Project Impact: This project evaluates the value of specific types of medical care provided in the last four weeks of life to Veterans dying of cancer, using a patient-centered perspective. The VA's top goals, as stated in the Blueprint for Excellence, are to deliver personalized, proactive, and patient-driven healthcare and to deliver high-value care. However, it is not currently clear at the end of life, what particular types of services are undesirable and low-value from a patient/family perspective, and importantly, whether desires for end-of-life care differ across socio-demographic groups (e.g., based on rural status, homelessness, marital status). In the last four weeks of life, it is important that patients receive high-quality, preference-concordant care that prioritizes symptom management and quality-of-life enhancing treatments over intensive medical services. This project will provide actionable information to VA managers to improve the end-of-life care experience for the more than 21,000 Veterans who die each year with advanced cancer, while also improving the value of care. For example, our results may indicate chemotherapy in the last 14 days of life is high cost, has a small positive impact on patient-centered outcomes, and occurs at low frequency. They may also indicate, for example, that ICU stay in the last month of life is high cost, has a large negative effect on patient-centerd outcomes, and occurs with high frequency. These results would indicate that to improve the value and the patient experience of end-of-life care, VA should prioritize reducing unnecessary ICU admissions over reducing unnecessary chemotherapy. Background: The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) have categorized certain services as unduly intensive at the end of life. These are: chemotherapy in the last 14 days of life; intensive care unit (ICU) admission in the last 30 days of life; more than 1 Emergency Department (ED) visit in the last 30 days of life; not admitted to hospice; and admitted to hospice for less than 3 days. There is strong agreement in the oncology and quality-of-care communities these services are inappropriate and avoidable, and represent a failure to provide appropriate palliative and supportive care to patients. Objective: While the medical community has come to strong consensus as to what constitutes unduly intensive care at the end-of-life, we evaluate whether patients and families have the same perceptions of these services. Specifically, we evaluate the value of these intensive end-of-life services, using a patient-centered perspective. We also evaluate any disparities that may exist in the receipt of these services by Veteran priority status, race, sex, age, marital status, homelessness, or rural status. Methods: In healthcare, value indicates an achievement of outcomes proportional to the resources spent to achieve them. We therefore examine the value of specific end-of-life services through analyses of administrative data regarding processes of and cost of care at the end of life combined with patient-centered outcomes obtained from the Bereaved Family Survey. Our study will produce a value quadrant, similar to that seen in cost-effectiveness analyses. This value quadrant will indicate which intensive services have: a) a large impact on costs and a large impact on outcomes; b) a large impact on costs and a small impact on outcomes; c) a small impact on costs and a small impact on outcomes; and d) a small impact on costs and a large impact on outcomes. Our results will also indicate the frequency with which each intensive service occurs in VA. This information regarding the value of end-of-life care represents an entirely new contribution to the literature.
The American Society of Clinical Oncology (ASCO), the National Quality Forum (NQF) and the Institute of Medicine (IOM) have all recommended a reduction in use of intensive medical services at end of life, noting these services are at odds with the focus on quality of life and pain and symptom management that would most benefit patients in their last days. While the medical community has come to strong consensus as to what constitutes unduly intensive care at the end-of-life, we evaluate whether Veterans and families have the same perceptions of these ASCO- and NQF-defined intensive services. Specifically, we evaluate the value of these intensive services provided in the last 30 days of life, using a Veteran-centered perspective. We also examine any socio-demographic disparities that exist in receipt of end-of-life care, particularly around homelessness or rurality. Results are highly actionable to our operational partners and can be directly used to improve the provision of high-value, preference-concordant end of life care to Veterans dying of cancer.
