Importance:
The impact of patients receiving immunotherapy within the last three months of life on healthcare utilization has yet to be determined.

Objective:
To evaluate whether receiving immunotherapy within the last three months of life predicts higher healthcare utilization in the form of hospital admissions, intensive-care unit (ICU) admissions, emergency department (ED) visits, and hospice claims.

Design, setting, and participants: Analysis of 14,150 patients ≥ 65 years old from the SEER-Medicare database who were diagnosed with head and neck cancer between 2007 and 2017 and died between 2007 and 2018. Patients were enrolled in both Part A and Part B for at least one month prior to diagnosis and were excluded from analysis for lapses in coverage or use of managed care.

Main Outcome(s) and Measure(s): Data were collected from the SEER-Medicare registry on patient demographics and tumor characteristics. Carrier claims files were used to determine whether patients received cetuximab, nivolumab, or pembrolizumab within the last three months of life. The primary outcomes of interest were hospital admissions, ICU admissions, ED visits, and hospice claims within the last three months of life. Associations between patient demographics, healthcare utilization and whether a patient received immunotherapy in the last three months of life was completed using Student’s t-testing and χ2 testing. All analysis was performed using SAS v9.4 (SAS Institute Inc., Cary, NC, USA).

Results: Among 14,150 patients with head and neck cancer meeting inclusion and exclusion criteria, 312 received immunotherapy within the last three months of life. Among those who did and did not receive immunotherapy, there were significant differences in age (p=0.0025), race (p=0.0078), site (p= 0.0102), stage (p<0.0001), histology (p=0.0011) and hospice length of stay (p<0.0001). There were no significant differences in grade, sex, or having any hospice claim during the final three months of life (Table 1). Within the last three months of life, healthcare utilization was significantly impacted by a patient receiving immunotherapy. Patients who received immunotherapy had significantly higher ED visits (2.7 ± 4.1 to 2.0 ± 42, p=0.0069) and significantly lower hospice claims (0.79 ± 1.0 to 1.0 ± 1.6, p<0.0001). There was no significant difference in hospital or ICU admissions. (Table 2).

Conclusion: Within the final three months of life, there was significantly higher ED visits among those who received immunotherapy and significantly lower hospice utilization. Further study of end-of-life healthcare utilization can offer insight into opportunities to improve end-of-life care amongst head and neck cancer patients nationally.