The impact of COVID-19 on time toxicity in patients with advanced cancer.

267 Background: The COVID-19 pandemic necessitated the rapid adoption of telemedicine but little is known about whether the changes in care delivery has led to differences in time toxicity for patients with advanced cancer. This study examines the impact of the pandemic on time toxicity, defined as the time burden of interacting with the healthcare system, by comparing healthcare contact days between pre-COVID and post-COVID periods. Methods: A retrospective cohort study was performed on patients with advanced (stage 4) cancer who died within one year of diagnosis at Kaiser Permanente Northern California between January 1, 2015 and June 30, 2023. Time toxicity was defined as the percentage of healthcare contact days over the course of survival period between cancer diagnosis and death (contact days/survival days). We included outpatient days (imaging, labs, treatment, provider visits), inpatient stays (emergency department, acute inpatient, non-acute institutional stays), and in-home days (in-home care, virtual care, home hospice). Differences between pre-COVID (diagnosed and died before March 1, 2020) and post-COVID (diagnosed after March 1, 2020) periods were analyzed using Wilcoxon tests. Results: The cohort included 9643 patients, with 6558 pre-COVID and 3085 post-COVID. Median age at diagnosis was 74 years, and the cohort was 46.9% female, largely white (64.5%), with a high comorbidity score (median Elixhauser score: 4). Post-COVID, there was an increase in institutional stay (8.7% vs. 9.3%) and outpatient service (imaging and labs) (4.4% vs. 3.1%), while in-person outpatient visits decreased (5.9% vs. 8.7%, p<0.0001). Additionally, in-home days increased (25.0% vs. 20.8%), with a significant rise in in-home virtual care (3.9% vs. 1.8%, all p<0.01). Conclusions: The COVID-19 pandemic led to notable shifts in healthcare utilization for patients with advanced cancer in the last year of life. The increase in telehealth and in-home services in the post-COVID era was accompanied by a slight increase in emergency and ancillary services. Further understanding patient experiences around these shifts is crucial for optimizing care and managing time toxicity in the evolving healthcare landscape. Description of outcomes pre and post-COVID-19 pandemic. Total Pre-COVID Post-COVID P-value Survival Days, median 86.0 84.0 89.0 0.02 Percentage of Contact, median (interquartile range) Comprehensive Contact 63.3 (41.0-92.0) 62.5 (40.7-91.0) 65.2 (41.7-94.1) 0.01 Institutional stay 9.0 (2.7-26.2) 8.7 (2.7-25.9) 9.3 (2.9-26.8) 0.11 Outpatient 12.4 (5.3-19.8) 12.9 (5.6-20.6) 11.2 (4.8-18.1) <.001 Outpatient visit 7.7 (2.8-13.4) 8.7 (3.5-14.6) 5.9 (1.6-10.7) <.0001 Outpatient service 3.5 (0.8-6.3) 3.1 (0.4-5.8) 4.4 (1.5-7.1) <.0001 In-home 22.2 (7.4-50.0) 20.8 (6.0-48.4) 25.0 (10.4-51.7) <.001 In-home care 18.1 (1.7-46.6) 17.4 (1.2-46.2) 19.2 (2.4-47.2) 0.03 In-home virtual care 2.2 (0.0-4.8) 1.8 (0.0-3.8) 3.9 (0.7-7.0) <.0001