Survival, Healthcare Utilization, and End-of-life Care Among Older Adults With Malignancy-associated Bowel Obstruction: Comparative Study of Surgery, Venting Gastrostomy, or Medical Management.
To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO).



MBO is a late complication of intra-abdominal malignancy for which surgeons are frequently consulted. Decisions about palliative treatments, which include medical management, surgery, or venting gastrostomy tube (VGT), are hampered by the paucity of outcomes data relevant to patients approaching the end of life.



Retrospective study using 2001 to 2012 Surveillance, Epidemiology, and End Results-Medicare data of patients 65 years or older with stage IV ovarian or pancreatic cancer who were hospitalized for MBO. Multivariate competing-risks regression models were used to compare the following outcomes: survival, readmission for MBO, hospice enrollment, intensive care unit (ICU) care in the last days of life, and location of death in an acute care hospital.



Median survival after MBO admission was 76 days (interquartile range 26-319 days). Survival was shorter after VGT [38 days (interquartile range 23-69)] than medical management [72 days (23-312)] or surgery [128 days (42-483)]. As compared to medical management, patients treated with VGT had fewer readmissions [subdistribution hazard ratio 0.41 (0.29-0.58)], increased hospice enrollment [1.65 (1.42-1.91)], and less ICU care [0.69 (0.52-0.93)] and in-hospital death [0.47 (0.36-0.63)]. Surgery was associated with fewer readmissions [0.69 (0.59-0.80)], decreased hospice enrollment [0.84 (0.76-0.92)], and higher likelihood of ICU care [1.38 (1.17-1.64)].



VGT is associated with fewer readmissions and lower intensity healthcare utilization at the end of life than do medical management or surgery. Given the limited survival, regardless of management, hospitalization with MBO carries prognostic significance and presents a critical opportunity to identify patients' priorities for end-of-life care.
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.|Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
Elizabeth J
EJ
Lilley
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.
John W
JW
Scott
Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Joel E
JE
Goldberg
Ariadne Labs, Boston, MA.|Department of Surgery, Massachusetts General Hospital, Boston, MA.
Christy E
CE
Cauley
Department of Surgery, Massachusetts General Hospital, Boston, MA.
Jennifer S
JS
Temel
Gastrointestinal Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
Andrew S
AS
Epstein
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
Stuart R
SR
Lipsitz
Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY.
Brittany L
BL
Smalls
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Adil H
AH
Haider
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.|Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
Angela M
AM
Bader
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
Joel S
JS
Weissman
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.|Department of Surgery, Brigham and Women's Hospital, Boston, MA.|Ariadne Labs, Boston, MA.
Zara
Z
Cooper
D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care / Q000706:statistics & numerical data*; D005260:Female; D005774:Gastrostomy; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D008297:Male; D006278:Medicare; D010051:Ovarian Neoplasms / Q000150:complications* / Q000401:mortality; D010166:Palliative Care / Q000706:statistics & numerical data*; D010190:Pancreatic Neoplasms / Q000150:complications* / Q000401:mortality; D010359:Patient Readmission / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology