title: Care in the months before death and hospice enrollment among older women with advanced breast cancer.
abstract: BACKGROUND
  Variations in hospice use are not well understood.
  
  
  OBJECTIVE
  Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment.
  
  
  METHODS
  Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results--Medicare database.
  
  
  METHODS
  There were 4,455 women aged > or =65 diagnosed with stage III/IV breast cancer during 1992-1999 who died before the end of 2001.
  
  
  METHODS
  Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death.
  
  
  RESULTS
  Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1-7 days, 46% if 8-20 days, 35% if > or =21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P > or = 0.10).
  
  
  CONCLUSIONS
  Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. keating@hcp.med.harvard.edu
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Keating
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Landrum
authors.forename: Edward
authors.initials: E
authors.lastname: Guadagnoli
authors.forename: Eric P
authors.initials: EP
authors.lastname: Winer
authors.forename: John Z
authors.initials: JZ
authors.lastname: Ayanian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D001943:Breast Neoplasms / Q000628:therapy*; D015331:Cohort Studies; D005260:Female; D017051:Hospice Care / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008495:Medical Oncology; D011320:Primary Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation; D012189:Retrospective Studies; D018426:SEER Program