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Care in the Months before Death and Hospice Enrollment Among Older Women with Advanced Breast Cancer

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Abstract

Background

Variations in hospice use are not well understood.

Objective

Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment.

Design/setting

Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results—Medicare database.

Patients

There were 4,455 women aged ≥65 diagnosed with stage III/IV breast cancer during 1992–1999 who died before the end of 2001.

Measurements

Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death.

Results

Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1–7 days, 46% if 8–20 days, 35% if ≥21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P ≥ 0.10).

Discussion

Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals.

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Acknowledgements

This study was funded by a Clinical Scientist Development Award from the Doris Duke Charitable Foundation.

This study used the linked SEER—Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER—Medicare database.

The authors thank Laurie Meneades, M.S., for expert programming assistance.

Conflict of Interest Statement

Dr. Ayanian is a consultant to Research Triangle Institute and DxCG, Inc. on the development of DCG risk adjustment models. None of the other authors have any potential conflicts of interest to report.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Nancy L. Keating MD, MPH & John Z. Ayanian MD, MPP

  2. Department of Health Care Policy, Harvard Medical School, Boston, MA, USA

    Nancy L. Keating MD, MPH, Mary Beth Landrum PhD, Edward Guadagnoli PhD & John Z. Ayanian MD, MPP

  3. Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Eric P. Winer MD

Authors
  1. Nancy L. Keating MD, MPH
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  2. Mary Beth Landrum PhD
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  3. Edward Guadagnoli PhD
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  4. Eric P. Winer MD
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  5. John Z. Ayanian MD, MPP
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Corresponding author

Correspondence to Nancy L. Keating MD, MPH.

Additional information

This study was funded by a Clinical Scientist Development Award to Dr. Keating from the Doris Duke Charitable Foundation. Dr. Ayanian is a consultant to Research Triangle Institute and DxCG, Inc. on the development of DCG risk adjustment models. The study was presented on April 26, 2007 at the 30th Annual Meeting of the Society of General Internal Medicine, Toronto, Ontario, Canada.

Appendix

Appendix

Current Procedure Technology codes used for identifying outpatient visits include codes 99201–99205, 99211–99215, 99241–99245, 99381–99387, 99391–99397, 99401–99404, 99411–99412, 99420–99429, 99354–99360.

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Keating, N.L., Landrum, M.B., Guadagnoli, E. et al. Care in the Months before Death and Hospice Enrollment Among Older Women with Advanced Breast Cancer. J GEN INTERN MED 23, 11–18 (2008). https://doi.org/10.1007/s11606-007-0422-y

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  • DOI: https://doi.org/10.1007/s11606-007-0422-y

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