Variation in hospital utilization of palliative interventions for patients with advanced gastrointestinal cancer near end of life

Abstract

Background: Patients with advanced gastrointestinal (GI) cancer often undergo noncurative interventions with palliative intent to relieve high symptom burden near end of life. Hospital-level variation in intervention utilization remains unclear.

Methods: National cohort study of 142 304 patients with stage III or IV GI cancer within the National Cancer Database (2004-2014) who died within 1-year of diagnosis. Hospitals were stratified by palliative intervention utilization (surgery, chemotherapy, radiation, pain management). Multivariable, multinomial regression evaluated the association between patient/hospital factors and palliative intervention utilization.

Results: Across 1322 hospitals, median hospital palliative intervention utilization was 12.0% [interquartile range: 0.0%-26.1%]. Utilization increased over time in all but lowest utilizing hospitals. Relative to lowest utilizing hospitals, factors associated with a lower likelihood of care at highest utilizing hospitals included: race (White [ref]; Black-Relative Risk Ratio [RRR] 0.81, 95% confidence interval [0.77-0.85]) and lower income (RRR 0.81 [0.78-0.84]). Factors associated with a higher likelihood included: lower education level (RRR 1.62 [1.55-1.69]) and hospital type (community program [ref]; comprehensive community-RRR 1.33 [1.26-1.41]; academic-RRR 1.88 [1.77-1.99]; integrated network-RRR 1.79 [1.66-1.93]).

Conclusion: Hospital variation in palliative intervention use is substantial and potentially associated with sociodemographic and hospital characteristics. Future work can examine how differences in hospital care processes translate to quantity/quality of life for cancer patients.

Keywords: end of life; gastrointestinal cancer; hospital variation; palliative.