Despite recommendations to the contrary, only about half of elderly patients with advanced cancer receive palliative care, according to new findings. Many of the patients who do receive it late in the course of their disease, as opposed to immediately after diagnosis, which is recommended in guidelines. The findings were published in the Journal of Palliative Medicine.

In addition, there are gaps between real-life practice and what is recommended when it comes to hospice care. And there are significant differences in hospice use between patients treated through the Department of Veterans Affairs (VA) system and those enrolled in Medicare.

“Palliative care and curative treatment can be provided concurrently, as is recommended by the American Society of Clinical Oncology.”

There is still confusion about palliative care, said lead author Risha Gidwani, DrPH, a health economist at the Veterans Affairs Palo Alto Health Economics Resource Center and consulting assistant professor of medicine at the Stanford University School of Medicine in California.

Palliative care and curative treatment can be provided concurrently, as is recommended by the American Society of Clinical Oncology, Dr Gidwani said. “It’s likely that patients’ lack of awareness of palliative care and provider misconceptions about use of palliative care are both contributing to low use,” she explained.

Most Exposed to Hospice/Palliative Care

Dr Gidwani and her colleagues conducted a retrospective analysis to gain understanding of “real-world” practice as far as the timing of palliative care, and to understand how the timing and duration of hospice care varies across Medicare, the VA system, and care purchased by the VA.

The study population consisted of 11,896 veterans 65 year and older who had cancer and died in 2012. The most common malignancies in the group were lung cancer (33.5%), prostate cancer (11.7%), and hematologic malignancies (10.2%). During the final 6 months of life, 85.6% of all veterans in the study had some exposure to hospice or palliative care.

Fewer than half the patients (43.7%) received chemotherapy or radiation, 58.5% received hospice care for at least the last 3 days of life, and 64.9% died while under hospice care. For about half the patients who received palliative care in the VA system, it began a median of 38 days before death (interquartile range [IQR], 13-94 days).

The timing of palliative care differed by cancer type (P < .001), ranging from a median of 54 days before death for prostate cancer (IQR, 19-121 days) to 27 days for hematologic malignancies (IQR, 9-86 days). For patients who received both treatment and palliative care, 46.1% received palliative care before their active cancer treatment ended; this was similar across cancer types (P = .262).

But the authors only looked at palliative care use in the VA system, not Medicare. Medicare was the largest payer of hospice care for veterans (61.2%), followed by the VA system (43.6%) and VA-purchased care (9.9%). Some patients received hospice care through multiple environments.

Entry into hospice care was slowest with the VA system and fastest with VA-purchased care. Patients in the VA system received hospice a median of 14 days before death; for those with VA-purchased care, it was a median of 28 days, and for Medicare beneficiaries, it was 16 days. VA providers can recommend that a veteran enroll in Medicare hospice, Dr Gidwani explained.

“While Medicare enrolls veterans earlier in hospice than does the VA, in comparing our work to existing literature, we see that veterans are getting better hospice care than nonveterans are through Medicare,” she said. “One cannot comment directly on palliative care because of the data availability problems for palliative care in Medicare datasets, but given the strong operational support VA has provided for palliative care, it is likely that VA far outperforms Medicare when it comes to palliative care.”

Finally, there were differences between systems as far as receiving active cancer treatment during hospice care. In this group, hospice started after treatment ended for 88.7% of Medicare patients, 81.5% of VA-purchased patients, and 68.2% of VA patients.

Therefore, a higher proportion of veterans who received hospice care directly from the VA were also being treated with active therapy. There is a great need to improve the access and timing of hospice care and to better integrate palliative care into standard oncology treatment, Dr Gidwani noted. Both provider and patient education campaigns would be useful to communicate the purpose and merit of palliative care.

“There is a not a lot in the published literature regarding why there is low use of palliative care,” she said. “I am actually conducting other research evaluating oncologists’ perceptions of the role of palliative care, and palliative care providers, in treating patients with advanced cancer.”

“That research is currently underway and will shed light on how to improve access to and timing of palliative care,” Dr Gidwani added.

Support for this research study was provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development.

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