Palliative care as a component of high-value and cost-saving care during hospitalization for metastatic cancer.
Authors: Lu Sifan , Rakovitch Eileen , Hannon Breffni , Zimmermann Camilla , Yan Michael , de Almeida John R , Yao Christopher , Gillespie Erin F. , Chino Fumiko , Yerramilli Divya , Abdel-Rahman Fadwa , Othman Hiba , Mheid Sara , Tsai Chiaojung Jillian 
Published: June 2023

6640

Background: Randomized controlled trials have demonstrated that palliative care can improve both quality of life and survival for outpatients with advanced cancer, but there is limited population-based data on the value of inpatient palliative care. We assessed palliative care as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer. We further identified care, patient, and hospital characteristics significantly associated with high costs. Methods: This study analyzed hospitalizations of patients ≥18 years with a primary diagnosis of metastatic cancer from the National Inpatient Sample (covering 97% of the U.S. population) from 2010-2019. We utilized multivariable mixed-effects logistic regression to assess medical services (receipt of palliative care, invasive medical ventilation [IMV], systemic therapy), patient demographics, and hospital characteristics that were associated with higher charges billed to insurance and hospital costs. We utilized generalized linear mixed-effects models to determine cost savings associated with provision of palliative care. Results: Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in 2010 to $56,098 in 2019, while the median hospital cost remained stable at $14,300. Receipt of inpatient palliative care was associated with significantly lower charges (Odds Ratio [OR], 0.62; 95% CI, 0.61-0.64; P < .001) and costs (OR, 0.59; 95%CI, 0.58-0.61; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), and young age (18-49 years, P < .001). For-profit hospitals were more likely to bill higher charges (OR, 5.05; 95%CI, 4.78-5.33, P < .001) but less likely to incur high hospital costs (OR, 0.51; 95%CI, 0.48-0.54, P < .001) than public hospitals. In adjusted generalized linear mixed effects regression, palliative care provision was associated with a $1,293 (-13.4%, P < .001) reduction in costs per hospitalization compared to no palliative care, independent of receipt of invasive care and age. Significant interactions were observed between receipt of palliative care and patient age group (-9.6% for 18-49 years; -14.7% for ≥70 years), receipt of IMV (-6.4% for IMV receipt; -14.0% for no IMV), hospital ownership (-19.6% for for-profit; -10.5% for public), and year of hospitalization (-15.4% for 2010; -8.9% for 2019). Conclusions: Inpatient palliative care is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Assuming inpatient palliative care receipt increases by 50%, we estimate $4,045,000 in annual national savings. Integration of inpatient palliative care may de-escalate costs incurred through low-value inpatient interventions.