Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer.
From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18).
Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care.
While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
This reflects the Hospice Election language: “The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment” .
Casarett D, Fishman J, Lu H, O’Dwyer P, Barg F, Naylor M et al (2009) The terrible choice: re-evaluating hospice eligibility criteria for cancer. J Clin Oncol 27:953–959. https://doi.org/10.1200/JCO.2008.17.8079
Casarett D (2011) Rethinking hospice eligibility criteria. JAMA 305:1031–1032. https://doi.org/10.1001/jama.2011.271
Lupu D, Ivanko B, Insana F, White P, Arnold R (2014) Hospice innovation impediments: can halfway efforts tame the terrible choice? J Palliat Med 17:1088–1090. https://doi.org/10.1089/jpm.2014.0268
Wright A, Katz I (2007) Letting go of the rope — aggressive treatment, hospice care, and open access. N Engl J Med 357:324–327. https://doi.org/10.1056/NEJMp078074
National Hospice and Palliative Care Organization (NHPCO) (2018) Facts and figures: hospice care in America. https://www.nhpco.org/sites/default/files/public/Statistics_Research/2017_Facts_Figures.pdf. Accessed 15 July 2018
Mor V, Teno J (2016) Regulating and paying for hospice and palliative care: reflections on the Medicare Hospice Benefit. J Health Polit Policy Law 41:697–716. https://doi.org/10.1215/03616878-3620893
Mor V, Joyce NR, Coté DL, Gidwani RA, Ersek M, Levy CR, Faricy-Anderson KE, Miller SC, Wagner TH, Kinosian BP, Lorenz KA, Shreve ST (2016) The rise of concurrent care for veterans with advanced cancer at the end of life. Cancer 122:782–790. https://doi.org/10.1002/cncr.29827
Harrison KL, Connor SR (2016) First Medicare demonstration of concurrent provision of curative and hospice services for end-of-life care. Am J Public Health 106:1405–1408. https://doi.org/10.2105/AJPH.2016.303238
U.S. Centers for Medicare & Medicaid Services (2015) Medicare care choices model enables concurrent palliative and curative care. J Pain Palliat Care Pharmacother 29:401–403. https://doi.org/10.3109/15360288.2015.1103358
Salz T, Brewer NT (2009) Offering chemotherapy and hospice jointly: one solution to hospice underuse. Med Decis Mak 29:521–531. https://doi.org/10.1177/0272989X09333123
Toy E, Macbeth F, Coles B, Melville A, Eastwood A (2003) Palliative thoracic radiotherapy for non-small-cell lung cancer: a systematic review. Am J Clin Oncol 26:112–120
Coy P, Schaafsma J, Schofield JA (2000) The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 48:1025–1033
Billingham LJ, Bathers S, Burton A, Bryan S, Cullen MH (2002) Patterns, costs and cost-effectiveness of care in a trial of chemotherapy for advanced non-small cell lung cancer. Lung Cancer 37:219–225
Dooms CA, Lievens YN, Vansteenkiste JF (2006) Cost-utility analysis of chemotherapy in symptomatic advanced nonsmall cell lung cancer. Eur Respir J 27:895–901. https://doi.org/10.1183/09031936.06.00102705
Rickerson E, Harrold J, Kapo J, Carroll JT, Casarett D (2005) Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better? J Am Geriatr Soc 53:819–823. https://doi.org/10.1111/j.1532-5415.2005.53259.x
Saito AM, Landrum MB, Neville BA, Ayanian JZ, Weeks JC, Earle CC (2011) Hospice care and survival among elderly patients with lung cancer. J Palliat Med 14:929–939. https://doi.org/10.1089/jpm.2010.0522
Sullivan DR, Ganzini L, Lapidus JA, Hansen L, Carney PA, Osborne ML, Fromme EK, Izumi S, Slatore CG (2018) Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system. Cancer 124:426–433. https://doi.org/10.1002/cncr.31047
Vig EK, Starks H, Taylor JS, Hopley EK, Fryer-Edwards K (2010) Why don’t patients enroll in hospice? Can we do anything about it? J Gen Intern Med 25:1009–1019. https://doi.org/10.1007/s11606-010-1423-9
Allison RD, Tong X, Moorman AC, Ly KN, Rupp L, Xu F, Gordon SC, Holmberg SD, Chronic Hepatitis Cohort Study (CHeCS) Investigators (2015) Increased incidence of cancer and cancer-related mortality among persons with chronic hepatitis C infection, 2006-2010. J Hepatol 63:822–828. https://doi.org/10.1016/j.jhep.2015.04.021
Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM (2014) Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 74:2913–2921. https://doi.org/10.1158/0008-5472.CAN-14-0155
Zullig LL, Sims KJ, McNeil R, Williams CD, Jackson GL, Provenzale D, Kelley MJ (2017) Cancer incidence among patients of the U.S. veterans affairs health care system: 2010 update. Mil Med 182:e1883–e1891. https://doi.org/10.7205/MILMED-D-16-00371
Pruchno R (2016) Veterans aging. Gerontologist 56:1–4. https://doi.org/10.1093/geront/gnv671
Bluethmann SM, Mariotto AB, Rowland JH (2016) Anticipating the “silver tsunami”: prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomark Prev 25:1029–1036. https://doi.org/10.1158/1055-9965.EPI-16-0133
Gidwani-Marszowski R, Needleman J, Mor V, Faricy-Anderson K, Boothroyd DB, Hsin G, Wagner TH, Lorenz KA, Patel MI, Joyce VR, Murrell SS, Ramchandran K, Asch SM (2018) Quality of end-of-life care is higher in the VA compared to care paid for by traditional Medicare. Health Aff 37:95–103. https://doi.org/10.1377/hlthaff.2017.0883
Ersek M, Miller SC, Wagner TH, Thorpe JM, Smith D, Levy CR, Gidwani R, Faricy-Anderson K, Lorenz KA, Kinosian B, Mor V (2017) Association between aggressive care and bereaved families’ evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer 123:3186–3194. https://doi.org/10.1002/cncr.30700
Hoffer Gittell J (2002) Coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects. Manag Sci 48:1408–1426. https://doi.org/10.1287/mnsc.48.11.1408.268
Gittell JH (2015) How interdependent parties build relational coordination to achieve their desired outcomes. Negot J 31:387–391. https://doi.org/10.1111/nejo.12114
Gittell JH (2015) Supervisory span, relational coordination, and flight departure performance: a reassessment of postbureaucracy theory. Organ Sci 12:468–483. https://doi.org/10.1017/CBO9781107415324.004
Havens DS, Vasey J, Gittell JH, Lin WT (2010) Relational coordination among nurses and other providers: impact on the quality of patient care. J Nurs Manag 18:926–937. https://doi.org/10.1111/j.1365-2834.2010.01138.x
Gittell JH, Weinberg D, Pfefferle S, Bishop C (2008) Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Hum Resour Manag J 18:154–170. https://doi.org/10.1111/j.1748-8583.2007.00063.x
Gittell JH, Godfrey M, Thistlethwaite J (2012) Interprofessional collaborative practice and relational coordination: improving healthcare through relationships. J Interprof Care 27:210–213. https://doi.org/10.3109/13561820.2012.730564
Creswell JW, Plano Clark VL (2011) Designing and conducting mixed methods research, 2nd edn. Sage, Thousand Oaks, CA
Polkinghorne D (2005) Language and meaning: data collection in qualitative research. J Couns Psychol 52:127–145
Creswell JW (2012) Qualitative inquiry and research design: choosing among five approaches, 3rd edition. Sage, Thousand Oaks, CA
Creswell JW (2014) Research design: qualitative, quantitative, and mixed methods approaches, 4th edition. Sage, Thousand Oaks, CA
Hesse-Biber S, Leavy PL (2010) The practice of qualitative research, second edition. Sage, Thousand Oaks, CA
Jones J, Nowels C, Sudore R, Ahuwalia S, Bekelman D (2015) The future as a series of transitions: qualitative study of heart failure patients and their informal caregivers. J Gen Intern Med 30(2):176–182. https://doi.org/10.1007/s11606-014-3085-5
Patton MQ (2014) Qualitative research & evaluation methods: integrating theory and practice, 4th edition. Sage, Thousand Oaks, CA
Morgan DL (2010) Reconsidering the role of interaction in analyzing and reporting focus groups. Qual Health Res 20:718–722. https://doi.org/10.1177/1049732310364627
Atlas.ti [computer program] Version 7.5.2. (2014) Archive for Technology, Lifeworld and Everyday Language. Berlin, Germany
Centers for Medicare & Medicaid Services (2015) Coverage of hospice services under hospital insurance. Medicare Benefit Policy Man. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf. Accessed 29 April 2018
Chabowski M, Polański J, Mazur G, Janczak D, Rosińczuk J (2017) Sociodemographic and clinical determinants of quality of life of patients with non-small cell lung cancer. Adv Exp Med Biol 1022:1–10. https://doi.org/10.1007/5584_2017_36
This research was funded by the Department of Veterans Affairs Health Services Research and Development grant number 11R 12-121.
We do not have a financial relationship with the funder, Department of Veterans Affairs Research and Development. This funding was in the form of a grant that was applied for and rewarded. We have full control of all primary data we collected ourselves and analyzed ourselves in this study, and we will allow the journal to review our data upon request.
Conflict of interest
The authors declare that they have no conflict of interest.
About this article
Cite this article
Haverhals, L.M., Manheim, C.E., Mor, V. et al. The experience of providing hospice care concurrent with cancer treatment in the VA. Support Care Cancer 27, 1263–1270 (2019). https://doi.org/10.1007/s00520-018-4552-z
- Concurrent care
- Palliative care