Hospice or Hospital: The Costs of Dying of Cancer in the Oncology Care Model.

Background: End-of-life management is a difficult aspect of cancer care. With the oncology care model (OCM), we have data to assess both clinical outcomes and total cost of care (TCOC). Objective: To measure and characterize the TCOC for those who received less than three days of hospice care (HC) at the end of life compared with those who received three days or more. Design: Assess data on costs and site and date of death from Medicare claims on patients identified in the OCM who received chemotherapy in the six months before death. Standard statistical methods were used to characterize both populations. Setting/Subjects: Subjects were Medicare patients with cancer who died while managed by U.S. oncology practices in the OCM. Measurements were TCOC in 30-day intervals for the last months of life, cost by site of care at the end of life, and demographic characteristics of the population and association with HC. Results: There were 7329 deaths. Dying in the hospital was twice the cost of dying at home under HC ($20,113 vs. $10,803). Of demographic groups measured, only black race and a lymphoma diagnosis had <50% hospice enrollment for three days or more before death. Conclusions: This study reinforces previous studies regarding costs in the last 30 days of life. The graphic representation highlights the dollar cost and the costs of lost opportunity. Using these data to improve communication, addressing socioeconomic support, and formal palliative care integration are potential strategies to improve care.

Improving incidence of code status documentation through process and discipline.

Documentation of a patient's preferred code status is a critical outcome of advance care planning. Although there is agreement that code status is valuable information, little progress has been made to increase the incidence of documented code status within the medical record in an outpatient setting. Incidence of code status documentation in the community oncology setting has not been studied. In April 2013, the US Oncology Network and McKesson Specialty Health launched a new advance care planning initiative for the purpose of promoting conversations between clinicians and patients regarding end-of-life care preferences. The program-My Choices, My Wishes-provides a systematic approach for learning about and documenting a patient's values and goals for care in the electronic health record. Code status documentation is one of several program performance measures. During the 14-month period from August 1, 2013, through September 30, 2014, collective sites participating in My Choices, My Wishes included discrete code status documentation within the medical record for 5,467 patients with metastatic disease. Although much work remains, early results show promise for improvement in incidence of code status documentation within health records in the outpatient setting.