Evaluation of Hospice Referral and Palliative Care For Ovarian Cancer in the Managed Care Environment

Background

The objective of this project is to describe end of life care and factors that may be associated with care (or lack of it) for women who die of ovarian cancer. An important goal of this study is to examine end-of-life care among a group of these patients who are diverse in terms of race, ethnicity, socioeconomic status, and geographic location. A special focus of this project is the experience of end-of-life care in managed care organizations. This particular focus means that patients have comprehensive health insurance coverage for physicians' services, hospital care, emergency room care, surgical procedures, radiology procedures, laboratory tests, prescribed drugs, home health care, and hospice care. These patients do not face the overwhelming financial barriers to access that challenge uninsured patients. Hence, observed variations in patterns of care for terminal ovarian cancer are more likely to be associated with patient/family preferences, provider preferences, and structure of the delivery system.

Study Aim

This study will address the following specific aims and research questions:

1. What were the clinical signs and symptoms documented in medical records during the last six months of life of ovarian cancer patients and how were these symptoms managed?
2. What therapies were used to manage these symptoms?
3. Is any evidence present that a determination was made that the patient was approaching the end of life? What clinical signs and symptoms led up to this determination? Is there evidence that this determination was discussed with the patient or family? Among those patients for whom a determination was made that the end of life is approaching, did physicians follow practice guidelines for end of life care?
4. Where did patients spend the last 6 months of their lives, e.g., hospice, hospital, intermediate care facility, nursing home, home, or some combination of these locations? Does the frequency of hospice referral vary according to the specialty of the provider (e.g., gynecologic oncologist) or by type of health care provider (e.g., academic institution vs. private practice)?
5. What type of medical utilization occurred after a determination that the disease was terminal, i.e., number of clinic and hospital visits? Were the signs and symptoms of hospitalized patients different from those of non hospitalized patients? What signs and symptoms were managed outside the hospital?
6. What major co-morbid conditions existed among patients who have died of ovarian cancer? How did these co-morbid conditions affect signs, symptoms, and hospitalizations at the end of life compared to patients without these co-morbid conditions? How did these conditions affect care or do patients with certain co-morbid conditions receive different care than patients without those conditions?
7. Do any of the factors listed in the questions above vary by stage or grade of disease at diagnosis? By patient race, ethnicity, age, socioeconomic status, or geographic variation (e.g., region of U.S., urban vs. rural residence)? By physician specialty, gender, age?

Significance

Ovarian cancer is the leading cause of death in women with gynecological cancers. It is estimated that 13,900 women died of ovarian cancer in 2002, with most women being diagnosed, unfortunately, at advanced stages. Although ovarian cancer is one of the most sensitive of all solid tumors in terms of response to chemotherapy, the majority of women with this disease relapse and develop drug resistant cancers, producing a distressingly high fatality-to-case ratio.

Project Status

This project was funded in September 2002 through a task order contract with the Centers for Disease Control. Data collection is in progress.

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