Palliative Care Specialist Use Among Medicare Decedents Who Had Poor-Prognosis Cancers

Abstract

Importance: Palliative care (PC) use patterns may have changed in recent years due to increased adoption of telehealth and the availability of more advanced practice clinicians who specialize in PC delivery.

Objective: To describe changes in the use of specialty PC during the last year of life among Medicare beneficiaries who had cancers with poor prognoses (cancers that commonly caused death, rare cancers with high mortality rates, or solid tumors with concurrent nonlymphatic metastases; hereinafter termed poor-prognosis cancers).

Design, setting, and participants: This retrospective cohort study includes all US Medicare fee-for-service beneficiaries who died from poor-prognosis cancers between January 1, 2018, and December 31, 2023, and received care in hospital and outpatient settings.

Exposures: Encounters with a PC specialist.

Main outcomes and measures: The primary outcome was the proportion of decedents with any specialty PC encounter in their last year of life. Secondary outcomes included mean number of PC encounters among decedents with at least 1 encounter with a PC specialist and telehealth use. PC specialists were clinicians who self-identified as a PC specialist or were clinicians with 80% or more of their Medicare encounters focused on PC.

Results: The cohort included 1 508 103 decedents (mean [SD] age, 79.6 [8.0] years; 54.6% male) with poor-prognosis cancers. Between 2018 and 2023, the proportion of decedents with at least 1 PC encounter increased from 29.84% to 37.21% (adjusted change, 7.21 [95% CI, 6.30-8.12] percentage points; relative change, 24.2%). The proportion who received outpatient PC increased from 10.66% to 20.56% (adjusted change, 9.41 [95% CI, 8.33-10.48] percentage points; relative change, 88.2%). In 2023, 22.84% of all decedents received PC from advanced practice clinicians vs 15.60% by self-designated PC physicians and 9.92% by other physicians. Telehealth was used for 18.2% of all outpatient palliative care encounters in 2023. Decedent characteristics associated with not receiving specialty PC included older age, lower income, and living in nonmetropolitan areas.

Conclusions and relevance: In this cohort study of decedents who had poor-prognosis cancers, an increasing proportion received any specialty PC. Advanced practice specialists were the most common clinician type who delivered specialty PC, and telehealth was used for a substantial proportion of outpatient visits. Despite these changes, only a minority of patients received specialty PC, and low use of specialty PC among certain subpopulations persisted, suggesting that different strategies are needed to overcome these barriers.

Figure 1.. Patterns in the Share of Monthly Decedents Who Had Poor-Prognosis Cancers and at Least 1 Palliative Care Specialist Encounter Before Death by Care Setting

The figure shows the share of decedents who had at least 1 palliative care specialist encounter in the year preceding their death date according to their month and year of death among decedents who had poor-prognosis cancers. If a decedent had both hospital and outpatient encounters, then they are only counted once in any setting.

Figure 2.. Patterns in the Share of Outpatient Encounters With a Palliative Care Specialist Among Decedents Who Had Poor-Prognosis Cancers

The figure shows patterns in the share of outpatient specialist encounters according to the specialist's clinician type and the share of telehealth use during the year preceding the beneficiary's death date.

Figure 3.. Changes in the Marginal Difference of Patient Characteristics for Any Use of Palliative Care Specialists

The forest plot shows estimated marginal differences between patient characteristics in 2018 and 2023 in the percentage of decedents with any specialist use. Error bars indicate 95% CIs. Differences shown for each characteristic are in relation to their reference group. For example, nonmetropolitan decedents were 10.40 percentage points less likely to use a palliative care specialist than metropolitan decedents in 2018 and were 13.30 percentage points less likely in 2023. Between 2018 and 2023, nonmetropolitan decedents became 1.47 percentage points less likely than metropolitan decedents to use palliative care specialists. ESKD indicates end-stage kidney disease.