John Z. Ayanian is site principal investigator on this project. Debby Collins is the project contact: 617-432-3467.

Concern has been raised about the “dramatic lack of data” on the quality of advanced cancer care. Our previous study identified the processes of overuse of chemotherapy, underuse of hospice services, and the outcomes of frequent emergency room visits, hospitalizations, and intensive care unit (ICU) admissions (possibly indicating misuse of aggressive intervention) near the end of life as potential quality indicators meriting further evaluation. Implementation in Medicare claims for older patients with terminal lung, breast, colorectal, and other gastrointestinal cancers found steadily increasing use of chemotherapy very near death over a four-year span in the mid-1990s, a trend that was also associated with a rise in potentially negative outcomes such as increased emergency room visits and ICU admissions, and delayed hospice admission.

In this study, we are further evaluating these quality-of-care indicators by expanding the analysis of determinants of aggressive practice to patients of different ages, insurance types, and diseases; evaluating the effect of aggressive care given near the end of life on outcomes such as survival, complications, site of death, and cost; and further validating the construct that overly aggressive care may be an indicator of poor-quality care.

Specifically, this project aims to:

• confirm that the associations and trends of aggressive end-of-life cancer care persist in patients with different types of cancer, patients with longer disease courses, and patients dying more recently;

• evaluate the following outcomes associated with aggressive care near death:

a) whether aggressive care is associated with improved survival through instrumental variable and propensity score analyses
b) describe the economic consequences of aggressive care on the total cancer-attributable costs of care
c) relate resource utilization to outcomes, dependent on the aggressiveness of care;

• further validate that the concepts of aggressive care, resultant complications, and lack of attention to hospice and palliative care can serve as quality-of-care indicators for end-of-life cancer care by using data collected as part of the CanCORS consortium linked to each patient’s Medicare claims to:

a) evaluate the reliability of measures by comparing claims-based measures from linked Medicare files with data from survey and chart review where possible
b) relate these claims-based measures to patient and family members’ evaluation of the quality of care and correlation with other measures of appropriate cancer care on survey
c) describe the patient, provider, and health system characteristics associated with aggressive anti-cancer treatment near the end of life.