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A Paro, D Dalmacy, JM Hyer, A Ejaz, J Cloyd, M Dillhoff, A Tsung, DI Tsilimigras, TM Pawlik
The Ohio State University

Little is known about different care settings in which patients spend most of their time following a cancer diagnosis. We sought to characterize periods of time spent in distinct care settings among patients with a diagnosis of pancreatic adenocarcinoma (PDAC).

Patients with PDAC diagnosed between 2004-2015 were identified in SEER-Medicare. A cluster analysis was performed based on percentage of time from diagnosis-to-death spent in six care settings (home self-care, home health-care, skilled nursing facility, acute in-hospital care, intensive in-hospital care or hospice care). Patients were classified into one of four groups according to predominant care settings: home self-care-dominant (HSC), acute in-hospital care-dominant (ACS), hospice care-dominant (HC) or mixed home and hospice care (MHH).

Among 32,816 patients with PDAC, median age at diagnosis was 76 years (IQR:71-81) and 17,885(54.5%) patients presented with stage IV disease; 20,043(61.1%) patients received chemotherapy, while 4,269(13.0%) underwent resection. Overall median survival was 150 days (IQR:63-341)(chemotherapy: 156 days vs. resection: 459 days vs. best-supportive care: 124 days). Following PDAC diagnosis, most patients were HSC (n=13,459, 41.0%) followed by MHH (n=9,091, 27.7%), ACS (n=5,737, 17.5%) and HC (n=4,529, 13.8%). ACS patients were more likely female (referent HSC, OR:1.25, 95%CI:1.16-1.34) and >70 years (OR:1.64, 95%CI:1.50-1.78). Two-thirds of patients (n=22,152, 67.5%) received hospice care at some point in their care; however, only 29.9%(n=4,028) and 35.3%(n=2,206) of HSC and ACS patients, respectively, received hospice services. Hospice care among HSC and ACS patients was initiated a median of 297 and 69 days, respectively, from time of PDAC diagnosis and lasted on average one week before death. In contrast, HC patients received hospice care earlier (median 36 days from PDAC diagnosis) and longer (59 days) prior to death. A subset of patients (n=5,188, 15.8%) died in-hospital, which was more common among ACS patients (n=1,640, 28.6%) versus other patients (n=3,548, 13.1%). PDAC associated expenditures varied according to health-care utilization(Figure).

Patients with PDAC had varied health-care utilization following diagnosis, which correlated with differences in survival length, time spent in hospice, site of death and spending. Understanding the heterogeneity in patterns-of-care among patients with PDAC should inform efforts to improve end-of-life care.

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