Predictors of high-intensity care at the end of life among older adults with solid tumors: A population-based study

Courtney E Baird; Elizabeth Wulff-Burchfield; Pamela C Egan; Lee A Hugar; Ami Vyas; Nikolaos A Trikalinos; Michael A Liu; Emmanuelle Bélanger; Adam J Olszewski; Leonidas E Bantis; Orestis A Panagiotou

doi:10.1016/j.jgo.2024.101774

Predictors of high-intensity care at the end of life among older adults with solid tumors: A population-based study

J Geriatr Oncol. 2024 Apr 26;15(5):101774. doi: 10.1016/j.jgo.2024.101774. Online ahead of print.

Affiliations

¹ Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA. Electronic address: courtney_baird@brown.edu.
² Medical Oncology Division and Palliative Medicine Division, Department of Internal Medicine, University of Kansas School of Medicine, University of Kansas Cancer Center, The University of Kansas Health System, Kansas City, KS, USA.
³ Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
⁴ Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
⁵ University of Rhode Island, College of Pharmacy, Department of Pharmacy Practice, Kingston, RI, USA.
⁶ Division of Oncology, Department of Medicine, Washington University Medical School Campus, St. Louis, MO, USA; Siteman Cancer Center, St. Louis, MO, USA.
⁷ Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA.
⁸ Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA.
⁹ Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, KS, USA.

PMID: 38676975
DOI: 10.1016/j.jgo.2024.101774

Abstract

Introduction: High-intensity end-of-life (EoL) care can be burdensome for patients, caregivers, and health systems and does not confer any meaningful clinical benefit. Yet, there are significant knowledge gaps regarding the predictors of high-intensity EoL care. In this study, we identify risk factors associated with high-intensity EoL care among older adults with the four most common malignancies, including breast, prostate, lung, and colorectal cancer.

Materials and methods: Using SEER-Medicare data, we conducted a retrospective analysis of Medicare beneficiaries aged 65 and older who died of breast, prostate, lung, or colorectal cancer between 2011 and 2015. We used multivariable logistic regression to identify clinical, demographic, socioeconomic, and geographic predictors of high-intensity EoL care, which we defined as death in an acute care hospital, receipt of any oral or parenteral chemotherapy within 14 days of death, one or more admissions to the intensive care unit within 30 days of death, two or more emergency department visits within 30 days of death, or two or more inpatient admissions within 30 days of death.

Results: Among 59,355 decedents, factors associated with increased likelihood of receiving high-intensity EoL care were increased comorbidity burden (odds ratio [OR]:1.29; 95% confidence interval [CI]:1.28-1.30), female sex (OR:1.05; 95% CI:1.01-1.09), Black race (OR:1.14; 95% CI:1.07-1.23), Other race/ethnicity (OR:1.20; 95% CI:1.10-1.30), stage III disease (OR:1.11; 95% CI:1.05-1.18), living in a county with >1,000,000 people (OR:1.23; 95% CI:1.16-1.31), living in a census tract with 10%-<20% poverty (OR:1.09; 95% CI:1.03-1.16) or 20%-100% poverty (OR:1.12; 95% CI:1.04-1.19), and having state-subsidized Medicare premiums (OR:1.18; 95% CI:1.12-1.24). The risk of high-intensity EoL care was lower among patients who were older (OR:0.98; 95% CI:0.98-0.99), lived in the Midwest (OR:0.69; 95% CI:0.65-0.75), South (OR:0.70; 95% CI:0.65-0.74), or West (OR:0.81; 95% CI:0.77-0.86), lived in mostly rural areas (OR:0.92; 95% CI:0.86-1.00), and had poor performance status (OR:0.26; 95% CI:0.25-0.28). Results were largely consistent across cancer types.

Discussion: The risk factors identified in our study can inform the development of new interventions for patients with cancer who are likely to receive high-intensity EoL care. Health systems should consider incorporating these risk factors into decision-support tools to assist clinicians in identifying which patients should be referred to hospice and palliative care.

Keywords: Breast cancer; Gastrointestinal cancer; Geriatric oncology; Lung cancer; Palliative care; Prostate cancer.