How might VA-Medicare differences inform the delivery of end-of-life cancer care?†

In this issue of Cancer, Keating et al evaluated differences in the use of aggressive medical interventions during the last 30 days of life between elderly patients with metastatic lung or colorectal cancer treated in the Veterans Health Administration (VHA) medical system or under fee-for-service Medicare. By using propensity score matching to control for differences in the patient populations, they compared receipt of chemotherapy within 14 days of death, intensive-care unit admissions within 30 days of death, and >1 emergency room visit within 30 days of death for 2913 male veterans who were diagnosed or received their initial course of treatment in the Department of Veterans Affairs (VA) and 2913 nonveterans by using linked VA-Medicare data (for veterans) and SEER-Medicare data (for nonveterans). Adjusted comparison found nonveterans more likely than veterans to receive chemotherapy within 14 days of death (7.5% vs 4.6%), more likely to be admitted to an intensive care unit (19.7% vs 12.5%), or to make more than 1 emergency room visit (14.7% vs 13.1%) in their last month of life. Although aggressive medical interventions may, at times, be indicated in patients with metastatic cancer, their use at the end of life raises concerns. Although much of the focus on high-intensity late-life care is about cost, such care also likely worsens symptom control and quality of life without improving survival. The multisite, prospective, longitudinal, Coping With Cancer cohort study focused on patients with advanced cancer and their informal caregivers. Among the 332 participants who died, investigators found that more aggressive medical care was associated with worse patient quality of life and higher risk of major depressive disorder in bereaved caregivers, whereas longer hospice stays were associated with better patient quality of life. Wright et al found lower rates of ventilation (1.6% vs 11.0%), resuscitation (0.8% vs 6.7%), and intensive-care unit admission (4.1% vs 12.4%), as well as earlier hospice enrollment (65.6% vs 44.5%) among patients who reported having end-of-life discussions. In the larger cohort of 603 patients, baseline end-of-life discussions were also associated with one-third lower overall costs. 2,3 Although the Keating et al study does not elucidate the reasons for the differences it observed, the authors offer several possible explanations. They suggest that 1 critical difference between VA and fee-for-service Medicare is the absence in VA services of financial incentives that reward providers for providing high-cost aggressive interventions when patients and families may be better served by quality-of-life–focused care. In addition, better end-of-life care may be fostered by the VA’s integrated delivery system, which is tied together with an electronic medical record, and includes comprehensive services delivered in community clinics, long-term care, and hospitals. Furthermore, perhaps veterans who tend to be sicker and more disabled than the general population are more predisposed than nonveterans to limit aggressive care when they are nearing the end of life. In support of these hypotheses, the VA differs from the Medicare environment in important ways. For one, hospitals, physicians, and patients face different, complex, financial incentives in the 2 systems, although the manner and extent to which they may influence end-of-life care have not been examined. Under fee-for-service Medicare, hospitals typically function as third-party purchasers, and Medicare’s physician incentives to restrict care are limited, although costs to