Margolis Benjamin, Chen Ling, Accordino Melissa K, Clarke Hillyer Grace, Hou June Y, Tergas Ana I, Burke William M, Neugut Alfred I, Ananth Cande V, Hershman Dawn L, Wright Jason D
Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY.
Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY.
Am J Obstet Gynecol. 2017 Oct;217(4):434.e1-434.e10. doi: 10.1016/j.ajog.2017.07.006. Epub 2017 Jul 11.
High-intensity care including hospitalizations, chemotherapy, and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end-of-life care and resource utilization for women with uterine cancer.
We examined the costs and predictors of aggressive end-of-life care for women with uterine cancer.
In this observational cohort study the Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify women age ≥65 years who died from uterine cancer from 2000 through 2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission, or use of chemotherapy in the last 14 days of life was examined. High-intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high-intensity care. Total Medicare expenditures in the last month of life are reported.
Of the 5873 patients identified, the majority had stage IV cancer (30.2%), were white (79.9%), and had endometrioid tumors (47.6%). High-intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had ≥2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission, and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high-intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern United States, and more recent diagnosis were associated with high-intensity care. The median Medicare payment during the last month of life was $7645. Total per beneficiary Medicare payments remained stable from $9656 (interquartile range $3190-15,890) in 2000 to $9208 (interquartile range $3309-18,554) by 2011. The median health care expenditure was 4 times as high for those who received high-intensity care compared to those who did not (median $16,173 vs $4099).
Among women with uterine cancer, high-intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.
高强度的临终关怀，包括住院治疗、化疗以及其他干预措施，成本高昂，且对癌症患者往往价值不大。对于子宫癌女性患者的临终关怀模式和资源利用情况，人们了解甚少。
我们研究了子宫癌女性患者临终时积极治疗的成本及预测因素。
在这项观察性队列研究中，利用监测、流行病学及最终结果-医疗保险链接数据库，识别出2000年至2011年期间死于子宫癌的65岁及以上女性。对临终前一个月的资源利用情况进行了研究，包括至少2次住院、超过1次急诊就诊、至少1次重症监护病房入院，或在生命的最后14天内使用化疗。高强度关怀被定义为出现上述任何一种情况。建立逻辑回归模型以确定与高强度关怀相关的因素。报告了临终前一个月医疗保险的总支出。
在识别出的5873例患者中，大多数患有IV期癌症（30.2%），为白人（79.9%），且患有子宫内膜样肿瘤（47.6%）。42.5%的女性接受了高强度关怀。在生命的最后一个月，15.0%的患者至少住院2次，9.0%的患者住院时间超过14天，15.3%的患者急诊就诊超过1次，18.3%的患者入住重症监护病房，6.6%的患者在生命的最后14天接受了化疗。在研究期间，接受高强度关怀的女性比例保持稳定。年龄较小、黑人种族、合并症数量较多、IV期疾病、居住在美国东部以及诊断时间较近等特征与高强度关怀相关。临终前一个月医疗保险支付的中位数为7645美元。每位受益人的医疗保险总支付从2000年的9656美元（四分位间距3190 - 15890美元）稳定至2011年的9208美元（四分位间距3309 - 18554美元）。接受高强度关怀的患者的医疗保健支出中位数是未接受者的4倍（中位数分别为16173美元和4099美元）。
在子宫癌女性患者中，高强度关怀在生命的最后一个月很常见，伴随着大量的金钱支出，且似乎并未减少。
