Survival, Healthcare Utilization, and End-of-life Care among Older Adults with Malignancy-associated Bowel Obstruction

Elizabeth J. Lilley, John W. Scott, Joel E. Goldberg, Christy E. Cauley, Jennifer S. Temel, Andrew S. Epstein, Stuart R. Lipsitz, Brittany L. Smalls, Adil H. Haider, Angela M. Bader, Joel S. Weissman, Zara Cooper

Research output: Contribution to journalArticlepeer-review

34 Scopus citations

Abstract

Objective: To compare survival, readmissions, and end-of-life care after palliative procedures compared with medical management for malignancy-associated bowel obstruction (MBO). Background: 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. Methods: 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. Results: 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)]. Conclusions: 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.

Original languageEnglish
Pages (from-to)692-699
Number of pages8
JournalAnnals of Surgery
Volume267
Issue number4
DOIs
StatePublished - Apr 1 2018

Bibliographical note

Funding Information:
This work was supported, in part, by funding from the Brigham Research Institute. Unrelated to this work, Dr Cauley received grant support from the National Cancer Institute at the NIH (R25CA092203) during the conduct of the study. Dr Cooper is supported by the Cambia Foundation. Dr Haider is a cofounder and equity holder of a Johns Hopkins University supported start up known as Patient Doctor Technologies which owns and operates the website www.doctella.com. The study design and analytic protocol were developed at the Massachusetts General Hospital Supportive Oncology Workshop, which is sponsored by a National Cancer Institute R25 grant. Drs Scott, Goldberg, Temel, Epstein, Lipsitz, Smalls, Bader, and Weissman report no conflicts of interest.

Publisher Copyright:
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Keywords

  • cancer
  • end-of-life care
  • geriatric patients
  • malignant bowel obstruction
  • palliative care
  • palliative surgery

ASJC Scopus subject areas

  • Surgery

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