Cancer patients younger than 65 who are discharged to a skilled nursing facility following hospitalization are less likely to receive cancer treatment and hospice care before death, new University of Colorado Cancer Center research shows.
The research, led by CU Cancer Center member Sarguni Singh, MD, an assistant professor of hospital medicine in the CU School of Medicine, is aligned with previous research studying post-acute care outcomes of all oncology patients discharged to skilled nursing facilities, which found similar outcomes in patients 65 and older.
“What’s always struck me with older adults who have advanced cancer is when we discharge them to a skilled nursing facility, we’re telling them they’re going there to get stronger and get more rehab, maybe more cancer treatment,” Singh explains. “But what I would see clinically is when we sent people to a skilled nursing facility, often they would come right back sicker and have really poorly controlled symptoms. In some cases, they would then end up having high-intensity care that wasn’t aligned with their wishes.
“In this paper, we wanted to look at the experiences of younger adults, and try to better understand their outcomes. What we learned was that while only about 3% of people younger than 65 were being discharged to skilled nursing facilities, their outcomes are equally poor.”
Differences following hospital discharge
Singh and her co-researchers, including Stacy Fischer, MD, co-leader of the CU Cancer Center Cancer Prevention and Control Program, aimed to better understand the outcomes of Colorado advanced cancer patients younger than 65 who are discharged to a skilled nursing facility from acute care. They also compared those outcomes with younger patients who are discharged home or with home health care six months after hospitalization.
They drew data from the Colorado All Payer Claims Database and the Colorado Central Cancer Registry with the aim of measuring whether people received cancer treatment, how many were readmitted to the hospital within 30 days of discharge, hospice use, and time to death. They focused on patients with stage III and stage IV advanced cancer.
In analyzing the Colorado-specific data, they found that 3% of advanced cancer patients were discharged to a skilled nursing facility, 79% were discharged home, and 18% were discharged to home health care. Of those discharged to a skilled nursing facility, 39% received hospice care compared with 58% of those discharged to home health.
Researchers also found that patients with Medicaid were more likely to be discharged to a skilled nursing facility, and that Black and Hispanic patients were more likely to have Medicaid. These patients also received less radiation and hospice care, irrespective of discharge location.
Focusing on patient care
“The bigger picture is that cancer is a disease of aging, and as our population ages, this pattern of care is just going to get worse,” Singh says. “We’re at a unique place with policy, where a lot of focus is on nursing homes and cancer care.”
She adds that skilled nursing facilities are part of a system in which reimbursement is linked, in part, to whether patients’ functional status is improving, “but what do you do if someone is not going to greatly improve?" Singh says. "If someone has advanced cancer and is approaching the end of their life in a nursing home, you’re probably not going to be able to demonstrate that they’re doing more activities and their functional status is improving.
"In our current reimbursement system, there’s no real incentive or way to reward nursing facilities who put in the effort to have goals-of-care discussions and show that they took really good care of this patient at the end of life. Instead, rehabilitative therapies and re-hospitalizations are incentivized regardless of a patient’s rehabilitation potential.”
There are many potential avenues to address these disparities in care, Singh says, from improving equity for people working in nursing homes to improving messaging about what may happen when a patient is discharged from hospital care.
“A lot of times, the messaging a late-stage cancer patient is getting in the hospital is, ‘You’re going to a nursing home for rehab, then you’ll go home, then you’ll meet with an oncologist to talk about getting more treatment,’” Singh says. “A lot of times for patients with advanced cancer, they’re having three or four transitions of care before death. This pattern of care has been called being ‘rehabbed to death.’ Patient information doesn’t travel between silos of care and it is up to patients and their family caregivers to repeatedly rehash the latest information about their health and preferences for care.
“Sometimes this can mean increased distress and patients not able to approach death on their own terms. I think there’s a lot of potential to reassess and refocus on what’s best for the patient.”