Digestive Diseases and Sciences

, Volume 63, Issue 5, pp 1173–1181 | Cite as

Determinants and Outcomes of Hospice Utilization Among Patients with Advance-Staged Hepatocellular Carcinoma in a Veteran Affairs Population

  • Winnie Y. Zou
  • Hashem B. El-Serag
  • Yvonne H. Sada
  • Sarah L. Temple
  • Shubhada Sansgiry
  • Fasiha Kanwal
  • Jessica A. Davila
Original Article



Hospice provides integrative palliative care for advance-staged hepatocellular carcinoma (HCC) patients, but hospice utilization in HCC patients in the USA is not clearly understood.


We examined hospice use and subsequent clinical course in advance-staged HCC patients.


We conducted a retrospective study on a national, Veterans Affairs cohort with stage C or D HCC. We evaluated demographics, clinical factors, treatment, and clinical course in relation to hospice use.


We identified 814 patients with advanced HCC, of whom 597 (73.3%) used hospice. Oncologist management consistently predicted hospice use, irrespective of HCC treatment [no treatment: OR 2.25 (1.18–4.3), treatment: OR 1.80 (1.10–2.95)]. Among patients who received HCC treatment, hospice users were less likely to have insurance beyond VA benefits (47.2 vs. 60.0%, p = 0.01). Among patients without HCC treatment, hospice users were older (62.2 [17.2] vs. 60.2 [14.0] years, p = 0.05), white (62.1 vs. 52.9%, p = 0.01), resided in the Southern USA (39.5 vs. 31.8%, p = 0.05), and had a performance score ≥ 3 (41.9 vs. 31.8%, p = 0.01). The median time from hospice entry to death or end of study was 1.05 [2.96] months for stage C and 0.53 [1.18] months for stage D patients.


26.7% advance-staged HCC patients never entered hospice, representing potential missed opportunities for improving end-of-life care. Age, race, location, performance, insurance, and managing specialty can predict hospice use. Differences in managing specialty and short-term hospice use suggest that interventions to optimize early palliative care are necessary.


Hospice Palliative care Hepatocellular carcinoma Veteran 



This project was supported in part by the National Cancer Institute (R01 CA160738; PI, J. Davila), and the facilities and resources Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Author’s contribution

WYZ designed the study, acquired, analyzed, and interpreted the data and drafted the manuscript. HBE and JAD conceptualized and designed the study and critically revised the manuscript. YHS, SLT, and SS acquired, analyzed, and interpreted the data. FK analyzed and interpreted the data and provided critical revision for the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Supplementary material

10620_2018_4989_MOESM1_ESM.pptx (56 kb)
Supplemental Figure 1 Kaplan–Meier survival analysis of late-stage HCC patients (BCLC stages C and D) grouped by hospice use and treatment status (PPTX 55 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Winnie Y. Zou
    • 1
    • 2
  • Hashem B. El-Serag
    • 1
    • 2
  • Yvonne H. Sada
    • 1
    • 2
  • Sarah L. Temple
    • 1
  • Shubhada Sansgiry
    • 1
    • 3
  • Fasiha Kanwal
    • 1
    • 2
  • Jessica A. Davila
    • 1
    • 2
  1. 1.Center of Innovation, Effectiveness and QualityThe Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of MedicineHoustonUSA
  2. 2.Sections of Health Services Research and Gastroenterology and HepatologyThe Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of MedicineHoustonUSA
  3. 3.South Central Mental Illness Research, Education and Clinical CentersThe Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of MedicineHoustonUSA

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