End of Life Cancer Care


The end of life (EOL) is difficult to predict, even for patients with incurable cancer. Despite interventions and quality-improvement initiatives focused upon integrating early palliative care into advanced cancer treatment, ICU admission in the last 30 days of life and late hospice referral have been secularly increasing. The American Society of Clinical Oncology (ASCO) and National Quality Forum (NQF) define the following metrics as aggressive, burdensome, and expensive treatment in cancer:

  • receipt of chemotherapy in the last 14 days of life
  • more than one emergency department visit in the last 30 days of life
  • intensive care unit (ICU) admission in the last 30 days of life
  • lack of hospice enrollment in the last 30 days of life
  • late hospice referral (enrolled in hospice for less than 3 days before death)


We have updated the Dartmouth Atlas Cancer Report profiling NQF EOL measures using previously documented methods using 2016 Center for Medicare & Medicaid Services (CMS) claims data (see Morden 2012 and the 2013 Dartmouth Atlas report, Trends in Cancer Care Near the End of Life ). We categorize hospitals into the following four mutually exclusive types: members of the National Comprehensive Cancer Network (NCCN; n=30); hospitals outside the network that were designated Comprehensive Cancer Centers by the National Cancer Institute (NCI; n=24); hospitals that were not in the network or designated comprehensive cancer centers but that were academic medical centers (n=161); and community hospitals, those institutions not in the above groups (n=4,240).

The algorithm used to profile cancer centers’ EOL quality follows three steps:

  1. Define the cohort
  2. Attribute cohort member’s medical care to the hospital providing largest number of hospitalizations for cancer care in the last six months of life
  3. Calculate EOL quality measures and additional measures in the six months preceding death for each patient assigned to one of the hospitals

The cohort includes a 100 percent sample of fee-for-service Medicare beneficiaries who died at ages 66–99, had continuous inpatient and outpatient Medicare insurance (Parts A, B) in the last six months of life, and had at least one hospital discharge or at least two clinician visits in the last six months of life with cancer diagnosis codes associated with a high risk of near-term death and at least one hospital admission for cancer care in the last six months of life. These criteria exclude patients with many common cancers not associated with a high likelihood of dying in the near term. (Note: for a 40 percent sub-sample of beneficiaries for whom we had Part D claims, we identified fills of oral chemotherapy to augment Part B chemotherapy and immunotherapy claims.) We calculate NQF measures using our linked Medicare Provider Analysis and Review (MedPAR) files, hospice files, Part B and Part D files. In a recently published study, we focus on National Comprehensive Cancer Network and Comprehensive Cancer Center hospitals because they set national standards for high quality care. For more detail, view the published study:

Wasp GT, Alam SS, Brooks GA, Khayal IS, Kapadia NS, Carmichael DQ, Austin AM, Barnato AE. End-of-life quality metrics among medicare decedents at minority-serving cancer centers: A retrospective study. Cancer Med. 2020 Jan 11. doi:

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Definitions of measures can be found in EOLCancer_2016_Data_dictionary.xlsx, here:

Wasp G, Alam S, Brooks G, Khayal I, Kapadia N, Carmichael D, Austin AM, Barnato A. Replication Data for: Quality of EOL care for Medicare decedents at minority-serving cancer centers: A retrospective study, 2019, https://doi.org/10.21989/D9/BWKLG5, Root, V2, UNF:6:EhIotcC8AG17XAV53KBvbg== [fileUNF]