The Role of Palliative Care at the Time of Stereotactic Radiosurgery on Healthcare Utilization for Frail Patients with Brain Metastases

Objectives The 5-factor modified frailty index (mFI-5) has been increasingly studied in the context of patients with central nervous system tumors. Previously, studies have demonstrated an inverse relationship between increasing mFI-5 scores and overall/progression free survival in patients with brain metastases (BMs) undergoing stereotactic radiosurgery (SRS). Methods A single payer insurance database was queried for patients undergoing SRS for BMs. Patients were stratified based on mFI-5 scores as follows: pre-frail (0-1), frail (2), and severely frail (≥3). Survival trends and healthcare utilization rates following treatment were analyzed across each frailty group. Results A total of 9927 patients were retrospectively analyzed. Overall survival (OS) was significantly decreased in the frail and severely frail groups compared to pre-frail patients (frail: HR: 1.55, 95% CI: 1.33-1.80, p<.0001) and (severely frail: HR: 2.12, 95% CI: 1.84-2.44, p<0.0001). Increased healthcare utilization was observed after SRS in frail and severely frail patients (frail: 90-day RR 1.07, 180-day RR 1.08. and 1-year RR 1.10, P<0.0001; severely frail: 90-day RR 1.16, 180-day RR 1.18, 1-year RR 1.21, p< 0.0001). In patients with established palliative care involvement at the time of SRS, healthcare utilization rates were decreased in the frail and severely frail groups. Conclusion Increasing frailty scores portended reduced OS with increased overall healthcare utilization rates. The introduction of palliative care prior to SRS decreased healthcare utilization rates across frailty cohorts.