TOPLINE: 

Starting palliative care early in patients with head and neck cancer may lower healthcare costs associated with tracheostomy or gastrostomy tube use during the last 6 months of life. However, early palliative care did not reduce emergency department visits or hospital admissions or facilitate home deaths.

METHODOLOGY:

• Patients with advanced head and neck cancer may receive tracheostomy or gastrostomy tubes in the last months of life, but this care is costly and can increase use of hospital care. Initiating palliative care early could reduce tube-associated end-of-life costs as well as hospitalizations.
• To assess this, researchers conducted a retrospective population-based cohort study using data from the Ontario Cancer Registry and the Ontario Health Insurance Plan (a single-payer insurance program). The analysis included 11,135 adults (mean age, 68.4 years; 74.0% men) diagnosed with head and neck cancer between January 2007 and December 2022 and who passed away before October 2023.
• First exposure to palliative care was categorized as early (initiated between 6-12 months before death), late (initiated within 6 months of death), or none. These groups were further divided into patients who received a tracheostomy or gastrostomy tube and those who did not.
• The primary outcome was the mean monthly healthcare cost for each patient in the last 6 months of life, adjusted to 2023 Canadian dollars (CAD $1.00 = US $0.74). Secondary outcomes included emergency department visits at the end of life, receipt of palliative chemotherapy, and the location and leading cause of death.
• Overall, almost 90% of patients received palliative care — 36.8% early and 52.6% late — while 10.6% did not receive palliative care. The rate of tube use was highest among those receiving early palliative care and lowest among those not receiving palliative care.

TAKEAWAY:

• In the last 6 months of life, late palliative care recipients incurred mean monthly costs of CAD $14,432 — nearly double that of nonrecipients (CAD $7259) and about 20% more than early palliative care recipients (CAD $11,520). Use of a tracheostomy or gastrostomy tube as well as hospital visits, receipt of palliative chemotherapy, and the location of death were factored into patient costs.
• Compared with not receiving palliative care or a tube, receiving palliative care was associated with higher mean monthly cost in the last 6 months of life, with late palliative care associated with the highest costs (rate ratio [RR], 2.07 for late and 1.87 for early).
• Compared with no palliative care or tube, receiving a tracheostomy or gastrostomy tube was associated with higher costs: The highest was for those receiving late palliative care (RR, 4.37 for tracheostomy and 3.66 for gastrostomy), followed by no palliative care (RR, 2.93 for tracheostomy and 3.31 for gastrostomy), and the lowest was for early palliative care (RR, 2.88 for tracheostomy and 2.55 for gastrostomy).
• Patients who received early or late palliative care (odds ratio, 0.53 or 0.37, respectively) had a lower likelihood of dying at home than those who did not receive palliative care. Similarly, in the last month and 6 months of life, the highest proportion of emergency room visits occurred among late palliative care recipients and the lowest among nonrecipients. Palliative chemotherapy was most common among early palliative care recipients. Emergency room visits and use of palliative chemotherapy increased costs for patients.

IN PRACTICE:

The findings call for a "coordinated, team-based approach to managing the care plan for patients with [head and neck cancer] and its associated high-care needs, including more thoughtful decision-making regarding tracheostomy and g-tube placement and prioritization of early [palliative care]," the authors concluded.

"The lack of association of [palliative care] with aggressive end-of-life care in this study — an inverse American Association for Clinical Oncology quality measure — suggests that there are opportunities to improve the quality of [palliative care] in this vulnerable patient population," Christine G. Gourin, MD, MPH, Thomas J. Smith, MD, and Rebecca A. Gersten, MD, of the Johns Hopkins Medical Institutions, Baltimore, wrote in an invited commentary. The findings of the current study are "provocative, but do not negate the value of [palliative care], which was developed as a medical and ethical solution to reduce the symptoms and distress of the patient and family and to improve quality of life and death," the commentary authors added.

SOURCE:

The study, led by Rui Fu, PhD, Cumming School of Medicine, University of Calgary, Alberta, was published online in JAMA Otolaryngology - Head & Neck Surgery, alongside an invited commentary.

LIMITATIONS:

The study focused on a simplified cross-sectional representation of palliative care timing and binary tube status. There was residual confounding in the regression analysis, which would require a quasi-experimental study design to overcome. Additionally, virtual palliative care consultations that became billable during COVID were not included as these visits were perceived to complement, rather than substitute, in-person palliative care visits.

DISCLOSURES:

The study received support from the Institute for Clinical Evaluative Sciences — funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care — the Ontario Health Data Platform, and a New Investigator Award from the Terry Fox Research Institute and the Canadian Institutes of Health Research. One author reported serving on the advisory board of EMD Serono outside the submitted work. No other disclosures were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.