% of the outpatient and inpatient population, respectively, were county indigent or state funded, with only 4.9% and 6.1%, respectively, funded by Medicare.”

Among the 116 subjects, the median age at diagnosis was 55 years, and the median age at death was 57 years. Most patients presented with stage III or IV disease. Cervical cancer accounted for most of the deaths (42%).

The researchers evaluated the patients’ clinicopathologic oncologic history and metrics of medical use, such as hospitalizations, outpatient visits, invasive procedures, chemotherapy infusions, radiology studies, and blood draws. Calculating the days between the last therapeutic intervention (surgery, radiation therapy, or chemotherapy) and death showed that 30% of patients received a therapeutic intervention within the last month of life, the researchers reported.

“The median time between a patient’s last therapeutic intervention and death was 55 days. The median time between the last chemotherapy infusion and death was 76 days (range, 4–363 days). Although 8% of patients received no treatment during their last 12 months of life, 3.4% received chemotherapy within 30 days of death, and 1 patient received chemotherapy within 14 days of death.            

“To determine whether or not patients underwent or received more diagnostic tests, interventions, and therapies simply as a result of increased availability of these services over the 6-year study period, we conducted time-trend analyses for the use of each variable within our health-care use evaluation,” the investigators wrote. These analyses revealed that only chemotherapy infusions significantly increased over time, by approximately two additional infusions per year. Use of each of the services, however, did increase significantly during the last year of a patient’s life (P < .001).

Patients who had been receiving continued care within the clinic for a longer period experienced overall fewer days of hospitalization and outpatient visits in their last months of life. Patients who had been under continuous care for a longer period by the same medical team also had fewer blood draws, radiology studies, and chemotherapy infusions in the last months of life. Patients registered in the health-care system for the shortest period were more likely to be admitted into the hospital at the end of life than to receive outpatient treatment and care.

“Importantly, our data showed that lengthier time in the same health-care system, with coordination and oversight of care by a stable medical team, may favorably affect the efficiency of resource use in the inpatient and outpatient settings,” the authors concluded. They also realized over the course of their study that there is a dearth of data concerning optimal timing for discussions about resuscitation/code status and how it would best fit into a model of comprehensive cancer care. “ASCO strongly suggests early integration of palliative care services to facilitate these discussions, especially for patients in advanced stages of cancer,” the authors noted. 

“Despite improvements in end-of-life planning and growing endorsement of hospice care over the past decade, multiple reports still show that such decisions continue to be delayed to within moments of death,” the authors noted. “What drives this procrastination, whether appropriate or not, warrants further investigation.” ■

Wu E, et al: J Oncol Pract 11:e163-e169, 2015.