Association of Public Policy With Palliative Care Uptake in Patients With Head and Neck Cancer

Introduction: Palliative care is an appropriate therapy for patients with advanced malignancies, but receipt remains low in head and neck cancer (HNC) patients. We investigated the association between Medicaid expansion under the Affordable Care Act (ACA) and other palliative care-specific policies with receiving palliative care in patients diagnosed with advanced-stage HNC.

Methods: Patients with HNC and terminal hospitalization were identified in the National Cancer Database between 2004 and 2019. Using the region variable in NCDB, we connected the Yale palliative Care GPS which has more granular data on PC-specific policies. Using difference-in-difference analysis, we looked at PC uptake after Medicaid expansion. Using logistic regression, we controlled for disease characteristics (CCI, stage, cancer site) and social determinants of health (gender, age, insurance, income, race), setting (facility type, rural/urban, distance, facility type).

Results: A total of 143,725 patients who died with stage III and IV head and neck cancer diagnoses were included in the study, amongst which 5.4% received palliative care. There was an increase in PC use in both states that had Medicaid expansion (4.6% vs 7.5%) and those that did not (4.3% vs 6.8%) before and after the ACA implementation. The difference in difference was positive but not statistically significant (DD: 0.38 percentage points; 95% CI: -1.2, 2.0, P = 0.6). When controlling for confounders, the total number of laws regardless of the status, the number of failed laws, and the number of specific types of laws (public awareness, payment, quality, clinical skills) were not associated with increased PC uptake. With 23, the South Atlantic had the highest number of enacted/adopted laws and with 36, West North Central had the highest number of vetoed/failed laws.

Conclusions: While there was an increase in PC over the years for patients at end of life with HNC, this positive increase is not significantly associated with PC policies or Medicaid expansion. This may suggest that while there are efforts to ease PC adoption, there is a lack of policy implementation.