Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer

Abstract

Background:

Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice.

Methods:

We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries.

Results:

Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%–41%; SM 60%–73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08–0.23, p < 0.001).

Conclusions:

Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.

Introduction

The Veterans Health Administration (VHA) allows simultaneous cancer-directed treatment (palliative or curative intent) and hospice, termed “concurrent care.”¹ The Centers for Medicare and Medicaid Services (CMS) do not allow concurrent care. Instead, patients and caregivers are required to forgo further cancer-directed treatment to enroll in the Medicare Hospice Benefit,² known as “the terrible choice.” Patients and caregivers are thus prevented from accessing the CMS hospice benefit if they would like to undergo any cancer-directed treatment whether of palliative or curative intent.³

The use of concurrent care is particularly important among patients with advanced lung cancer. Lung cancer is the most common cause of all cancer-related deaths.⁴ One health care outcome of interest for advanced lung cancer is aggressive end-of-life care. Aggressive end-of-life care is a previously defined quality measure reflecting the use of different types of care, such as chemotherapy, intensive care unit (ICU) admissions, multiple inpatient admissions, mechanical ventilation, and/or cardiopulmonary resuscitation (CPR), within a certain period of time before death.^5,6 This type of care is expensive and often not aligned with the patient's or caregiver's goals.⁷ Despite this, a high prevalence of aggressive care at the end of life has been demonstrated in both CMS and VHA health care systems.^8–10

This study examined temporal trends of aggressive care quality measures at the end of life among VHA and Medicare beneficiaries with advanced nonsmall cell lung cancer (NSCLC). We evaluated the differences in aggressive care at the end of life between these groups and Medicare regional practice patterns to assess the potential effect of concurrent care on aggressive care at the end of life for Veterans.

Methods

Study design

This longitudinal study included Veterans and Medicare beneficiaries diagnosed with stage IV NSCLC who died between January 1, 2006 and December 31, 2012 and were enrolled within the VHA or fee-for-service Medicare during the last 30 days of life. We used 2006 to 2012 as it coincides with the increased hospice utilization and use of concurrent care within the VHA as reported by previous studies.^1,11 We compared patterns of aggressive care at the end of life between both health care systems and evaluated the relationship between hospital referral region (HRR)-level Medicare spending and hospice utilization and aggressive care use at VHA. The VHA and Yale University Institutional Review Boards determined that this study did not constitute human subjects' research and included a waiver of informed consent. The VHA and Surveillance, Epidemiology, and End Results (SEER)-Medicare analyses were conducted separately and at no point were the datasets linked.

VHA sample

Decedents were identified from the Veterans Central Cancer Registry (VACCR). All Veterans with NSCLC in VACCR were diagnosed and/or received their first course of treatment within the VHA. Veterans with at least one inpatient or outpatient treatment record for diagnosis of cancer within the last six months of life were included.¹ The data used for this analysis were collected over the last 30 days before the date of death. The study sample had to have a defined facility, where the patients received care. Veterans were assigned the VHA facility, where they received the majority of their care as derived from inpatient and outpatient claims in the last six months of life.¹ All VHA-specific data were obtained from the VHA Information Resource Center.

Medicare sample

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. This database includes demographics and tumor characteristics for patients reported to tumor registries across the United States, covering ∼28% of the U.S. population.¹² We included patients who were diagnosed with stage IV NSCLC at ages 67 to 94 years who died between 2006 and 2012. Patients must have been enrolled in fee-for-service Medicare Parts A and B continuously from two years before diagnosis until death.

Outcomes

The primary outcome, end-of-life aggressive care receipt within the last 30 days of life, was defined as the exposure to any of the following five types of care: intravenous chemotherapy, ICU admission, mechanical ventilation, CPR, or >1 inpatient admission (see Appendix). Chemotherapy use for both cohorts was defined using claims for administration of intravenous chemotherapy. ICU admission was defined as any identification of an ICU as the location of care. For the VHA sample, hospice care use was defined as any inpatient or outpatient hospice service claims in the VHA care files, VHA fee basis file, or Medicare hospice benefit claims files.

Statistical analysis

The demographic, clinical, and cancer-specific characteristics of the veteran and Medicare decedents and their exposure to the six aggressive care measures (intravenous chemotherapy, ICU admission, mechanical ventilation, CPR, >1 inpatient admission, or no-hospice use) were summarized using mean and standard deviation (SD), or frequency and percentages, as appropriate. To depict the overall trend of end-of-life care use within both the VHA and SEER-Medicare over time, we calculated prevalence proportions of each type of end-of-life care for each study year among all the decedents during that year, assuming a binomial distribution for these estimates. We compared aggregate rates of each aggressive care measure using descriptive statistics.

Results

Between 2006 and 2012, among the 18,371 Veterans and 25,180 Medicare beneficiaries, 64.8% versus 56.3% received at least one aggressive end-of-life measure, respectively (Table 1). The mean age of the VHA cohort was 67 years (SD 9.7 years) compared with 76 years (SD 6.3 years) in the SEER-Medicare cohort. The majority were male in the VHA cohort (98.3%) versus SEER-Medicare (52.7%). Geographic region and Black race also differed between the two groups (Table 1).

Table 1.

Description of VHA and Seer-Medicare Cohorts for Death Years 2006–2012

Cohort	VHA		SEER-Medicare
Total (N)	18,371		25,180
Age in years: mean and standard deviation	67.1	9.7	76.4	6.3

	n	%	n	%
Sex
Male	18,054	98.3	13,277	52.7
Female	317	1.7	11,903	47.3
Race
White	14,634	80.8	21,648	85.97
Black	3380	18.7	2175	8.64
Other	105	0.6	1357	5.39
Histology
Adenocarcinoma	6843	37.3	11,121	44.2
Squamous cell carcinoma	5402	29.4	5058	20.1
Other	6126	33.3	9001	35.7
Region
Midwest	4126	22.5	3400	13.5
Northeast	2213	12.1	5122	20.34
South	8329	45.3	7075	28.1
West	3090	16.8	9583	38.06
Not applicable	613	3.3	0	0
Comorbidity
0	6322	34.4	10,275	40.8
1	6655	36.2	7515	29.9
2	3475	18.9	4077	16.2
≥3	1919	10.5	3313	13.2
Aggressive care measure
Chemotherapy	2808	15.3	3660	14.5
ICU admission	1794	9.8	6361	25.3
CPR	89	0.5	526	2.1
Mechanical ventilation	1089	5.9	5516	21.9
>1 inpatient admission	665	3.6	3123	12.4
No hospice	11,347	61.8	9194	36.5
Number of aggressive measures
0 of 6	6464	35.19	11,017	43.8
1 of 6	5655	30.78	6066	24.1
2 of 6	3550	19.32	3781	15.0
3 of 6	1797	9.78	2789	11.1
4 of 6	712	3.88	1264	5.0
5 of 6	185	1.01	249	1.0
6 of 6	<10	0.04	14	0.1
1 or more	11,907	64.8	14,163	56.3

CPR, cardiopulmonary resuscitation; ICU, intensive care unit; SEER, Surveillance, Epidemiology, and End Results; VHA, Veterans Health Administration.

Both cohorts had significantly decreased rates of aggressive care over the study period (chi-squared p < 0.001, within each cohort). Aggressive care use within the VHA decreased from 46.0% to 31.0%, while it decreased from 41.9% to 38.0% in Medicare (15.0% vs. 3.8% decrease, respectively). The VHA had significantly lower rates of any aggressive care at the end of life compared with Medicare beneficiaries at each death year, except 2006 (chi-squared comparison of cohorts p < 0.05, Fig. 1a). In addition, the difference in the temporal trends in receipt of aggressive care was statistically significant between the VHA and Medicare populations (model p < 0.001 for both the five- and six-measure aggressive care outcomes). When evaluating the six-measure aggressive care outcome, in comparison to SEER-Medicare, VHA had a higher percentage of any aggressive care use throughout the study period, but aggressive care use decreased more within the VHA from 2006 to 2012 (12% for VHA vs. 9.5% SEER-Medicare, Fig. 1b).

FIG. 1.

(a, b) Percent of receipt of any aggressive care at the end of life for all five measures excluding no-hospice use and all six measures including no-hospice use within the last 30 days before death for the VHA and SM. SM, SEER-Medicare; SEER, Surveillance, Epidemiology, and End Results; VHA, Veterans Health Administration.

Throughout the study period, there were similar percentages of chemotherapy given in both cohorts, except for 2006. Overall, the VHA had significantly lower rates of CPR, mechanical ventilation, and ICU admissions compared with SEER-Medicare (p < 0.001, Fig. 2a–d). In contrast, patients in SEER-Medicare had significantly lower rates of multiple inpatient admissions (p < 0.001, Fig. 2e). Both groups had significant decreases in no-hospice use (less aggressive care); however, rates were lower in the SEER-Medicare cohort (Fig. 2f).

FIG. 2.

Percentage of decedents receiving each aggressive care measure within the last 30 days before death by care setting. (a) Chemotherapy; (b) cardiopulmonary resuscitation; (c) mechanical ventilation; (d) intensive care unit admission; (e) >1 inpatient admission; (f) no hospice use.

At the HRR level, there was a significant inverse association between the percentage of hospice admissions among Medicare beneficiaries and the receipt of aggressive care at the end of life for Veterans in the same regions (p < 0.001). More specifically, as the percentage of hospice admissions in a Medicare HRR increased, the receipt of aggressive care at the end of life for Veterans receiving care in the matched VHA facility decreased (adjusted odds ratio [aOR]: 0.13, 95% confidence interval [CI]: 0.08–0.23, p < 0.001). Per $1,000 increase in Medicare HRR spending at the end of life, there was a nonsignificant increase in the odds of receiving aggressive care at the end of life within the matched VHA facility (aOR: 1.004, 95% CI: 1.00–1.009, p = 0.072, Table 2).

Table 2.

Patient-Level Analysis of Association between Total Hospital Referral Region, Medicare Spending (Per $1,000 Increase), and Aggressive Care Use among Hospital Referral Region-Matched Veterans Affairs Facilities VA (FC) for Years 2008–2012 (N = 13,723, Veterans Only)

Exposure	OR	95% CI		p	Note
End-of-life Medicare HRR spending per $1,000 increase	1.004	1.000	1.009	0.072	Adjusted for age, non-White race, female, 15 comorbidities
% Hospice admissions/Medicare HRR	0.131	0.077	0.225	<0.0001	Adjusted for age, non-White race, female, 15 comorbidities
HRR % in-hospital deaths	1.019	1.002	1.036	0.024	Adjusted for age, non-White race, female, 15 comorbidities

CI, confidence interval; HRR, hospital referral region; OR, odds ratio.

Limitations

The major limitation of this study is that cancer-directed treatments have advanced substantially since the data for this study were collected (2006–2012). The VHA cohort was younger and primarily of male sex with higher percentages in the South and Midwest regions as compared with the Medicare cohort. However, it documents aggressive care use at the end of life ahead of CMS' Innovation MCCM project, and demonstrates a trend in Medicare HRR spending that could be further explored and leveraged to improve the care of all patients at the end of life.

Discussion

During the study period, within the VHA, all other measures of aggressive care decreased precipitously more so than within the Medicare health system. This significant difference in the decline of aggressive care at the end of life may be due to the increase in concurrent care within the VHA but without a decrease in receipt of chemotherapy. Even though the rates of chemotherapy were similar, the rates of other types of aggressive care dropped more significantly in the VHA versus Medicare. Veterans and their families did not have to make “the terrible choice.” They may be benefiting from hospice and aggressive symptom management at home rather than visiting the Emergency Department or hospital due to uncontrolled symptoms. These results are similar to those detailed by Miller et al., but this brief report specifically focuses on participants with advanced lung cancer.¹³

We also found evidence supporting the hypothesis that regional contextual factors are associated with end-of-life care within VHA facilities. We found a relation between how Medicare patients are treated in a specific region (i.e., hospice use) and how VHA patients in the same region are treated at the end of life. This highlights the importance of regional practice style and resources for both health care systems, which makes sense as the VHA purchases hospice services from non-VHA health care systems. Specifically, the availability of hospice agencies and providers within a specific Medicare HRR is significantly associated with a decrease in aggressive care at the end of life within the VHA in the same region.

In conclusion, our findings suggest that increasing the availability of hospice care could further decrease aggressive care at the end of life, while the use of chemotherapy or novel treatments would remain the same or even decrease. Even though the use of cancer-directed treatment stayed the same, there was a continued decrease in other high-cost health care, such as emergency department (ED) visits and ICU admissions. Rates of multiple inpatient admissions and no-hospice use were higher in the VHA potentially due to admissions for inpatient hospice care within the VHA setting or because some hospice care is delivered by private hospice agencies but paid for by the VHA.

These findings need to be confirmed in newer VHA and SEER-Medicare data. With increased availability of hospice care, the health care system would be aligning with patient goals and through costing more upfront, could potentially save money through less aggressive care at the end of life.¹⁴ This attractive possibility stands in contrast to the Medicare system that has continued increases in aggressive care across all cancer decedents.^9,15 Improving access to hospice and palliative care during cancer-directed treatment at the end of life may further decrease receipt of aggressive care, resulting in a more compassionate treatment plan and a higher quality of life for patients and their caregivers.

Appendix. Definition of Aggressive Care Measures in Last 30 Days of Life in SEER-Medicare Cohort^*

	International Classification of Diseases 9th Revision Diagnosis Code	Procedure	Healthcare Common Procedure Coding System	Other
Chemotherapy	V07.39, V58.1, V58.11, V58.12, 999.81	99.25, 00.10, 00.15, 99.28	96401, 96402, 96405, 96406, 96408, 96409, 96410, 96411, 96412, 96413, 96414, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96445, 96446, 96450, 96520, 96521, 96522, 96523, 96530, 96542, 96545, 96549
Mechanical ventilation	518.5, 518.51, 518.53, 518.81, 518.83, 518.84, V44.0, V55.0, V46.13, V46.1, V46.11	96.04, 96.70, 96.71, 96.72, 31.1, 31.2, 31.21, 31.29
ICU admission				Any claim in the MedPAR file where either the ICU or coronary care indicator codes is not blank
No hospice				No claims in the Medicare Hospice file
>1 inpatient admission				Any claim in the MedPAR file not for SNF
CPR use			92950

^* Unless otherwise specified, measures were assessed using the following Medicare claims files: MedPAR, Outpatient Facility, Carrier, Hospice, Home Health Agency, Durable Medical Equipment.

Funding Information

The work for this project was funded by grants from the Veterans Affairs Robert Wood Johnson Foundation Clinical Scholar Program and the Yale Lung SPORE Career Development Award (P50CA196530). Dr. Carolyn Presley was a Paul Calabresi Scholar supported by the OSU K12 Training Grant for Clinical Faculty Investigators (K12 CA133250). Dr. Han and Mr. O'Leary were funded by National Institute of Aging Pepper Center Grant P30AG021342.

Author Disclosure Statement

Dr. Gross has received research funding from the NCCN Foundation (Pfizer/AstraZeneca) and Genentech through Yale University, funding from Johnson & Johnson to help devise and implement new approaches to sharing clinical trial data, and funding from Flatiron Inc., for travel to and speaking at a scientific conference.