366 n www.ajmc.com n MAY 2014 CLINICAL © Managed Care & Healthcare Communications, LLC T he 5-year survival rate for patients with melanoma detected at the earliest stages is approximately 95%, 1 but falls precipitously to 15% for patients di- agnosed with metastatic disease. 2 Melanoma also places a signifcant economic burden on society and patients. 3 The estimated annual cost of melanoma care in the United States is $249 million and the average lifetime disease-associated cost for a patient from the time of diagnosis with melanoma until death is approximately $28,210. 3 Furthermore, 40% of the annual cost is attributed to stage 4 melanoma, which includes only around 3% of melanoma patients. 3 Since stage 4 melanoma is rarely curable, most medical treatment for these patients—including surgery, radiation therapy, chemotherapy, and biologic therapy—is prescribed with limited expectations for long-term survival, and often with palliative intent. Increasingly, hospice care has become an acceptable alternative for patients with metastatic cancer. Hospices provide the necessary care, pain management, and emotional support to provide a comfortable end-of-life experi- ence. The use of hospice also likely results in a decrease in uti- lization of surgery, radiation therapy, and chemotherapy, 4 thus likely leading to a decrease in medical costs, although this has not been studied among patients with metastatic melanoma. Other investigators have shown that hospice utilization does not result in shortened survival for other terminal illnesses such as advanced lung cancer and pancreatic cancer. 5,6 How- ever, no studies have examined whether survival is reduced when patients elect hospice care for metastatic melanoma. Our goal is to examine the associations of use of hospice care with survival and costs among patients with metastatic mela- noma and to analyze the cost-efectiveness for diferent dura- tions of hospice care in patients with this disease. METHODS Data Source and Cohort Definition We conducted this study using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Re- Survival and Cost-Efectiveness of Hospice Care for Metastatic Melanoma Patients Jinhai Huo, PhD, MD, MPH; David R. Lairson, PhD; Xianglin L. Du, MD, PhD; Wenyaw Chan, PhD; Thomas A. Buchholz, MD; and B. Ashleigh Guadagnolo, MD, MPH Objectives We analyzed the association of hospice use with survival and healthcare costs among patients diagnosed with metastatic melanoma. Methods We used the Surveillance, Epidemiology, and End Results (SEER)- Medicare-linked databases to identify patients 65 years or older with metastatic melanoma who died between 2000 and 2009. We analyzed claims data to ascertain cancer treatment utilization and costs. Survival, end-of-life costs, and incremental cost-effective- ness ratio were evaluated using propensity score methods. Costs were analyzed from the payer perspective in 2009 dollars. Results Of 862 patients, 225 (26%) received no hospice care, 523 (61%) received 1 to 3 days of hospice care, and 114 (13%) received 4 or more days of hospice care. The median survival time was 6.1 months for patients with no hospice care, 6.5 months for patients enrolled in hospice for 1 to 3 days, and 10.2 months for patients enrolled for 4 or more days (P <.001). The hazard ratio for survival among patients with 4 or more days of hospice use was 0.66; 95% confidence interval, 0.54-0.81, P <.0001 in the propensity score–matched model. Patients with 4 or more days of hospice care incurred lower end-of-life costs than the comparison groups ($14,594 vs $22,647 for the 1-to-3-days hospice care, and $28,923 for patients with no hospice care; P <.0001). Conclusions Patients diagnosed with metastatic melanoma who enrolled in 4 or more days of hospice care had longer survival than those who had 1 to 3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs. Am J Manag Care. 2014;20(5):366-373