Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Program Number: B142
Session Name: Poster Session
Costs and healthcare utilization at the end of life for head and neck cancer patients: a population-based cohort study
Rui Fu, PhD1; Qing Li, MSc2; Noémie Villemure-Poliquin, MD, MSc1; Kelvin K.W. Chan, MD, MSC, PhD1; Irene Karam, MD1; Julie Hallet, MD, MSc1; Antoine Eskander, MD, ScM1; 1Sunnybrook Research Institute; 2Institute for Clinical and Evaluative Sciences (IC/ES)Importance: The most resource-intensive periods for cancer patients are the year following diagnosis and the last year of life. Individuals with head and neck cancer (HNC) face unique challenges at the end of life that may necessitate the use of aggressive interventions (tracheostomy/gastrostomy tubes) with profound but unclear economic implications to the healthcare system.
Objective:
1) To quantify the use of palliative care initiated at different time points and use of tracheostomy/gastrostomy tubes in last 12 months of life, 2) to assess the association between use of these services and monthly per-person cost incurred 6 months and 1 month preceding death from the perspective of a public healthcare payer.
Design: This was a population-based retrospective cohort study using linked administrative data on adult decedents with a diagnosis of HNC in Ontario, Canada. Primary exposure was a 6-level categorical variable combining the receipt status of palliative care (early [12 to 6 months before death], late [6 months before death], none) with tracheostomy use (yes/no) in last 12 months of life. Another 6-level categorial variable was created for palliative care+gastrostomy tube use as a secondary exposure. Separate multivariable negative binomial regression models were used to assess the cost association with the exposures.
Participants: Patients with a first-time diagnosis of HNC at age >=18 between January 1, 2007 and December 31, 2022 who later died from any cause before October 1, 2023 (n=11,135).
Main Outcomes: Mean monthly healthcare costs in last 6 months of life estimated using an established patient-level case-costing algorithm. Costs incurred in the last month of life and place of death were studied as secondary outcomes.
Results: Nearly 90% of the cohort used palliative care (36.8% early, 52.7% late) and 11% had a tube (11.6% tracheostomy, 11.1% gastrostomy) placed in last 12 months of life. Compared to patients who received neither palliative care nor tracheostomy, using a tracheostomy alone was associated with a larger cost increase in the last 6 months of life (RR 2.93, 95% CI 2.32-3.71) than using palliative care alone (early: RR 1.87, 95% CI 1.76-1.99; late: RR 2.07, 95% CI 1.95-2.19) or combining tracheostomy with early palliative care (RR 2.88, 95% CI 2.63-3.15). However, costs were highest for those who combined tracheostomy with late palliative care (RR 4.37, 95% CI 4.00-4.77). Similar results were concluded for gastrostomy tube and costs in last month of life.
Conclusions and Relevance: While receiving palliative care alone was associated with a modest increase in end-of-life costs, receiving a tube placement alone was associated with dramatic cost increases. For tube users, early initiation of palliative care may be able to attenuate the high cost. These findings call for more thoughtful considerations on tube placement for HNC patients with a limited life span and prioritization of early palliative care for those with the highest disease burden.
Figure Monthly per-person costs (log-transformed) in last 6 months of life among head and neck cancer patients by palliative care and tracheostomy (upper) and gastrostomy (lower) tube group
