Multiple chronic conditions and intensity of end-of-life care among patients with cancer.

Abstract

47 Background: Multiple chronic conditions (MCCs) are associated with increased intensity of end-of-life (EOL) care in many conditions but their effect has not been well explored in patients with cancer. We examined intensity of EOL care and advance care planning (ACP) by patients with cancer and MCCs versus those without MCCs to better understand how MCCs affect EOL healthcare use in this population. Methods: Our sample included patients with cancer in the UW Medicine system who died between 2010-2017. MCCs were defined using the Dartmouth Atlas of Healthcare for the most common categories of severe illness in the last two years of life. These included chronic pulmonary disease, coronary artery disease (CAD), heart failure, severe chronic liver disease, chronic renal disease, dementia, diabetes with end organ damage, or peripheral vascular disease. Patients were categorized as having none or 1+ MCCs. We used a claims-based indicator for the presence of functional limitation. Outcomes included ACP documentation in the electronic health record, death in hospital, and inpatient or ICU admission in the last month of life. We performed logistic regression for all outcomes controlling for confounders defined a priori (age at death, race, sex, marital status, insurance, education, functional limitation). Results: Of 15,092 patients with cancer, 10,596 (70%) had 1+MCCs (range 1-8 MCCs). Common MCCs were pulmonary (25%), CAD (23%), and renal (18%). Those with MCCs were older (median 66 years (range 18-104) vs 63 years (range 18-102)), with more functional limitations (65% vs 43%). Those with 1+ MCC had more ACP documentation (43% vs. 23%) compared to those with no MCCs. Patients with 1+ MCC were more likely to die in hospital (OR 1.86, 95% CI 1.72-2.02) and to have inpatient (OR 2.45, 95% CI 2.20-2.72) or ICU admissions (OR 2.95, 95% CI 2.55-3.42) in their last 30 days versus patients with cancer and no MCCs. Conclusions: Among patients with cancer in a single healthcare system, patients with cancer and MCCs were more likely to have ACP documentation, die in hospital and experience high-intensity hospital-based care at or near EOL. Further research is needed to explore if such high-intensity care is aligned with patient and family goals for care.