The impact of emergency general surgery on end-of-life care among older patients with metastatic cancer.

Abstract

56 Background: Despite high post-discharge mortality among older patients with metastatic cancer who undergo emergency general surgery (EGS), little is known about the impact of EGS on the type of end-of-life care received. We sought to examine the association between EGS and established markers of high intensity or poor quality end-of-life care for cancer patients. Methods: This retrospective cohort study used 2001-2013 Surveillance, Epidemiology, and End Results-Medicare to identify beneficiaries 65 years or older, diagnosed initially with stage IV cancer (lung, colorectal, breast, ovarian, pancreatic, or melanoma), who received one of the seven highest-burden EGS operations, and died within 180 days of surgery. Non-EGS controls were exact-matched by age, sex, race, cancer type, and cancer diagnosis date then assigned a pseudo-exposure date corresponding to the EGS date. Conditional logistic regression adjusting for region and Charlson score was performed among pairs discharged alive to compare location of death (facility or home/hospice), healthcare utilization (hospitalization, intensive care unit (ICU) stay, emergency department (ED) visit) in the last 30 days of life, and hospice use (death in hospice, hospice enrollment less than three days from death). Results: Among 1,129 matched pairs, EGS patients had higher odds of death in facility (OR [95% CI]: 1.29 [1.05 - 1.58]) as well as hospitalization (1.83 [1.54 - 2.18]), ICU stay (2.05 [1.66 - 2.53]) or ED visit (1.76 [1.47 - 2.10]) in the last 30 days of life compared to non-EGS patients. EGS patients had higher odds of dying in hospice (1.22 [1.02 - 1.45]), but also experienced higher odds of hospice enrollment less than three days from death (1.72 [1.20 - 2.46]). Conclusions: Older patients with metastatic cancer who survive EGS experienced higher intensity end-of-life care than similar non-EGS patients. Such EGS patients may benefit from targeted interventions during the emergent hospitalization to improve the end-of-life care received.