3696 - Advance Care Planning among Medicare Beneficiaries with Poor Prognosis Cancers

E. Mehanna¹, E. J. Orav^2,3, and M. Lam^4,5; ¹Harvard Radiation Oncology Program, Boston, MA, ²Department of Medicine, Harvard Medical School, Boston, MA, ³Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, ⁴Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, ⁵Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA

Purpose/Objective(s): Advance care planning (ACP) is a service provided by clinicians to patients and their family members or caregivers to discuss the patient’s health care wishes should they become unable to make their own medical decisions. Prior research has shown that ACP is associated with improved quality of end-of-life care. To encourage clinicians to have ACP discussions with patients who may benefit from them, as well as acknowledge the lengthy discussions and additional paperwork required by clinicians, the Centers for Medicare and Medicaid Services introduced new billing codes in 2016 that reimburse for ACP conversations. In this study, we aim to evaluate how often ACP discussions are occurring in patients with cancer. Materials/

Methods: We performed a retrospective analysis using traditional fee-for-service Medicare claims between 2017-2021. The study population included patients with poor prognosis primary cancers and metastatic solid tumors (poor prognosis defined in prior literature). ACP claims were identified using Current Procedural Terminology codes 99497 or 99498. The index date of diagnosis or recurrence was identified based on the first occurrence of a cancer-related claim with the absence of cancer-related claims for one year prior. The primary endpoint was the presence of an ACP visit following diagnosis. Logistic regression was used to identify patient and clinical factors associated with the presence of an ACP visit.
Results: We identified 280,786 patients with newly diagnosed or recurrent poor prognosis cancers from 2017-2021. Mean age was 75, 49.4% were female, and 82.6% were non-Hispanic White, 7.4% were Black, and 4.5% were Hispanic. The most common cancer types were lung (25.4%), lymphoma/leukemia (18.6%), and hepatobiliary (12.1%). The overall incidence of an ACP visit during the index year of diagnosis or recurrence was 9.7% (95% CI 9.6-9.8), a rate that increased over the study period from 6.5% in 2017 to 13.6% in 2021 (p<0.001). Multivariable logistic regression identified that the odds of having an ACP discussion were higher among older patients (OR for patients aged 83-109 vs. 65-67 years = 2.2, 95% CI 2.1-2.3) and lower for patients with breast cancer (OR 0.8, 95% CI 0.8-0.9), or prostate cancer (OR 0.7, 95% CI 0.7-0.8), relative the reference of colorectal cancer. Among patients who did not have an ACP visit during the index year of diagnosis or recurrence, 21.0% died within that year, and an additional 15.2% died within the following year.
Conclusion: Among Medicare beneficiaries with poor prognosis cancers, ACP visits have increased since the implementation of the reimbursement codes in 2016. However, ACP remains underutilized among this patient cohort who would benefit from this service. Further studies are warranted to investigate barriers to ACP discussions.