Hospice Utilization Among Elderly Patients With Brain Metastases

Abstract

Purpose: Brain metastases are associated with significant morbidity and mortality. Integration of hospice services at the end of life offers patients symptom relief and improves quality of life, particularly for elderly patients who are less able to tolerate brain-directed therapy. Population-level investigations of hospice utilization among elderly patients with brain metastases are limited. The purpose of the current study is to use the Surveillance, Epidemiology and End Results (SEER)-Medicare database to identify the incidence, timing and predictors of hospice utilization among elderly patients with brain metastases. Methods: Using the SEER-Medicare database for primary cancer sites that commonly metastasize to the brain (lung cancer, melanoma, breast cancer, renal cancer, colorectal cancer, esophageal cancer, ovarian cancer and testicular cancer), we identified 50,148 patients (age ≥ 66 years) diagnosed with brain metastases between 2005-2016. The primary outcome was hospice enrollment (yes versus no). As a subset analysis, we determined the percentage of cases for whom hospice was initiated < 7 days prior to death. We used multivariable logistic regression to identify sociodemographic, clinical and hospital-related predictors of incidence and timing of hospice enrollment. Results: The incidence of hospice enrollment was 71.4% (95%CI 71.0-71.9, p <0.001), a rate which increased over the study period (p <0.001). The odds of enrollment for black (OR 0.76, 95%CI 0.71-0.82, p <0.001), Hispanic (OR 0.80, 95%CI 0.72-0.87, p <0.001) and Asian patients (OR 0.52, 95%CI 0.48-0.57, p <0.001) were substantially lower than white patients; males were less likely to be enrolled in hospice than females (OR 0.78, 95%CI 0.74-0.81, p <0.001). Among patients enrolled in hospice, 32.6% (95%CI 32.1-33.1, p <0.001) were enrolled <7 days prior to death, a rate which was stable over the study period. Conclusions: Hospice is utilized for a majority of elderly patients with brain metastases although a significant percentage of patients die without hospice services. Many patients enroll in hospice late, and significant sociodemographic disparities exist in hospice utilization. Further investigations to facilitate targeted interventions addressing such disparities are warranted.