Association of early completion of portable medical orders with inpatient costs at end-of-life for patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS).

Abstract

6645 Background: Patients with hematologic malignancies receive more aggressive care at end-of-life (EOL) compared to patients with solid tumors. Costs of care in patients with hematologic malignancies at EOL are high, particularly in the inpatient setting. We previously found that early completion of portable medical orders [termed medical orders for life sustaining treatment (MOLST) in New York state] is associated with less intense care at EOL for patients with AML and MDS. Thus, we hypothesized that early MOLST completion would also be associated with lower inpatient costs at EOL among patients with AML and MDS. Methods: We previously conducted a retrospective study of 358 adults patients with AML or MDS treated at Wilmot Cancer Institute and its affiliated sites who died between January 1, 2014, and December 31, 2019. Of these, 271 patients were eligible for cost analysis. Cost of inpatient care received at the University of Rochester Medical Center (URMC) within the last 30 days of life was obtained from our Finance Decision Support Department. Patients were excluded if inpatient costs at EOL were unavailable. Results: Mean age of patients was 69 years (N=271, range 20-95); 84% (n=227) of patients were hospitalized within 30 days of death. One-third (34%, n=93) of patients completed a MOLST early (>30 days prior to death) whereas 66% (n=178) either did not complete a MOLST or completed a MOLST late (less than or equal to 30 days prior to death). Mean and median inpatient cost of care for all patients at EOL was $39,284 and $19,703, respectively. The rate of hospitalization was lower for patients who completed a MOLST early vs late/never (73.1% vs 90.5%, respectively; p=0.0003), although there was no difference in the number of inpatient visits between the two groups (median=1 visit in both groups; p=0.23). In addition, median cost of inpatient care was lower for patients who completed a MOLST early vs late/never ($10,673 vs $23,177, respectively; p<0.0001). After adjusting for age, sex, and diagnosis, there was a trend toward lower EOL costs in patients completing a MOLST early (p=0.07). Conclusions: In patients with AML or MDS, early MOLST completion may be associated with lower inpatient costs at EOL. Viewing MOLST completion as a surrogate for a goals-of-care discussion, it follows that interventions aimed to increase the frequency of early goals-of-care discussions, advanced care planning, and MOLST completion are likely to improve quality of care and decrease costs at EOL in these patient populations.