End-of-life care for lung cancer patients in the United States and Ontario

Background — Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.

Methods — Identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999–2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N=13,533) and the Ontario Cancer Registry (N=8,100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. Rates per person-months (PM) were identified for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.

Results — Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs. Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI=18.3 to 29.1 per 100 PM, P<0.001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs. Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI=7.7 to 12.1 per 100 PM, P<0.001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI=22.9 to 34.4 per 100 PM, P<0.001; longer-term survivors, 44.1 vs. 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI=18.5 to 27.5 per 100 PM, P<0.001).

Conclusions — NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.