Cancer patients treated by the Department of Veterans Affairs are less likely to receive excessive end-of-life interventions than those treated through Medicare, according to a study led by researchers at the Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System.
The study will be published online Jan. 8 in Health Affairs.
"The findings are not just important for veterans and VA policy, but for anybody who needs medical care at the end of life, which is a majority of us," said Risha Gidwani-Marszowski, DrPH, a consulting assistant professor of medicine at Stanford. "We as a society need to ensure we are setting up the organization of health care and its financial incentives to ensure that the services patients receive are the ones that are in their best interests at the end of life."
Gidwani-Marszowski, the lead author, is also a health economist at the VA Health Economics Resource Center. The senior author is Steven Asch, MD, professor of medicine at Stanford.
Many Americans say they would prefer to die at home and forgo intensive medical care at the end of their lives. Yet in the last month of life, many studies have shown that the use and cost of health care accelerates. Approximately 4 percent of the entire federal budget is spent on care for Medicare patients in their last year of life, according to some estimates.
In addition, changes are afoot at the VA. Several efforts, including the proposed Veterans Empowerment Act, would change the VA so that it mostly funds medical services, along the lines of Medicare, rather than providing all the care itself.
Those changes could expose veterans to any effects a Medicare-like funding approach has on end-of-life care, Gidwani-Marszowski said.
Testing a funding model
The researchers tested whether the way that care is organized affects the provision of end-of-life services for veterans dying of cancer. The study looked at 87,251 veterans older than 66 who had solid tumors and died between October 2009 and September 2014.
The researchers based the analysis of care quality on guidelines developed by the American Society of Clinical Oncology and the National Quality Forum, as well as on research that has shown patients consider some services undesirable or burdensome at the end of life. Specific criteria included whether patients received chemotherapy; whether they had two or more emergency department visits; whether they were admitted to the hospital and, if so, how many days they spent there; whether they died in the hospital; and whether they were admitted to intensive care. In the study, higher numbers of veterans receiving these services indicates lower quality of care.
The researchers then compared the use of these services by veterans with cancer who used VA health care with veterans with cancer who received their care through Medicare. More than 90 percent of older veterans are enrolled in Medicare as well as the VA, so the population that is eligible for both programs is ideal for evaluating differences in care due to health care system factors, Gidwani-Marszowski said. Researchers accounted for several characteristics that could affect which system veterans choose for care, including the distance they live from medical facilities, Gidwani-Marszowski said.
The study showed that Medicare patients were more likely to receive unduly intensive care at the end of life including chemotherapy, hospitalization, admission to the intensive care unit, longer stays in the hospital and death in the hospital than those who received care through the VA.
Gidwani-Marszowski said the study's findings that Medicare patients receive lower-quality, higher-intensity end-of-life care make sense given the different financial incentives of the two systems. VA physicians are salaried, while Medicare-funded physicians bill according to the services provided, which is known as fee for service. Therefore, additional services provided through Medicare generate funds for physicians and health care organizations.
Emergency department use differs
The researchers also found that the VA patients were more likely than the Medicare patients to have two or more emergency department visits. One possible explanation, Gidwani-Marszowski said, is that extended hours or access to appointments are not available at all VA facilities and that veterans may instead need to go to the emergency department for their care. Another is that Medicare patients may be hospitalized for care that VA patients get in the emergency department.
"The VA has long been a leader in providing patient-centered care at the end of life," Asch said. "Our study showed that veterans can expect appropriately lower-intensity care as they face late-stage cancer at VA facilities. If they choose instead to use their Medicare benefits outside the VA, they are at greater risk of getting chemotherapy, hospitalization and other services that will likely not help them in their last days."
The work is an example of Stanford Medicine's focus on precision health, the goal of which is to anticipate and prevent disease in the healthy and precisely diagnose and treat disease in the ill.
The study's other Stanford authors are Todd Wagner, PhD, associate professor of surgery and director of the Health Economics Research Center at the VA Palo Alto; Karl Lorenz, MD, professor of medicine and section chief of the VA Palo Alto-Stanford Palliative Care Program; Manali Patel, MD, assistant professor of medicine; Kavitha Ramchandran, MD, clinical assistant professor of medicine; Derek Boothroyd, PhD, senior biostatistician; Gary Hsin, MD, clinical associate professor of medicine and director of the Hospice and Palliative Care Center at the VA Palo Alto; Samantha Murrell, research associate at the VA Palo Alto and Stanford surgical affiliate; and Vilija Joyce, research associate at VA Palo Alto.
Researchers at the University of California-Los Angeles and Brown University also contributed to the study.
The research was funded by the Department of Veterans Affairs Health Services Research and Development Program; and the VA Health Services Research and Development Service, VA Information Resource Center.
Stanford Health Policy and Stanford's Department of Medicine also supported the work.
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