Identifying potential indicators of the quality of end-of-life cancer care from administrative data

PURPOSE

To explore potential indicators of the quality of end-of-life services for cancer patients that could be monitored using existing administrative data.

METHODS

Quality indicators were identified and assessed by literature review for proposed indicators, focus groups with cancer patients and family members to assess candidate indicators and generate new ideas, and an expert panel ranking the meaningfulness and importance of each potential indicator using a modified Delphi approach.

RESULTS

There were three major concepts of poor quality of end-of-life cancer care that could be examined using currently-available administrative data (such as Medicare claims): institution of new anticancer therapies or continuation of ongoing treatments very near death; a high number of emergency room visits, inpatient hospital admissions, or intensive care unit days near the end of life; and a high proportion of patients never enrolled in hospice, only admitted in the last few days of life, or dying in an acute-care setting. Concepts such as access to psychosocial and other multidisciplinary services and pain and symptom control are important and may eventually be feasible, but they cannot currently be applied in most data systems. Indicators based on limiting the use of treatments with low probability of benefit or indicators based on economic efficiency were not acceptable to patients, family members, or physicians.

CONCLUSION

Several promising claims-based quality indicators were identified that, if found to be valid and reliable within data systems, could be useful in identifying health-care systems in need of improving end-of-life services.

A survey exploring the educational needs of care practitioners in learning disability (LD) settings in relation to death, dying and people with learning disabilities

This paper presents the findings of a small scale pilot study which explored the educational base and needs of qualified care practitioners in Learning Disability (LD) settings in relation to death, dying and people with learning disabilities. Eighty questionnaires were sent to two NHS Trusts in the South of England. The response rate for the qualified care practitioners from Cherry Blossom (CB) was 100%, whereas for Greengages (GG), the response rate was only 25%. The response from the unqualified care practitioners was disappointingly low, hence we declared them null and void. The analysis of data highlighted major concerns: namely, a lack of consistent policy in the recording of death in residential homes for dying persons with LD; a lack of knowledge, particularly in psychosocial aspects and skills in care of dying persons. The majority of the qualified care practitioners surveyed highlighted the importance of communication with clients and their families. We recommend that communication and interpersonal skills in the care and management of the terminally ill persons with LD be the core component in the nursing curriculum which at present only indicates a trace of it. It is not made explicit that it is essential. This study supports the notion that issues of LD override and obscure physical illness. Our study also highlights ambiguity in the use of concepts and terminology, and demonstrates some limitations in our methodology. We propose that further research, using different methodological approaches, such as Ethnography, Ethnomethodology, or a combination of these, would be appropriate.

'If only someone had told me . . .' A review of the care of patients dying in hospital

Approximately half of all patients who die do so in hospital. Despite the advent of palliative care in the UK, there is evidence that the care that many patients receive in the final phase of their illness in hospital is poor. Building on a study of bereaved relatives' views of the information provided by an inner city hospital trust during an admission in which a patient died, this article explores the factors that may contribute to sub-optimal care for patients dying in hospital. In particular, a lack of open communication, difficulties in accurate prognostication and a lack of planning of end-of-life care can all result in poor care. Strategies to improve care, such as the use of integrated care pathways, advance directives and education initiatives, are discussed.

Measuring quality of palliative care: psychometric properties of the FAMCARE Scale

This study measures quality of palliative care in 181 family members (i.e. spouse, child) to cancer victims with terminal disease 1 month after the time of death. The specific aim was to explore the underlying factor structure and dimensionality of the 20 items of the FAMCARE Scale, measuring family satisfaction with health care given to the patient and to them. The results from a factor analysis, a Mokken Scaling Program analysis, and a reliability analysis, showed that 19 out of the 20 items form a strong one-dimensional scale. Since the scale is one-dimensional, the possibility of reducing the number of items should be explored in future research. Our recommendation is to measure satisfaction with care 1-2 months after the death of the patient. One should also explore the possibilities of measuring satisfaction with care prospectively as an integral part of the palliative care program.

The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care

BACKGROUND

The health implications of regional differences in Medicare spending are unknown.

OBJECTIVE

To determine whether regions with higher Medicare spending provide better care.

DESIGN

Cohort study.

SETTING

National study of Medicare beneficiaries.

PATIENTS

Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306).

OUTCOME MEASUREMENTS

Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care).

RESULTS

Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse.

CONCLUSIONS

Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.

The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care

BACKGROUND

The health implications of regional differences in Medicare spending are unknown.

OBJECTIVE

To determine whether regions with higher Medicare spending achieve better survival, functional status, or satisfaction with care.

DESIGN

Cohort study.

SETTING

National study of Medicare beneficiaries.

PATIENTS

Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (MCBS) (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306).

OUTCOME MEASUREMENTS

5-year mortality rate (all four cohorts), change in functional status (MCBS cohort), and satisfaction (MCBS cohort).

RESULTS

Cohort members were similar in baseline health status, but those in regions with higher end-of-life spending received 60% more care. Each 10% increase in regional end-of-life spending was associated with the following relative risks for death: hip fracture cohort, 1.003 (95% CI, 0.999 to 1.006); colorectal cancer cohort, 1.012 (CI, 1.004 to 1.019); acute myocardial infarction cohort, 1.007 (CI, 1.001 to 1.014); and MCBS cohort, 1.01 (CI, 0.99 to 1.03). There were no differences in the rate of decline in functional status across spending levels and no consistent differences in satisfaction.

CONCLUSIONS

Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.

Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers

OBJECTIVE

To describe the experiences of illness and needs and use of services in two groups of patients with incurable cancer, one in a developed country and the other in a developing country.

DESIGN

Scotland: longitudinal study with qualitative interviews. Kenya: cross sectional study with qualitative interviews.

SETTINGS

Lothian region, Scotland, and Meru District, Kenya.

PARTICIPANTS

Scotland: 20 patients with inoperable lung cancer and their carers. Kenya: 24 patients with common advanced cancers and their main informal carers.

MAIN OUTCOME MEASURES

Descriptions of experiences, needs, and available services.

RESULTS

67 interviews were conducted in Scotland and 46 in Kenya. The emotional pain of facing death was the prime concern of Scottish patients and their carers, while physical pain and financial worries dominated the lives of Kenyan patients and their carers. In Scotland, free health and social services (including financial assistance) were available, but sometimes underused. In Kenya, analgesia, essential equipment, suitable food, and assistance in care were often inaccessible and unaffordable, resulting in considerable unmet physical needs. Kenyan patients thought that their psychological, social, and spiritual needs were met by their families, local community, and religious groups. Some Scottish patients thought that such non-physical needs went unmet.

CONCLUSIONS

In patients living in developed and developing countries there are differences not only in resources available for patients dying from cancer but also in their lived experience of illness. The expression of needs and how they are met in different cultural contexts can inform local assessment of needs and provide insights for initiatives in holistic cancer care.

Beyond ethical dilemmas: improving the quality of end-of-life care in the intensive care unit

Consensus guidelines on providing optimal end-of-life care in the intensive care unit (ICU) are important tools. However, despite 30 years of ethical discourse and consensus on many of the principles that guide end-of-life care in the ICU, care remains inadequate. Although consensus on the most challenging ethical aspects of some cases will remain elusive, this need not deter clinicians from engaging in practical quality improvement, best practice, and educational interventions to provide compassionate care to all critically ill patients, including those who ultimately die.

ESRD Workgroup Final Report Summary on End-of-Life Care: recommendations to the field

In 1997, The Robert Wood Johnson Foundation launched a national program Promoting Excellence in End-of-Life Care with a mission of improving care and quality of life for dying Americans and their families. We soon realized that the metaphor of a jigsaw puzzle seemed apt in describing our efforts to expand access to services and improve quality of care in a wide range of settings and with diverse populations. No single approach would suffice--a variety of strategies, models of care, and stakeholders are necessary to successfully complete the picture. This monograph represents one aspect of our work and one piece of the puzzle of ensuring that the highest quality of care, including palliative care, is available to all seriously ill patients and their families.

Surveys to assess satisfaction with end-of-life care: does timing matter?

The goals of this study were to determine whether post-death surveys of family members cause more distress if they are administered closer in time to the patient's death, and whether family members are less likely to respond to earlier surveys. Caregivers of hospice patients were randomly assigned to receive a survey at 2 weeks (n = 107) or at 6 weeks (n = 100) after the patient's death. Response rates and self-reported distress experienced in completing the survey were recorded. There were no differences in self-ratings of distress between 2- and 6-week surveys, and response rates were identical (2-week: 54%; 6-week: 54%). Distress and response rate do not appear to be influenced by the timing of data collection, even when surveys are administered very soon after death.

[Health care quality in terminal cardiac decompensation: a "multidisciplinary" reflexion]

Although improved, the prognosis of chronic heart failure is still malignant, the survival rate being similar to that of cancer. Due to the relevant epidemiology of this disease, the terminal care of heart failure has a significant impact, searching for the best quality of cure and care.

Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers?

Palliative care provision varies widely, and the effectiveness of palliative and hospice care teams (PCHCT) is unproven. To determine the effect of PCHCT, 10 electronic databases (to 2000), 4 relevant journals, associated reference lists, and the grey literature were searched. All PCHCT evaluations were included. Anecdotal and case reports were excluded. Forty-four studies evaluated PCHCT provision. Teams were home care (22), hospital-based (9), combined home/hospital care (4), inpatient units (3), and integrated teams (6). Studies were mostly Grade II or III quality. Funnel plots indicated slight publication bias. Meta-regression (26 studies) found slight positive effect, of approximately 0.1, of PCHCTs on patient outcomes, independent of team make-up, patient diagnosis, country, or study design. Meta-analysis (19 studies) demonstrated small benefit on patients' pain (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.23-0.64), other symptoms (OR: 0.51, CI: 0.30-0.88), and a non-significant trend towards benefits for satisfaction, and therapeutic interventions. Data regarding home deaths were equivocal. Meta-synthesis (all studies) found wide variations in the type of service delivered by each team; there was no discernible difference in outcomes between city, urban, and rural areas. Evidence of benefit was strongest for home care. Only one study provided full economic cost-benefit evaluation. This is the first study to quantitatively demonstrate benefit from PCHCTs. Such comparisons were limited by the quality of the research.

Analysis of the circumstances at the end of life in children with cancer: a single institution's experience in Japan

BACKGROUND

With the aim of improving the quality of life of children with cancer, this study presents an analysis of one hospital's experience with terminal care.

METHODS

Between 1994 and 2000, 28 children died after treatment for cancer at Hamamatsu University Hospital. The circumstances of their deaths were analyzed through medical records and interviews with 8 sets of bereaved parents. We compared results of this analysis with our previous data collected from 1978 to 1993.

RESULTS

Of the 28 children, 11 had leukemia/lymphoma (LL group) and 17 had solid tumors (ST group). Six children (21.4%), all of whom were in the LL group, died of treatment-related complications. Twenty children (71.4%) died during terminal care: three (27.3%) were in the LL group and 17 (100%) in the ST group. Eleven children (39.3%) received terminal care at home and eight (28.6%) of these died at home. The number of children who received terminal care and died at home had increased in comparison with the previous period. Among problems with terminal care identified by parents were the lack of opportunity for the child to continue with education and an inadequate support system after the child's death.

CONCLUSIONS

Some advances in the quality of life of the children were recognized. However, these advances were extended to a greater percentage of children in the ST group than in the LL group. The psychosocial problems faced by children and their families are now changing for the better.

The challenges and opportunities in providing end-of-life care in nursing homes

Approximately 20% of deaths in the United States occur in nursing homes. That percentage is expected to increase as the population continues to age. As a setting for end-of-life care, nursing homes provide both challenges and opportunities. This article examines factors that impede the delivery of high-quality end-of-life care in nursing homes, such as inadequate staff and physician training, regulatory and reimbursement issues, poor symptom management, and lack of psychosocial support for staff, residents, and families. In addition to discussing hindrances to providing end-of-life care, this article explores characteristics of nursing homes and their staff that support the care of terminally ill residents. Also included is an overview of models for delivering end-of-life care in nursing homes, including provision of hospice services, specialized palliative care units, and consultation services. Finally, this article discusses educational programs and current educational initiatives to enhance end-of-life care in nursing homes.