Hospice, palliative care, and care experiences among Medicare beneficiaries with cancer.

Associations between illness burden and care experiences among Medicare beneficiaries before or after a cancer diagnosis

Medicare Advantage (MA) beneficiaries are increasingly enrolling in integrated MA plans. Legacy-integrated plans share unique features that may differ from newer integrated MA plans. It is unclear whether integrated and legacy-integrated MA plans are associated with a better beneficiary care experience compared with non-legacy-integrated and nonintegrated MA plans. To assess whether enrollment in integrated, legacy-integrated, non-legacy-integrated, and nonintegrated MA plans is associated with better beneficiary care experiences. This cross-sectional study included MA beneficiaries who responded to Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys conducted annually between 2015 and 2019. Data analysis was performed between October 1, 2023, and July 31, 2024. Medicare Advantage plan integration status, categorized as integrated, legacy-integrated, non-legacy-integrated, and nonintegrated. The CAHPS surveys assessed 9 care experience measures. To assess differences in care experience measures, mixed linear regression analyses were performed, adjusting for demographic characteristics, plan random effects, and state fixed effects. The sample consisted of 857 695 respondents. Their mean (SD) age was 72.6 (10.3) years, and 58.1% were women. A total of 12.7% of respondents were Black, 10.7% were Hispanic, and 71.0% were White. Compared with respondents in nonintegrated MA plans, respondents in integrated MA plans were younger (mean [SD] age, 72.7 [10.3] vs 72.2 [10.3] years, respectively) and were less likely to be Black (13.1% vs 11.2%, respectively), female (58.4% vs 57.2%, respectively), and partially dual eligible (8.7% vs 6.2%, respectively). Integrated MA plans were associated with meaningfully better mean ratings only of customer service (1.6 points [95% CI, 1.1-2.1]) and health plan (1.0 points [95% CI, 0.6-1.5]) compared with nonintegrated MA plans. Legacy-integrated MA plans were associated with meaningfully better mean ratings of drug plan (3.7 points [95% CI, 2.4-5.0]), health plan (3.1 points [95% CI, 1.7-4.5]), customer service (2.8 points [95% CI, 1.3-4.4]), getting appointments and care quickly (2.6 points [95% CI, 1.2-4.0]), health care quality (1.9 points [95% CI, 1.0-2.7]), physicians who communicate well (1.1 points [95% CI, 0.4-1.8]), and care coordination (1.1 points [95% CI, 0.4-1.9]) compared with nonintegrated MA plans. In this study, integrated MA plans were not associated with better beneficiary care experiences compared with nonintegrated MA plans. Legacy-integrated MA plans were associated with higher ratings on all care experience measures compared with both non-legacy-integrated and nonintegrated MA plans. Monitoring of integrated MA plans is needed to assess whether they are adding meaningful value to MA beneficiaries and to determine their effects on the health care system.

Although enrollment in both hospice care and Medicare Advantage (MA) have grown substantially, little is known about the quality of hospice care received by MA beneficiaries relative to traditional Medicare fee-for-service (FFS) beneficiaries. To compare hospice enrollment and the quality of hospices serving MA and FFS beneficiaries. This population-based cross-sectional study used Medicare enrollment and claims data from January 1, 2018, through December 31, 2019, and Hospice Quality Reporting Program (HQRP) data released between November 1, 2020, and August 30, 2022, to compare the probability of enrolling in hospice before death and the probability of using high- vs low-quality hospices between MA and FFS beneficiaries. Two sample populations were assessed: (1) all Medicare beneficiaries who died in 2018 or 2019, and (2) all Medicare hospice enrollees in 2018 and 2019, excluding beneficiaries with hospice use in 2017. Data were analyzed between April 1, 2023, and April 30, 2024. MA enrollment was assessed 6 months prior to death for decedents and in the month of hospice admission for hospice enrollees. MA beneficiaries were further classified by plan type: regular MA, special needs plan (SNP), and Medicare-Medicaid plan (MMP). For decedents, the outcome of interest was the prevalence of any hospice use in the last 6 months of life. For hospice enrollees, the outcome of interest was 9 HQRP measures of hospice quality. Data from 4 215 648 decedents (51.6% female; mean [SD] age, 80.1 [11.6] years) and 2 211 826 hospice enrollees (56.6% female; mean [SD] age, 82.4 [10.5] years) were included. In the decedent sample, beneficiaries enrolled in every type of MA plan were significantly more likely than beneficiaries enrolled in FFS to use hospice care in the last 6 months of life (regular MA beneficiaries were 3.4 percentage points more likely to use hospice; MA SNP beneficiaries, 2.4 percentage points; and MA MMP beneficiaries, 3.6 percentage points). Regular MA and FFS beneficiaries enrolled in hospices of similar quality. However, beneficiaries in SNPs and MMPs were significantly more likely than FFS beneficiaries to use hospices with inferior quality (eg, MA SNP beneficiaries were 4.3 [95% CI, 3.9-4.7] percentage points more likely to use a hospice with a low Consumer Assessment of Healthcare Providers and Systems (CAHPS) global rating, and MA MMP beneficiaries were 6.8 [95% CI, 6.0-7.7] percentage points more likely). When beneficiaries entered hospice from the same hospital or nursing home the results were attenuated: the MA SNP beneficiaries entering from the same hospital were 0.9 (95% CI, 0.5-1.4) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 3.8 (95% CI, 2.4-5.1) percentage points more likely; MA SNP beneficiaries entering from the same nursing home were 2.8 (95% CI, 2.3-3.3) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 1.9 (95% CI, 0.9-2.9) percentage points more likely. These results suggest that referral networks were an important mechanism of the hospice quality choice. These findings suggest that policymakers should consider policies for MA programs that incentivize referrals to high-quality hospices and approaches to educating beneficiaries on identifying high-quality hospice care.

Random survival forests using linked data to measure illness burden among individuals before or after a cancer diagnosis: Development and internal validation of the SEER-CAHPS illness burden index

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

80 Background: High-quality EOL care is critical for patients and families. However, little is known about factors influencing patient satisfaction with their healthcare near EOL. This study’s objective is to assess the role of characteristics of individuals with cancer near EOL on their ratings for medical care, health plans, and physicians. Methods: Retrospective analyses of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Survey linked to NCI’s Surveillance, Epidemiology, and End Results (SEER) Program. CAHPS collected Medicare beneficiaries’ ratings for overall care, physicians, health plans, and 5 composite scores of aspects of care; SEER provided data on cancer diagnosis and characteristics. The study included 5,102 Medicare beneficiaries diagnosed with cancer in SEER regions 1997-2011 who completed CAHPS following diagnosis and within one year before death. Logistic regression was used to examine associations of EOL patient characteristics with their ratings. Results: Self-reported very good or excellent (vs. poor) general health significantly (p < 0.05) predicted greater likelihood of higher ratings for all measures (ORs ranged 1.5 to 2.2). Very good/excellent mental health also predicted increased likelihood of higher ratings for all except one category (ORs 1.8 to 2.7). Other patient factors were significantly associated with a subset of ratings. For example, Hispanics (vs. Whites) were more likely to provide higher ratings for health plans (OR 1.5) and specialist physicians (OR 1.7) but lower ratings for getting needed care (OR 0.62). Fee-for-service (vs. Medicare Advantage) beneficiaries were more likely to provide higher ratings for health plans, getting needed care, and getting care quickly (ORs 1.4, 1.3, 1.6). Patient age, cancer site, and time since diagnosis had few or no significant associations with any measure. Conclusions: Among cancer patients near EOL, better self-reported general and mental health consistently predicted higher ratings. Fee-for-service Medicare patients provided higher ratings for several important categories. These results may help guide future research on interventions to improve the EOL experience among Medicare beneficiaries.

Patient Perceptions and Experiences of ESRD Care: Quality and Satisfaction

Disparities of Palliative Care Utilization in End-of-Life Hospitalized Patients with Leukemia: An Analysis of National Inpatient Sample Database

213 Background: Cancer survivors may have unique medical care needs due to chronic/late-occurring effects of cancer or cancer treatment. “Shared care,” survivorship care delivered by both oncologists and primary care providers (PCPs), may better address these needs. Little is known about outcomes for survivors receiving shared care vs. oncologist-led or PCP-led patterns of care. We compared patient reported experiences of care for survivors receiving oncologist-led, PCP-led, shared care, or other patterns of care. Methods: Analyses of SEER-CAHPS, a data resource linking NCI's Surveillance, Epidemiology, and End Results (SEER) registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. Individuals age ≥ 65 in SEER-CAHPS diagnosed 2000-2011 with breast, cervical, colorectal, lung, renal, or prostate cancer or hematologic malignancies who completed a Medicare CAHPS survey ≥ 18 months after diagnosis and were continuously enrolled in Medicare A & B ≥ 6 months before and 6 months after survey completion were included. CAHPS included ratings of Overall Care, Personal Doctor, Specialist Physician, Health Plan, and composite scores for Doctor Communication, Care Coordination, Getting Needed Care, Getting Care Quickly, and Getting Needed Drugs. Survivorship care patterns were identified using proportions of oncologist, PCP, and other physician encounters. Multivariable regressions examined associations between survivorship care patterns and CAHPS outcomes. Results: Among 10,132 survivors, 15% received Shared Care; 10% Oncologist-led; 33% PCP-led; and 42% Other. Compared with Shared Care, we found no significant differences in survivors' experience of care except for Getting Needed Drugs (lower for PCP-led and Other). Sensitivity analyses using different pattern of care definitions showed no associations between survivorship model and experience of care. Conclusions: Survivors’ experiences of care were similar for those in Shared Care vs. Oncologist-led, PCP-led, and Other patterns of care. Within the study’s limitations, these results do not indicate enhanced patient reported medical care experiences for survivors receiving shared care.

Cancer patients' care experiences encompass the range of interactions with the health care system and are an important indicator of care quality, which may influence survival outcomes. This study evaluates relationships between care experiences and survival using a large, nationally representative sample of cancer patients. We used linked SEER (Surveillance Epidemiology and End Results)-CAHPS (Consumer Assessment of Healthcare Providers and Systems) data to identify people diagnosed 8/2006-12/2013, focusing on 10 solid tumor cancer sites with the highest mortality rates among those > 65. CAHPS measures included 5 global ratings and 3 composite scores. We used survey-weighted Cox proportional hazard models comparing survival time for those who had lower (0-8) vs higher ratings (9-10) and lower (0-89) vs higher (90-100) composite scores, adjusting for case-mix and additional covariates. We identified 2,263 eligible people; 26% died by 5-year post-survey completion or end of follow-up (12/31/2017). We found lower Prescription Drug Plan (PDP) ratings were significantly associated with lower mortality (adjusted HR = 0.67, p = 0.03). Lower Getting Needed Care scores were also significantly associated with lower mortality (adjusted HR = 0.79, p = 0.04). For other care experience measures, general health status, cancer stage, and comorbidities were more predictive of survival (p < .05). Except for PDP and Getting Needed Care, survival was similar for those with worse versus better care experiences. Patients with poorer cancer prognoses may perceive better services from their drug plan and more responsive care from clinical providers compared to those with better prognoses. Further research is needed examining processes underlying perceptions of care experiences and survival.

59 Background: Liver cancer is the fourth cause of cancer death in the world. Hepatocellular carcinoma represents around 90% of all liver cancer, with an increase in incidence and a worsening survival rate over the years. Liver cirrhosis is the major risk factor for liver cancer development. Early involvement in palliative care/hospice care focusing on quality of life, is associated with improved physical and psychological symptoms and improvement in caregiver stress and bereavement. We examined as primary outcome the utilization and trend of palliative care (PC) among hospitalized patients with liver cancer and cirrhosis using the NIS. Methods: This is a retrospective study using NIS data from 2016 to 2021. We included patients aged 18 years or older who were admitted with a diagnosis of malignancy of the liver and the intrahepatic bile duct and who also had a diagnosis of fibrosis and cirrhosis of the liver. Patients who had a PC encounter during hospitalization were identified. The cohort was divided between patients with PC encounters and those without PC encounters. Cohorts were matched in a 1:1 ratio with no replacement using propensity scores. Total charges during hospitalization, length of stay (LOS), mortality, and disposition were measured as outcomes. Results: A total of 53,475 admissions with a diagnosis of liver malignancy and liver cirrhosis were identified. Of those, 20.8% had an encounter with a PC. The mean age of those with a PC encounter was 65.1 years (SD±7.86), while the mean age for those without was 64.5 years (SD±7.35). Sex and race were similar between both cohorts. Patients with PC encounters had a higher mean Elixhauser index (6.43 vs 5.58, p &lt; 0.001) than those without a PC encounter. Patients with PC encounters had lower total hospital charges ($70,988 vs $94,518, p &lt; 0.001), longer LOS (6.83 vs. 5.82 days, p &lt; 0.001), and higher odds of mortality (aOR 7.20, CI 5.56- 9.32, p &lt; 0.001) compared to those without a PC encounter. Patients with a PC encounter were more frequently discharged to a long-term facility (23.9% vs. 12.6%) or with home health care (36.1% vs. 18.4%) and less often had a routine hospital discharge (13.5% vs. 60.1%), compared to those without a PC encounter. Conclusions: This study highlights the impact of PC on patients hospitalized with liver malignancy and cirrhosis. Despite being underutilized, with only 20.8% of patients receiving PC, those who do experienced lower hospital charges, longer hospital stays, and higher in- hospital mortality. These findings suggest that PC focuses on symptom management and quality of life rather than extending life expectancy. Patients receiving PC are more frequently discharged to long-term care or home health care, indicating a shift towards supportive care. The results advocate for the broader and earlier integration of palliative care in treating liver cancer and cirrhosis to improve patient outcomes and support.

Palliative care (PC) use patterns may have changed in recent years due to increased adoption of telehealth and the availability of more advanced practice clinicians who specialize in PC delivery. To describe changes in the use of specialty PC during the last year of life among Medicare beneficiaries who had cancers with poor prognoses (cancers that commonly caused death, rare cancers with high mortality rates, or solid tumors with concurrent nonlymphatic metastases; hereinafter termed poor-prognosis cancers). This retrospective cohort study includes all US Medicare fee-for-service beneficiaries who died from poor-prognosis cancers between January 1, 2018, and December 31, 2023, and received care in hospital and outpatient settings. Encounters with a PC specialist. The primary outcome was the proportion of decedents with any specialty PC encounter in their last year of life. Secondary outcomes included mean number of PC encounters among decedents with at least 1 encounter with a PC specialist and telehealth use. PC specialists were clinicians who self-identified as a PC specialist or were clinicians with 80% or more of their Medicare encounters focused on PC. The cohort included 1 508 103 decedents (mean [SD] age, 79.6 [8.0] years; 54.6% male) with poor-prognosis cancers. Between 2018 and 2023, the proportion of decedents with at least 1 PC encounter increased from 29.84% to 37.21% (adjusted change, 7.21 [95% CI, 6.30-8.12] percentage points; relative change, 24.2%). The proportion who received outpatient PC increased from 10.66% to 20.56% (adjusted change, 9.41 [95% CI, 8.33-10.48] percentage points; relative change, 88.2%). In 2023, 22.84% of all decedents received PC from advanced practice clinicians vs 15.60% by self-designated PC physicians and 9.92% by other physicians. Telehealth was used for 18.2% of all outpatient palliative care encounters in 2023. Decedent characteristics associated with not receiving specialty PC included older age, lower income, and living in nonmetropolitan areas. In this cohort study of decedents who had poor-prognosis cancers, an increasing proportion received any specialty PC. Advanced practice specialists were the most common clinician type who delivered specialty PC, and telehealth was used for a substantial proportion of outpatient visits. Despite these changes, only a minority of patients received specialty PC, and low use of specialty PC among certain subpopulations persisted, suggesting that different strategies are needed to overcome these barriers.

Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters). This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245). Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64). This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

Despite guideline recommendations, evidence suggests many women with metastatic breast cancer (mBC) do not receive specialty palliative care services despite high morbidity burden. Given the varied prognoses and disease trajectories of women with mBC, relatively little is known about palliative care delivery in this growing population, including timing and frequency of visits, location (inpatient vs. outpatient), and reasons for referral. Using electronic health record and tumor registry data from a North Texas Comprehensive Cancer Center (2010-2023), we identified women who died with de novo or recurrent mBC. We examined receipt of palliative care (inpatient and outpatient), reasons for referral, and timing of palliative care encounters by duration of patient survival. We used multivariable logistic regression to assess associations between receipt of specialty palliative care and demographic, clinical, and survival characteristics. Among 265 women with mBC, 55.5% received no palliative care. Only women with short survival (< 18months) received palliative care within 8weeks of diagnosis. Most palliative care encounters were inpatient and occurred within ~ 1month of death. In adjusted models, comorbidities and younger age were strongly associated with receiving outpatient palliative care. Most women were referred to palliative care for multiple reasons, with long-term survivors more likely to be referred for goals of care discussions alone. Palliative care for women with mBC is infrequent and often late, with referrals seemingly driven by the imminence of death rather than metastatic diagnosis. Strategies to better identify and triage specialty palliative care needs and make timely referrals are needed.

Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients. We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis. A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients. Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer.