Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer | Lung Cancer | JAMA Oncology | JAMA Network
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Original Investigation
March 28, 2019

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

Author Affiliations
  • 1Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island
  • 2Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
  • 3Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California
  • 4Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
  • 5Stanford University School of Medicine, Palo Alto, California
  • 6Eastern Colorado VA Healthcare System, Denver
  • 7University of Colorado, Division of Health Care Policy and Research, Aurora
  • 8Veteran Experience Center (formerly, the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 9University of Pennsylvania School of Nursing, Philadelphia
  • 10Division of Primary Care and Population Health, Stanford University, Stanford, California
  • 11Alpert Medical School of Brown University, Providence, Rhode Island
  • 12Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 13Hospice and Palliative Care Program, U.S. Department of Veterans Affairs
  • 14Penn State College of Medicine, Hershey, Pennsylvania
JAMA Oncol. 2019;5(6):810-816. doi:10.1001/jamaoncol.2019.0081
Key Points

Question  Is increased availability of hospice for veterans associated with reduced aggressive treatments and medical care costs at the end of life?

Findings  In this cohort study of 13 085 veterans, those with newly diagnosed end-stage lung cancer treated at Veterans Affairs Medical Centers (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.

Meaning  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.


Importance  Medicare 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.

Objective  To 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 Participants  A 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 13 085 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.

Exposures  Using 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 Measures  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 6 months after diagnosis.

Results  Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (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 Relevance  Increasing 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.