Predictors of in-hospital mortality and palliative care utilization in metastatic renal cell carcinoma: A nationwide analysis of 2018–2022 U.S. hospitalizations.

Abstract

e16567 Background: Despite transformative advances in systemic therapy, metastatic renal cell carcinoma (mRCC) remains associated with high symptom burden, frequent hospitalizations, and inpatient mortality. National data characterizing inpatient outcomes and palliative care utilization in the contemporary immunotherapy era are limited. We sought to identify patient, disease, and hospital-level predictors of in-hospital mortality and palliative care use to inform earlier, risk-aligned serious-illness care. Methods: We analyzed the 2018–2022 National Inpatient Sample to identify adult hospitalizations with renal cell carcinoma and documented metastatic disease. Survey-weighted analyses generated nationally representative estimates. The primary outcome was in-hospital mortality; secondary outcomes included palliative care consultation, length of stay (LOS), and total hospital charges. Multivariable survey-weighted logistic regression models evaluated independent predictors of mortality and palliative care utilization, adjusting for demographics, socioeconomic status, hospital characteristics, comorbidities, acute complications, and metastatic sites. Results: We identified an estimated 24,570 weighted hospitalizations for mRCC during 2018–2022 (mean age 71.9 years, 39.2% female, 80% White, 72% Medicare, 82% urban teaching hospitals). Metastatic involvement was present in 13% of RCC hospitalizations, most commonly lung (7%), bone (5%), and liver (5%). In-hospital mortality was 2.65%, mean LOS was 5 days, and mean total charges were $87,000 per hospitalization. Palliative care consultation occurred in only 6.3% of mRCC hospitalizations but was dramatically higher among decedents (56.9% vs 4.7%, p < 0.001). In adjusted multivariable analyses, mortality was independently associated with palliative care consultation (OR 12.0), congestive heart failure (OR 2.3), protein–energy malnutrition (OR 1.8), electrolyte disorders (OR 3.0), and liver metastases (OR 2.7), while elective admission was strongly protective (OR 0.07). Palliative care utilization was independently associated with older age, urban teaching hospital status and metastatic burden. Conclusions: In this large, nationally representative analysis, patients hospitalized with mRCC experienced substantial inpatient mortality, while palliative care consultation was infrequent and largely confined to patients at extreme risk of death. The strong clustering of palliative care with advanced metastatic burden and acute physiologic decompensation suggests predominantly late, reactive referral patterns. These findings identify a critical opportunity for earlier, systematic integration of inpatient palliative care in mRCC to improve goal-concordant care, resource utilization, and equity across hospital settings.