Patterns, resource impact, and disparities in low value care during terminal hospitalizations for lung cancer: A national analysis (2016-2019).

Abstract

e23228 Background: High-intensity interventions near the end of life, including invasive mechanical ventilation (IMV) and inpatient antitumor therapy, may offer limited benefit for patients with advanced lung cancer while contributing substantially to resource use. National patterns of these practices during terminal hospitalization and their associated disparities remain poorly characterized. Methods: We conducted a retrospective cohort study using the 2016-2019 Nationwide Inpatient Sample. Adults (≥18 years) who died during a hospitalization with a lung cancer diagnosis were included. Exposures were the receipt of IMV and/or inpatient antitumor therapy (chemotherapy, immunotherapy, or radiation), categorized into four mutually exclusive patterns: Neither, IMV only, Antitumor only, Both. Survey-weighted linear and logistic regression models were used, adjusting for age, sex, race, insurance, income quartile, hospital region, hospital location and teaching status (urban or rural, teaching or not), and year. Missing data were limited and analyses were conducted using complete cases. Sensitivity analyses added a proxy for clinical complexity (number of diagnosis codes). A study protocol was developed before implementation and reviewed by the Duke Health Institutional Review Board with a waiver of consent. Results: Among 28,127 lung cancer patients who had terminal hospitalization, 31.4% of patients received IMV only, 2.1% received inpatient antitumor therapy only, and 1.2% received both interventions. Compared with patients who received neither intervention, receiving inpatient antitumor therapy was associated with a longer adjusted length of stay, with an increase of 9.14 days for antitumor therapy alone (95% CI, 8.13-10.15; P < 0.001) and 11.40 days for combined IMV and antitumor therapy (95% CI, 9.63-13.17; P < 0.001). Adjusted hospital charges were 3.41 times higher among patients receiving antitumor therapy alone and 5.42 times higher among those receiving both interventions (P < 0.001). Disparities were observed by race and insurance status, with Medicaid patients experiencing the longest adjusted stays and Medicare patients incurring the highest charges. Findings were robust in sensitivity analyses accounting for clinical complexity. Conclusions: Invasive mechanical ventilation and inpatient antitumor therapy are commonly used during terminal hospitalization for lung cancer and are associated with substantially prolonged hospitalization and higher costs. Significant disparities in these low-value care procedures were associated with race and insurance status. Our findings highlight the need for value-based strategies to promote more appropriate use of end-of-life care.