Timing of hospice care initiation and aggressive care utilization in patients with cancer: a retrospective nationwide study in Korea.

BACKGROUND: Timely hospice initiation may reduce aggressive end-of-life (EOL) care, but studies on this topic are limited. This study investigated the association between time-to-hospice use and aggressive care utilization at EOL in terminally ill patients with cancer. METHODS: Using linked K-CURE claims and cancer registry data, this retrospective cohort study in South Korea included cancer patients who received hospice care between 2015 and 2022. Hospice timing was defined as the interval between the last systemic anticancer therapy (SACT), including cytotoxic chemotherapy, hormonal/endocrine therapy, targeted therapy, and immunotherapy, and the first use of hospice care. The interval was categorized as ≤ 30 days, 31-60 days, 61-90 days, and >90 days. Aggressive care outcomes included intensive care unit (ICU) admission, emergency department (ED) visits ≥2 times, and a composite measure of these outcomes occurring before hospice initiation. Multivariable logistic regression analyses were conducted, adjusting for sociodemographic and clinical variables. RESULTS: Among 37,996 hospice users, 54.7% initiated hospice care more than 30 days after their last SACT, and this proportion exceeded 50% throughout most of the study period. The proportion initiating hospice care >90 days after the last SACT increased over time (annual percentage change, 8.2%; p for trend = 0.0001). ICU admission and ED visits ≥2 times before hospice initiation occurred in 3.4 and 16.4% of the patients, respectively. Compared with hospice initiation within 30 days after the last SACT, progressively higher odds of ICU admission, ED visits ≥2 times, and the composite outcome were observed with longer intervals: at 31-60 days (ORs, 3.515, 5.877, and 5.285, respectively), 61-90 days (ORs, 5.678, 13.610, and 11.806), and >90 days (ORs, 9.108, 31.127, and 25.174), indicating a clear dose-response relationship. CONCLUSIONS: Delayed hospice initiation was associated with increased use of aggressive EOL care, supporting the need for timely transition to hospice care.