Association of Palliative Care Use and Setting with Healthcare Utilization and Quality of Care at the End of Life Among Patients with Advanced Lung Cancer

Abstract Background Palliative care is associated with improved survival and quality of life among patients with lung cancer; however, its influence on healthcare utilization and quality of care is unclear. Research Question Is palliative care, and the setting in which it occurs, associated with healthcare resource utilization and quality of care among patients with advanced lung cancer? Study Design and Methods Retrospective cohort study of 23,142 patients with Stage IIIB/IV lung cancer in the VA HealthCare System between 2007-2013. Exposures included the receipt of specialist-delivered palliative care, and setting of the initial palliative care encounter (inpatient or outpatient) received after cancer diagnosis. Primary outcomes included rates of emergency department (ED) visits, along with rates of hospitalization and odds of ICU admission within the last 30 days of life. Secondary outcomes included any healthcare utilization (ED, hospital, or ICU) related to chemotherapy toxicity. We used propensity score methods to perform Poisson and logistic regression modeling. Results Among 23,142 patients, 57% received palliative care, and 36% of initial palliative care encounters were outpatient. Compared to no palliative care, initial palliative care encounter in the outpatient setting was associated with reduced rates of ED visits (aIRR=0.86, 95% CI:0.77-0.96) and hospitalizations in the last 30 days of life (aIRR=0.64, 95% CI:0.59-0.70). Initial palliative care encounters in both inpatient (aOR=0.63, 95% CI 0.53-0.75) and outpatient (aOR=0.42, 95% CI 0.35-0.52) settings were associated with reduced odds of ICU admission in the last 30 days of life. Palliative care was also associated with reduced healthcare utilization related to chemotherapy toxicity (aOR=0.88, 95% CI:0.82-0.95). Interpretation Palliative care (particularly in outpatient settings) is associated with reduced healthcare utilization at the end of life and may improve the quality of care among patients with advanced lung cancer. These findings support the role of palliative care as an important component of comprehensive cancer care and highlight the potential benefits of outpatient palliative care services.