title: The rise of concurrent care for veterans with advanced cancer at the end of life.
abstract: BACKGROUND
  Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the "terrible choice" between receipt of hospice services or disease-modifying chemotherapy/radiation therapy. For this report, the authors characterized the VA's provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.
  
  
  METHODS
  This retrospective cohort study included veteran decedents with cancer during 2006 through 2012 who were identified from claims with cancer diagnoses. Hospice and cancer treatment were identified using VA and Medicare administrative data. Descriptive statistics were used to characterize the changes in concurrent care, hospice, palliative care, and chemotherapy or radiation treatment.
  
  
  RESULTS
  The proportion of veterans receiving chemotherapy or radiation therapy remained stable at approximately 45%, whereas the proportion of veterans who received hospice increased from 55% to 68%. The receipt of concurrent care also increased during this time from 16.2% to 24.5%. The median time between hospice initiation and death remained stable at around 21 days. Among veterans who received chemotherapy or radiation therapy in their last 6 months of life, the median time between treatment termination and death ranged from 35 to 40 days. There was considerable variation between VA medical centers in the use of concurrent care (interquartile range, 16%-34% in 2012).
  
  
  CONCLUSIONS
  Concurrent receipt of hospice and chemotherapy or radiation therapy increased among veterans dying from cancer without reductions in the receipt of cancer therapy. This approach reflects the expansion of hospice services in the VA with VA policy allowing the concurrent receipt of hospice and antineoplastic therapies. Cancer 2016;122:782-790. © 2015 American Cancer Society.
authors.affiliation: Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island.|Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.affiliation: Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island.|Department of Health Policy, Harvard Medical School, Boston, Massachusetts.
authors.forename: Nina R
authors.initials: NR
authors.lastname: Joyce
authors.affiliation: Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island.
authors.forename: Danielle L
authors.initials: DL
authors.lastname: Coté
authors.affiliation: VA Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.|Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.|School of Medicine, Stanford University, Stanford, California.
authors.forename: Risha A
authors.initials: RA
authors.lastname: Gidwani
authors.affiliation: Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.|National Performance Reporting and Outcomes Measurement to Improve the Standard of Care at End-of-Life (PROMISE) Center, US Department of Veterans Affairs, Washington, DC.
authors.forename: Mary
authors.initials: M
authors.lastname: Ersek
authors.affiliation: Eastern Colorado VA Healthcare System, Denver, Colorado.
authors.forename: Cari R
authors.initials: CR
authors.lastname: Levy
authors.affiliation: Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island.|Warren Alpert Medical School of Brown University, Providence, Rhode Island.
authors.forename: Katherine E
authors.initials: KE
authors.lastname: Faricy-Anderson
authors.affiliation: Center of Innovation, Providence Veterans Health Administration (VA) Medical Center, Providence, Rhode Island.|Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
authors.forename: Susan C
authors.initials: SC
authors.lastname: Miller
authors.affiliation: VA Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.|Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.|School of Medicine, Stanford University, Stanford, California.
authors.forename: Todd H
authors.initials: TH
authors.lastname: Wagner
authors.affiliation: Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.|Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Bruce P
authors.initials: BP
authors.lastname: Kinosian
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.|School of Medicine, Stanford University, Stanford, California.
authors.forename: Karl A
authors.initials: KA
authors.lastname: Lorenz
authors.affiliation: Hospice and Palliative Care Program, US Department of Veterans Affairs, Washington, DC.|Penn State College of Medicine, Hershey, Pennsylvania.
authors.forename: Scott T
authors.initials: ST
authors.lastname: Shreve
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000473:pathology / Q000628:therapy; D004358:Drug Therapy / Q000706:statistics & numerical data* / Q000639:trends; D005260:Female; D006258:Head and Neck Neoplasms / Q000473:pathology / Q000628:therapy; D019337:Hematologic Neoplasms / Q000473:pathology / Q000628:therapy; D017051:Hospice Care / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000628:therapy; D008175:Lung Neoplasms / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000473:pathology / Q000628:therapy*; D010166:Palliative Care / Q000706:statistics & numerical data* / Q000639:trends; D011471:Prostatic Neoplasms / Q000473:pathology / Q000628:therapy; D011878:Radiotherapy / Q000706:statistics & numerical data* / Q000639:trends; D012189:Retrospective Studies; D013727:Terminal Care / Q000706:statistics & numerical data / Q000639:trends; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data*
keywords: end-of-life care; hospices; neoplasms; palliative care; veterans