title: End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector.
abstract: BACKGROUND
  Treatment of older cancer patients at the end of life has become increasingly aggressive, despite the absence of evidence for better outcomes. We compared aggressiveness of end-of-life care of older metastatic cancer patients treated in the Veterans Health Administration (VHA) and those under fee-for-service Medicare arrangements.
  
  
  METHODS
  Using propensity score methods, we matched 2913 male veterans who were diagnosed with stage IV lung or colorectal cancer in 2001-2002 and died before 2006 with 2913 similar men enrolled in fee-for-service Medicare living in Surveillance, Epidemiology, and End Result (SEER) areas. We assessed chemotherapy within 14 days of death, intensive care unit (ICU) admissions within 30 days of death, and >1 emergency room visit within 30 days of death.
  
  
  RESULTS
  Among matched cohorts, men treated in the VHA were less likely than men in the private sector to receive chemotherapy within 14 days of death (4.6% vs 7.5%, P<.001), be admitted to an ICU within 30 days of death (12.5% vs 19.7%, P<.001), or have >1 emergency room visit within 30 days of death (13.1 vs 14.7, P=.09).
  
  
  CONCLUSIONS
  Older men with metastatic lung or colorectal cancer treated in the VHA healthcare system received less aggressive end-of-life care than similar men in fee-for-service Medicare. This may result from the absence of financial incentives for more intensive care in the VHA or because this integrated delivery system is better structured to limit potentially overly aggressive care. Additional studies are needed to assess whether men undergoing less aggressive end-of-life care also experience better outcomes.
authors.affiliation: The Division of General Internal Medicine, Brigham and Women's Hospital, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115, 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: Elizabeth B
authors.initials: EB
authors.lastname: Lamont
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Bozeman
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: McNeil
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D015179:Colorectal Neoplasms / Q000473:pathology / Q000628:therapy*; D003695:Delivery of Health Care; D004636:Emergency Service, Hospital; D006787:Hospitals, Veterans; D006801:Humans; D007362:Intensive Care Units; D008175:Lung Neoplasms / Q000473:pathology / Q000628:therapy*; D008297:Male; D006278:Medicare; D009362:Neoplasm Metastasis; D018426:SEER Program; D013727:Terminal Care; D014481:United States
chemical_list: D000970:Antineoplastic Agents