Palliative care for hepatocellular carcinoma: A national analysis of temporal trends, outcomes, and a utilization plateau among decedents.

11 Background: Palliative care (PC) is crucial in managing advanced hepatocellular carcinoma (HCC). However, contemporary national data on its utilization trends, particularly among decedents, and its impact on resource use after methodological corrections are limited. This study aimed to analyze PC trends and associated outcomes in hospitalized U.S. patients with HCC. Methods: This retrospective cohort study utilized the National Inpatient Sample (NIS) from 2018-2022. Adult hospitalizations with a primary or secondary HCC diagnosis (C22.0). PC (Z51.5) and Do-Not-Resuscitate (DNR, Z66) status were identified. Temporal trends in PC/DNR utilization (overall and among in-hospital deaths) were assessed using logistic regression. Propensity score matching (PSM; 1:1, nearest neighbor, caliper 0.1) was performed to balance baseline characteristics (age, sex, race, payer, income quartile, comorbidities [liver disease, metastases, ascites, hepatic encephalopathy, renal failure, sepsis], severity score, hospital volume, year) between PC and non-PC groups. Outcomes in the matched cohort included in-hospital mortality and total hospital charges (log-transformed for regression). Results: Among 49,822 HCC admissions (mean age 65.7, 73.5% male), overall PC utilization increased from 18.9% in 2018 to 20.4% in 2022 (OR 1.028/year, 95% CI 1.012-1.044, p=0.001). However, among 4,870 in-hospital deaths, PC utilization plateaued (2018: 64.5%; 2022: 63.7%; OR 0.989/year, 95% CI 0.950-1.031, p=0.614). Similar trends were observed for DNR status (Overall OR 1.024/year, p=0.001; Deaths OR 0.989/year, p=0.607). In the PSM cohort (N=47,662; 9,283 PC patients). Regression analysis in the matched cohort revealed that PC was associated with a 13.06% reduction in mean total charges (95% CI -16.39% to -9.59%; p<0.001). The unadjusted mean cost difference was -$8,771 (p<0.0001). This cost-saving effect of PC appeared to diminish over study duration. Conclusions: This large, corrected national analysis reveals a concerning plateau in PC and DNR utilization among hospitalized HCC decedents since 2018, despite increasing overall PC use. PC is associated with substantial cost savings, underscoring its value. The observed plateau highlights a critical gap and the need for targeted strategies to improve timely PC delivery for HCC patients nearing end-of-life. Key temporal trends and matched cohort outcomes. Metric Group 2018 2022 Trend (OR) P-value PC Utilization (%) Overall 18.9 20.4 1.028 0.001 PC Utilization (%) Deaths Only 64.5 63.7 0.989 0.614 DNR Status (%) Overall 23.2 24.9 1.024 0.001 DNR Status (%) Deaths Only 68.1 67.8 0.989 0.607 Matched Cohort Outcomes (N=47,662) PC No-PC Difference P-value Mortality (%) 30.85 4.56 +26.29% <0.001 Cost Reduction (%)* - - -13.06% <0.001 *Cost reduction based on regression of log-transformed charges in matched cohort.