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Grant Details

Grant Number: 5R01CA164021-03 Interpret this number
Primary Investigator: Keating, Nancy
Organization: Harvard Medical School
Project Title: Explaining Variations in End-of-Life Care Intensity
Fiscal Year: 2014


DESCRIPTION (provided by applicant): Health care expenditures account for 17.3% of gross domestic product in the United States and are disproportionately allocated to care at the end-of-life (EOL). Much of this results from intensive use of services (hospitalizations, mechanical ventilation) in the last months of life. Yet, data suggest that terminally-ill patients who receive aggressive EOL care have worse quality of life than other patients. Research is needed to determine the factors that contribute to the intensity of EOL care. A large body of evidence demonstrates substantial regional variations in intensity of care and health care spending at the EOL across the U.S. Studies have also demonstrated notable differences in EOL care by race/ethnicity and health systems. Available data have not had sufficient detail, variation, or siz to assess the extent to which area variations are explained by patient, physician, and health system factors, nor to assess if racial/ethnic disparities in EOL care can be explained by differences in patients' beliefs and other. characteristics, physicians' practice styles, the hospitals where care is received, or area practice patterns. We will use data from the Cancer Care Outcomes and Research Surveillance (CanCORS) Consortium, a multi-regional prospective study examining care delivered to population and health-system based cohorts of more than 10,000 patients diagnosed with lung or colorectal cancer during 2003-2005. We will use CanCORS patient survey data, medical record data and physician survey data linked with administrative data from Medicare, private health plans, Medicaid, and the VA to examine the intensity of EOL care among over 4,000 patients with advanced lung or colorectal cancer followed through 2012. We will use hierarchical models to assess the patient, physician, hospital, and area factors influencing intensity of EOL care. Specifically, we will: 1. Validate th retrospective Dartmouth measures of EOL spending with measures of care intensity and expenditures for prospectively identified patients with advanced cancer. 2. Understand the factors contributing to area-level variations in intensity of EOL care, including patient and tumo characteristics (e.g., demographics, comorbid illness, site of metastases), patient beliefs (e.g., preferences for life-prolonging care, beliefs about the effectiveness of chemotherapy for advanced cancer), physician practice style and beliefs (e.g., greater use of chemotherapy for advanced cancer patients, self- reported timing and comfort with EOL discussions, personal preference for hospice if terminally-ill), hospital characteristics and practice patterns, and are service availability. 3. Within areas, assess to what extent racial/ethnic differences in intensityof EOL care are explained by patient, physician, and hospital differences. 4. Understand differences in intensity of EOL care across health system (fee-for-service Medicare, Medicare managed care, VA), and assess patient and physician characteristics and beliefs across systems.


Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients.
Authors: Keating N.L. , Huskamp H.A. , Kouri E. , Schrag D. , Hornbrook M.C. , Haggstrom D.A. , Landrum M.B. .
Source: Health affairs (Project Hope), 2018 Jul; 37(7), p. 1136-1143.
PMID: 29985699
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Family Perspectives on Hospice Care Experiences of Patients with Cancer.
Authors: Kumar P. , Wright A.A. , Hatfield L.A. , Temel J.S. , Keating N.L. .
Source: Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017 Feb; 35(4), p. 432-439.
EPub date: 2016-12-19.
PMID: 27992271
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Dartmouth Atlas Area-Level Estimates of End-of-Life Expenditures: How Well Do They Reflect Expenditures for Prospectively Identified Advanced Lung Cancer Patients?
Authors: Keating N.L. , Landrum M.B. , Huskamp H.A. , Kouri E.M. , Prigerson H.G. , Schrag D. , Maciejewski P.K. , Hornbrook M.C. , Haggstrom D.A. .
Source: Health services research, 2016 Aug; 51(4), p. 1584-94.
EPub date: 2016-01-22.
PMID: 26799913
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Lower Patient Ratings of Physician Communication Are Associated With Unmet Need for Symptom Management in Patients With Lung and Colorectal Cancer.
Authors: Walling A.M. , Keating N.L. , Kahn K.L. , Dy S. , Mack J.W. , Malin J. , Arora N.K. , Adams J.L. , Antonio A.L. , Tisnado D. .
Source: Journal of oncology practice, 2016 Jun; 12(6), p. e654-69.
EPub date: 2016-05-24.
PMID: 27221991
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Family Perspectives on Aggressive Cancer Care Near the End of Life.
Authors: Wright A.A. , Keating N.L. , Ayanian J.Z. , Chrischilles E.A. , Kahn K.L. , Ritchie C.S. , Weeks J.C. , Earle C.C. , Landrum M.B. .
Source: JAMA, 2016-01-19; 315(3), p. 284-92.
PMID: 26784776
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Intensity of Medical Interventions between Diagnosis and Death in Patients with Advanced Lung and Colorectal Cancer: A CanCORS Analysis.
Authors: Brooks G.A. , Cronin A.M. , Uno H. , Schrag D. , Keating N.L. , Mack J.W. .
Source: Journal of palliative medicine, 2016 Jan; 19(1), p. 42-50.
EPub date: 2015-11-24.
PMID: 26600474
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Patient beliefs that chemotherapy may be curative and care received at the end of life among patients with metastatic lung and colorectal cancer.
Authors: Mack J.W. , Walling A. , Dy S. , Antonio A.L. , Adams J. , Keating N.L. , Tisnado D. .
Source: Cancer, 2015-06-01; 121(11), p. 1891-7.
EPub date: 2015-02-11.
PMID: 25677655
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Tumor board participation among physicians caring for patients with lung or colorectal cancer.
Authors: Kehl K.L. , Landrum M.B. , Kahn K.L. , Gray S.W. , Chen A.B. , Keating N.L. .
Source: Journal of oncology practice, 2015 May; 11(3), p. e267-78.
EPub date: 2015-04-28.
PMID: 25922221
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Association of Actual and Preferred Decision Roles With Patient-Reported Quality of Care: Shared Decision Making in Cancer Care.
Authors: Kehl K.L. , Landrum M.B. , Arora N.K. , Ganz P.A. , van Ryn M. , Mack J.W. , Keating N.L. .
Source: JAMA oncology, 2015 Apr; 1(1), p. 50-8.
PMID: 26182303
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The Association between Fatalistic Beliefs and Late Stage at Diagnosis of Lung and Colorectal Cancer.
Authors: Lyratzopoulos G. , Liu M.P. , Abel G.A. , Wardle J. , Keating N.L. .
Source: Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 2015 Apr; 24(4), p. 720-6.
EPub date: 2015-02-03.
PMID: 25650183
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Symptom prevalence in lung and colorectal cancer patients.
Authors: Walling A.M. , Weeks J.C. , Kahn K.L. , Tisnado D. , Keating N.L. , Dy S.M. , Arora N.K. , Mack J.W. , Pantoja P.M. , Malin J.L. .
Source: Journal of pain and symptom management, 2015 Feb; 49(2), p. 192-202.
EPub date: 2014-06-26.
PMID: 24973624
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End-of-life care for older patients with ovarian cancer is intensive despite high rates of hospice use.
Authors: Wright A.A. , Hatfield L.A. , Earle C.C. , Keating N.L. .
Source: Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-11-01; 32(31), p. 3534-9.
EPub date: 2014-10-06.
PMID: 25287831
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Associations between palliative chemotherapy and adult cancer patients' end of life care and place of death: prospective cohort study.
Authors: Wright A.A. , Zhang B. , Keating N.L. , Weeks J.C. , Prigerson H.G. .
Source: BMJ (Clinical research ed.), 2014-03-04; 348, p. g1219.
EPub date: 2014-03-04.
PMID: 24594868
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Physicians' preferences for hospice if they were terminally ill and the timing of hospice discussions with their patients.
Authors: Chinn G.M. , Liu P.H. , Klabunde C.N. , Kahn K.L. , Keating N.L. .
Source: JAMA internal medicine, 2014 Mar; 174(3), p. 466-8.
PMID: 24342971
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