Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer
Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer
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DOI：
10.1001/jamaoncol.2019.0081
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发表时间：
2019-06-01
期刊：
影响因子：
28.4
通讯作者：
Shreve, Scott
中科院分区：
文献类型：
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作者：
Mor, Vincent;Wagner, Todd H.;Shreve, Scott
重要的是，医疗保险临终关怀受益人停止疾病修饰治疗，因为临终关怀福利限制访问。虽然退伍军人可以同时获得临终关怀和退伍军人事务部（VA）医疗中心（VAMC）提供的治疗，但这与退伍军人临终关怀的治疗和费用变化之间的关系尚不清楚。目的确定临终关怀的可获得性增加，而不限制疾病改善治疗，是否与减少生命结束时的积极治疗和医疗费用有关。设计、设置和患者一项改良的差异中差异研究设计，使用设施固定效应，比较了相对较高与较低临终关怀使用率的患者结局。本研究评估了13085名新诊断为IV期非小细胞肺癌（NSCLC）的退伍军人，这些退伍军人来自113个VAMC，其中2006年至2012年期间每年至少有5名退伍军人被诊断为IV期NSCLC。数据分析在2017年1月至2018年7月期间进行。暴露使用VA住院患者，门诊患者，药房索赔和类似的医疗保险数据，我们创建了VAMC级别的所有死于癌症的患者的年度汇总，这些患者在生命的最后一个月内使用临终关怀，癌症治疗和/或同时接受这两种治疗，将所有VAMC年划分为五分之一的临终关怀可用性。主要结局和测量指标确诊后前6个月内接受积极治疗（30天内2次或2次以上住院，管饲，机械通气，重症监护室[ICU]住院）和总费用。结果在纳入研究的13085名退伍军人中，12858名（98%）为男性，10531名（81%）为白色，5949名（46%）年龄大于65岁。接受VAMC治疗的NSCLC退伍军人在临终关怀前五分之一（79%的临终关怀使用者）中，相对于临终关怀后五分之一（55%的临终关怀使用者），在开始临终关怀后同时接受癌症治疗的可能性是后者的两倍多（调整后比值比[AOR]，2.28; 95% CI，1.67-3.31）。尽管如此，对于在最高五分之一的临终关怀VAMC中观察到的NSCLC退伍军人，相对于在最低五分之一的临终关怀VAMC中观察到的患者，在诊断后6个月内接受积极治疗的AOR为0.66（95%CI，0.53-0.81），使用ICU的AOR为0.78（95%CI，0.62-0.99）。高五分位数组与低五分位数组相比，6个月的费用估计每天低266美元（95% CI，-358至-164美元）。没有生存差异。结论和相关性增加临终关怀的可用性，而不限制晚期肺癌退伍军人的治疗与积极的医疗和显着降低成本，同时仍然提供癌症治疗。
ImportanceMedicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown. ObjectiveTo determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. Design, Setting, and ParticipantsA modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. ExposuresUsing VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. Main Outcomes and MeasuresReceipt 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 6 months after diagnosis. ResultsOf the 13085 veterans included in the study, 12858 (98%) were men; 10531 (81%) were white, and 5949 (46%) were older than 65 years. 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 (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. Conclusions and RelevanceIncreasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.