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Adsersen M, Thygesen LC, Jensen AB, Neergaard MA, Sjøgren P, Groenvold M. Is admittance to specialised palliative care among cancer patients related to sex, age and cancer diagnosis? A nation-wide study from the Danish Palliative Care Database (DPD). BMC Palliat Care 2017; 16:21. [PMID: 28330507 PMCID: PMC5363002 DOI: 10.1186/s12904-017-0194-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were to investigate whether cancer patients' admittance to SPC in Denmark varied in relation to sex, age and diagnosis, and whether the patterns differed by type of institution (hospital-based palliative care team/unit, hospice, or both). METHODS This was a register-based study of adult patients living in Denmark who died from cancer in 2010-2012. Data sources were the Danish Palliative Care Database, Danish Register of Causes of Death and Danish Cancer Registry. The associations between the explanatory variables (sex, age, diagnosis) and admittance to SPC were investigated using logistic regression. RESULTS In the study population (N = 44,548) the overall admittance proportion to SPC was 37%. Higher odds of overall admittance to SPC were found for women (OR = 1.23; 1.17-1.28), younger patients (<40 compared with 80+ years old) (OR = 6.44; 5.19-7.99) and patients with sarcoma, pancreatic and stomach cancers, whereas the lowest were for patients with haematological malignancies. The higher admission found for women was most pronounced for hospices compared to hospital-based palliative care teams/units, whereas higher admission of younger patients was more pronounced for hospital-based palliative care teams/units. Patients with brain cancer were more often admitted to hospices, whereas patients with prostate cancer were more often admitted to hospital-based palliative care teams/units. CONCLUSION It is unlikely that the variations in relation to sex, age and cancer diagnoses can be fully explained by differences in need. Future research should investigate whether the groups having the lowest admittance to SPC receive sufficient palliative care elsewhere.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Personas enfermas al final de la vida: vivencias en la accesibilidad a recursos sociosanitarios. ENFERMERÍA UNIVERSITARIA 2017. [DOI: 10.1016/j.reu.2016.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rosenwax L, Spilsbury K, McNamara BA, Semmens JB. A retrospective population based cohort study of access to specialist palliative care in the last year of life: who is still missing out a decade on? BMC Palliat Care 2016; 15:46. [PMID: 27165411 PMCID: PMC4862038 DOI: 10.1186/s12904-016-0119-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/27/2016] [Indexed: 12/31/2022] Open
Abstract
Background Historically, specialist palliative care has been accessed by a greater proportion of people dying with cancer compared to people with other life-limiting conditions. More recently, a variety of measures to improve access to palliative care for people dying from non-cancer conditions have been implemented. There are few rigorous population-based studies that document changes in palliative care service delivery relative to the number of patients who could benefit from such services. Method A retrospective cohort study of the last year of life of persons with an underlying cause of death in 2009–10 from cancer, heart failure, renal failure, liver failure, chronic obstructive pulmonary disease, Alzheimer’s disease, motor neurone disease, Parkinson’s disease, Huntington’s disease and/or HIV/AIDS. The proportion of decedents receiving specialist palliative care was compared to a 2000–02 cohort. Logistic regression models were used identify social and demographic factors associated with accessing specialist palliative care. Results There were 12,817 deaths included into the cohort; 7166 (56 %) from cancer, 527 (4 %) from both cancer and non-cancer conditions and 5124 (40 %) from non-cancer conditions. Overall, 46.3 % of decedents received community and/or hospital based specialist palliative care; a 3.5 % (95 % CI 2.3–4.7) increase on specialist palliative care access reported ten years earlier. The majority (69 %; n = 4928) of decedents with cancer accessed palliative care during the last year of life. Only 14 % (n = 729) of decedents with non-cancer conditions accessed specialist palliative care, however, this represented a 6.1 % (95 % CI 4.9–7.3) increase on the specialist palliative care access reported for the same decedent group ten years earlier. Compared to decedents with heart failure, increased odds of palliative care access was observed for decedents with cancer (OR 10.5; 95 % CI 9.1–12.2), renal failure (OR 1.5; 95 % CI 1.3–1.9), liver failure (OR 2.3; 95 % CI 1.7–3.3) or motor neurone disease (OR 4.5; 95 % CI 3.1–6.6). Living in major cities, being female, having a partner and living in a private residence was associated with increased odds of access to specialist palliative care. Conclusion There is small but significant increase in access to specialist palliative care services in Western Australia, specifically in patients dying with non-cancer conditions. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0119-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lorna Rosenwax
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845, Australia.
| | - Katrina Spilsbury
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Beverley A McNamara
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845, Australia
| | - James B Semmens
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
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Johnston G, Urquhart R, Lethbridge L, MacIntyre M. Increasing our understanding of dying of breast cancer: Comorbidities and care. PROGRESS IN PALLIATIVE CARE 2016; 24:147-152. [PMID: 27365898 PMCID: PMC4917901 DOI: 10.1080/09699260.2015.1108638] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background: Screening and treatment for breast cancer have improved. However, attention to palliative support and non-cancer co-morbidities has been limited. This study identified types of care for and co-morbidities of persons dying of breast cancer compared to persons dying from all cancers and from non-cancer causes. Methods: Linked administrative data from population-based registries were used to examine 121,458 deaths in Nova Scotia from 1995 to 2009. Results: Breast cancer decedents' mean age was similar to that of all cancer decedents (72.0 versus 72.1 years), but their age spread was greater (20-59 years: 23.1% versus 16.7%; 90+ years: 11.2% versus 6.5%). Among women dying of breast cancer, 15.6% were enrolled in the diabetes registry and 15.1% in the cardiovascular registry, indicating that they had these non-cancer conditions prior to their death. Compared to all cancer decedents, breast cancer decedents were twice as likely to have dementia as a cause of death, and were less likely to die in hospital but more likely to die in a nursing home. Breast cancer decedents had place of death rates more similar to non-cancer than cancer decedents. Conclusions: Rates of dementia and diabetes among the breast cancer decedents were particularly note-worthy in this novel study given that these comorbidities have not received much attention in the breast cancer research literature. Further collaboration with non-cancer disease programs is advised. The extent of adequate comprehensive palliative support for the 20% of the breast cancer decedents who are nursing home residents requires investigation.
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Affiliation(s)
- G.M. Johnston
- School of Health Administration, Dalhousie University, Halifax, Canada
- Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Canada
| | - R. Urquhart
- Department of Surgery, Dalhousie University, Halifax, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - L. Lethbridge
- School of Health Administration, Dalhousie University, Halifax, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - M. MacIntyre
- Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Canada
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Health service use and costs in the last 6 months of life in elderly decedents with a history of cancer: a comprehensive analysis from a health payer perspective. Br J Cancer 2016; 114:1293-302. [PMID: 27115468 PMCID: PMC4891509 DOI: 10.1038/bjc.2016.75] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/27/2015] [Accepted: 12/04/2015] [Indexed: 01/02/2023] Open
Abstract
Background: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end. Methods: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes. Results: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life. Conclusions: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery.
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Bainbridge D, Seow H, Sussman J, Pond G, Barbera L. Factors associated with not receiving homecare, end-of-life homecare, or early homecare referral among cancer decedents: A population-based cohort study. Health Policy 2015; 119:831-9. [DOI: 10.1016/j.healthpol.2014.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 10/27/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
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Morin L, Aubry R. Accessibilité de l’offre de soins palliatifs à l’hôpital en France : de fortes inégalités entre régions. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2015. [DOI: 10.1016/j.medpal.2015.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Resource use, costs and quality of end-of-life care: observations in a cohort of elderly Australian cancer decedents. Implement Sci 2015; 10:25. [PMID: 25884470 PMCID: PMC4350285 DOI: 10.1186/s13012-014-0148-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/19/2014] [Indexed: 11/10/2022] Open
Abstract
Background The last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data. Methods/Design This study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans’ Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes. Discussion This will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0148-2) contains supplementary material, which is available to authorized users.
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Urquhart R, Johnston G, Abdolell M, Porter GA. Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis. BMC Palliat Care 2015; 14:2. [PMID: 25674038 PMCID: PMC4324424 DOI: 10.1186/1472-684x-14-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/14/2015] [Indexed: 01/08/2023] Open
Abstract
Background Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis. Methods Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases. Results The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis. Conclusions Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.
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Affiliation(s)
- Robin Urquhart
- Department of Surgery, Dalhousie University, Halifax, NS Canada ; Cancer Outcomes Research Program, Dalhousie University/Capital District Health Authority, Halifax, NS Canada
| | - Grace Johnston
- School of Health Administration, Dalhousie University, Halifax, NS Canada
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS Canada
| | - Geoff A Porter
- Department of Surgery, Dalhousie University, Halifax, NS Canada ; Cancer Outcomes Research Program, Dalhousie University/Capital District Health Authority, Halifax, NS Canada
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Freeman S, Hirdes JP, Stolee P, Garcia J, Smith TF, Steel K, Morris JN. Care planning needs of palliative home care clients: Development of the interRAI palliative care assessment clinical assessment protocols (CAPs). BMC Palliat Care 2014; 13:58. [PMID: 25550682 PMCID: PMC4279598 DOI: 10.1186/1472-684x-13-58] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The interRAI Palliative Care (interRAI PC) assessment instrument provides a standardized, comprehensive means to identify person-specific need and supports clinicians to address important factors such as aspects of function, health, and social support. The interRAI Clinical Assessment Protocols (CAPs) inform clinicians of priority issues requiring further investigation where specific intervention may be warranted and equip clinicians with evidence to better inform development of a person-specific plan of care. This is the first study to describe the interRAI PC CAP development process and provide an overview of distributional properties of the eight interRAI PC CAPs among community dwelling adults receiving palliative home care services. METHODS Secondary data analysis used interRAI PC assessments (N = 6,769) collected as part of regular clinical practice at baseline (N = 6,769) and follow-up (N = 1,000). Clients across six regional jurisdictions in Ontario, Canada, assessed to receive palliative homecare services between 2006 and 2011 were included (mean age 70.0 years; ±13.4 years). Descriptive analyses focused on the eight interRAI PC CAPs: Fatigue, Sleep Disturbance, Nutrition, Pressure Ulcers, Pain, Dyspnea, Mood Disturbance and Delirium. RESULTS The majority of clients triggered at least one CAP while two thirds triggered two or more. Triggering rates ranged from 74% for the Fatigue CAP to less than 15% for the Delirium and Pressure Ulcers CAPs. The hierarchical CAP triggering structure suggested Fatigue and Dyspnea CAPs were persistent issues prevalent among the majority of clients while Delirium and Pressure Ulcers CAPs rarely trigger in isolation and most often trigger later in the illness trajectory. CONCLUSION When any of the eight interRAI PC CAPs are triggered, clinicians should take notice. CAPs triggered at high rates such as fatigue, dyspnea, and pain warrant increased attention for the majority of clients. Consideration of triggered CAPs provide evidence to inform a collaborative decision making process on whether or not issues raised by the CAPs should be addressed in the plan of care. Integrating evidence from the interRAI PC CAPs into the clinical decision making process support care planning to address client strengths, preferences and needs with greater acuity.
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Affiliation(s)
- Shannon Freeman
- School of Health Sciences, University of Northern British Columbia, 3333 University Way, Prince George, British Columbia V2N 4Z9 Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. West, Waterloo, ON N2L 6P4 Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. West, Waterloo, ON N2L 6P4 Canada
| | - John Garcia
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave. West, Waterloo, ON N2L 6P4 Canada
| | - Trevor Frise Smith
- Department of Sociology, Nipissing University, North Bay, Ontario Canada
| | - Knight Steel
- Retired Chief Emeritus of Geriatrics, Hackensack University Medical Center, 20 Prospect Ave, Hackensack, NJ 07601 USA
| | - John N Morris
- Hebrew Senior Life, 1200 Centre Street, Boston, MA 02131 USA
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Salami AC, Barden GM, Castillo DL, Hanna M, Petersen NJ, Davila JA, Naik AD, Anaya DA. Establishment of a Regional Virtual Tumor Board Program to Improve the Process of Care for Patients With Hepatocellular Carcinoma. J Oncol Pract 2014; 11:e66-74. [PMID: 25466708 DOI: 10.1200/jop.2014.000679] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Multidisciplinary evaluation (MDE) of hepatocellular cancer (HCC) is the current standard, often provided through a tumor board (TB) forum; this standard is limited by oncology workforce shortages and lack of a TB at every institution. Virtual TBs (VTBs) may help overcome these limitations. Our study aim was to assess the impact of a regional VTB on the MDE process for patients with HCC. METHODS A retrospective cohort study was conducted, including patients with HCC referred to a tertiary cancer center from regional facilities (2009 to 2013). Baseline characteristics and outcomes were compared based on the referral mechanism: VTB versus subspecialty consultation (non-VTB). The primary outcome was comprehensive MDE (all required specialists present and key topics discussed). Secondary outcomes included timeliness of MDE and travel burden to complete MDE. Univariable and multivariable logistic regressions were performed to examine the association of a VTB with comprehensive MDE. RESULTS A total of 116 patients were included in the study; 48 (41.4%) were evaluated through the VTB. A higher proportion of VTB patients received comprehensive MDE (91.7% v 64.7%; P = .001); the VTB was independently associated with higher odds of accomplishing comprehensive MDE (odds ratio, 6.0; 95% CI, 1.2 to 29.9; P = .02). VTB patients completed MDE significantly faster (median, 23 v 39 days; P < .001), with lower travel burden (median, 0 v 683 miles traveled; P < .001). CONCLUSION This VTB program positively affected the process of care for patients with HCC by improving the quality and timeliness of the MDE process, while avoiding the burden arising from travel needs. Future studies should focus on implementation of VTB programs on a wider scale.
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Affiliation(s)
- Aitua C Salami
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Gala M Barden
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Diana L Castillo
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Mina Hanna
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Nancy J Petersen
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Jessica A Davila
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Aanand D Naik
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
| | - Daniel A Anaya
- Houston Veterans Affairs (VA) Center for Innovations in Quality, Effectiveness and Safety; Michael E. DeBakey VA Medical Center; and Baylor College of Medicine, Houston, TX
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Langton JM, Blanch B, Drew AK, Haas M, Ingham JM, Pearson SA. Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review. Palliat Med 2014; 28:1167-96. [PMID: 24866758 DOI: 10.1177/0269216314533813] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care. AIM To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care. DESIGN A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology. DATA SOURCES We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus. RESULTS We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services. CONCLUSION Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.
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Affiliation(s)
- Julia M Langton
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Bianca Blanch
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Anna K Drew
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Marion Haas
- Centre for Health Economics Research and Evaluation, The University of Technology Sydney, Sydney, NSW, Australia
| | - Jane M Ingham
- Cunningham Centre for Palliative Care, Sacred Heart Health Service, NSW, Australia St Vincents' Hospital Clinical School, Faculty of Medicine, The University of New South Wales, NSW, Australia
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Huang J, Wai ES, Lau F, Blood PA. Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study. BMC Palliat Care 2014; 13:49. [PMID: 25419181 PMCID: PMC4240806 DOI: 10.1186/1472-684x-13-49] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/29/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The use of palliative radiotherapy (PRT) is variable in advanced cancer. Little is known about PRT utilization by end-of-life (EOL) cancer patients in Canada. This study examined the PRT utilization rates and factors associated with its use in a cohort of cancer patients who died in British Columbia (BC). METHODS BC residents with invasive cancer who died between April 1, 2010 and March 31, 2011 were included in the study. Their cancer registry and radiotherapy treatment records were extracted from the BC Cancer Agency information systems and linked for the analysis. The PRT utilization rates by age, sex, primary cancer diagnosis, geographic region, survival time and travel time to the cancer centre were examined. Multivariable logistic regression was used to determine the factors that influenced the PRT utilization rates. RESULTS Of the 12,300 decedents in the study 2,669 (21.7%) had received at least one course of PRT in their last year of life. The utilization rates dropped to 5.0% and 2.2% in the last 30 and 14 days of life, respectively. PRT utilization varied across diagnosis and was highest for lung cancer (45.7%) and lowest for colorectal cancer (8.9%). The rates also varied by age, survival time and travel time to the nearest radiotherapy centre. There was a greater odds of receiving PRT for those with primary lung cancer, survival time between 1.5-26 months from diagnosis or living within 2 hours from a cancer centre. The 85+ age group was least likely to receive PRT in their last year of life. CONCLUSIONS This study found PRT utilization rates of EOL cancer decedents to be variable across the province of BC. Age, diagnosis, survival time and travel time to the nearest radiotherapy centre were found to influence the odds of PRT treatment. Further work is still needed to establish the appropriate PRT utilization rates for the EOL cancer population.
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Affiliation(s)
- Jin Huang
- />School of Health Information Science, University of Victoria, PO BOX 1700 STN CSC, Victoria, British Columbia Canada
| | - Elaine S Wai
- />Department of Surgery, Faculty of Medicine, University of British Columbia, 950 West 10th. Avenue, Vancouver, BC Canada
- />Division of Radiation Oncology, BC Cancer Agency, Vancouver Island Centre, 2nd Floor, 2410 Lee Avenue, Victoria, BC Canada
| | - Francis Lau
- />School of Health Information Science, University of Victoria, PO BOX 1700 STN CSC, Victoria, British Columbia Canada
| | - Paul A Blood
- />Department of Surgery, Faculty of Medicine, University of British Columbia, 950 West 10th. Avenue, Vancouver, BC Canada
- />Division of Radiation Oncology, BC Cancer Agency, Vancouver Island Centre, 2nd Floor, 2410 Lee Avenue, Victoria, BC Canada
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Sinding C, Warren R, Fitzpatrick-Lewis D, Sussman J. Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours. Support Care Cancer 2014; 22:3101-20. [PMID: 25120008 DOI: 10.1007/s00520-014-2348-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/29/2014] [Indexed: 02/03/2023]
Abstract
The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.
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Affiliation(s)
- Christina Sinding
- School of Social Work & Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada,
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Johnston GM, Lethbridge L, Talbot P, Dunbar M, Jewell L, Henderson D, D'Intino AF, McIntyre P. Identifying persons with diabetes who could benefit from a palliative approach to care. Can J Diabetes 2014; 39:29-35. [PMID: 25065477 DOI: 10.1016/j.jcjd.2014.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the need for diabetes mellitus palliative care, we identified persons with a diagnosis of diabetes who accessed palliative care programs and those who may have benefited from a palliative approach to care. METHODS This retrospective, descriptive research used 6 linked databases comprising 66 634 Nova Scotians from 3 health districts who died between 1995 and 2009, each with access to a palliative care program and diabetes centres. RESULTS The percentage of persons with diabetes enrolled in palliative care increased from 3.2% in 1995 to 34.3% in 2009; 31.5% were enrolled within their last 2 weeks of life. Most did not have their diabetes recorded in palliative data. Among the 5353 persons with a diagnosis of diabetes who died between 2005 and 2009, 61.0% were in the Diabetes Care Program of Nova Scotia registry. An additional 19.6% were identified in the Cardiovascular Health Nova Scotia registry, and a further 3.7% in palliative data. Applying the criteria of Rosenwax et al to the 5353, 65.8% to 97.9% may have benefitted from a palliative approach. CONCLUSIONS Rates of palliative enrollment for persons with diabetes are increasing. Diabetes care providers need to prepare patients and their families for changes in diabetes management that will be beneficial as end of life approaches. Collaboration among chronic disease programs, palliative care and primary care is advised to identify persons at end of life who have diabetes and to develop and implement care guidelines for this population.
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Affiliation(s)
- Grace M Johnston
- School of Health Administration, Dalhousie University, and Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Halifax, Nova Scotia.
| | - Lynn Lethbridge
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia
| | - Pam Talbot
- Diabetes Care Program of Nova Scotia, Halifax, Nova Scotia
| | | | - Laura Jewell
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia
| | - David Henderson
- Palliative Care Service, Colchester East Hants Health Authority, Truro, and Faculty of Medicine and Departments of Medicine and Family Medicine, Dalhousie University, Halifax, Nova Scotia
| | | | - Paul McIntyre
- Division of Palliative Medicine/Capital Health Integrated Palliative Care Service, Capital Health, and Departments of Medicine and Family Medicine, Dalhousie University, Halifax, Nova Scotia
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Broom A, Kirby E, Good P, Wootton J, Adams J. The troubles of telling: managing communication about the end of life. QUALITATIVE HEALTH RESEARCH 2014; 24:151-162. [PMID: 24469692 DOI: 10.1177/1049732313519709] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Communication about palliative care represents one of the most difficult interpersonal aspects of medicine. Delivering the "terminal" diagnosis has traditionally been the focus of research, yet transitions to specialist palliative care are equally critical clinical moments. Here we focus on 20 medical specialists' strategies for engaging patients around referral to specialist palliative care. Our aim was to develop an understanding of the logics that underpin their communication strategies when negotiating this transition. We draw on qualitative interviews to explore their accounts of deciding whether and when to engage in referral discussions; the role of uncertainty and the need for hope in shaping communication; and their perceptions of how patient biographies might shape their approaches to, and communication about, the end of life. On the basis of our analysis, we argue that communication is embedded in social relations of hope, justice, and uncertainty, as well as being shaped by patient biographies.
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Affiliation(s)
- Alex Broom
- 1The University of Queensland, Brisbane, Queensland, Australia
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Hunt KJ, Shlomo N, Addington-Hall J. End-of-life care and preferences for place of death among the oldest old: results of a population-based survey using VOICES-Short Form. J Palliat Med 2014; 17:176-82. [PMID: 24438096 DOI: 10.1089/jpm.2013.0385] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND End-of-life care (EOLC) is a key component in care of older people. However, evidence suggests that the oldest old (>85 years) are less likely to access specialist EOLC. OBJECTIVE The study's objective was to explore experiences of EOLC among the oldest old and determine their reported preference for place of death. DESIGN The study involved a self-completion postbereavement survey. METHODS A census was taken of deaths registered between October 2009 and April 2010 in two health districts, identified from death certificates. Views of Informal Carers-Evalution of Service (VOICES)-Short Form was sent to each informant (n=1422, usually bereaved relative) 6 to 12 months after the death. RESULTS Of 473 (33%) who responded, 48% of decedents were age 85 or over. There were no age differences in reported care quality in the last three months, but in the last two days the oldest old were reported to receive poorer relief of nonpain symptoms and less emotional and spiritual support. Compared to people under age 85, the over 85s were less likely to be reported to know they were dying, to have a record of their preferences for place of death, to die in their preferred place, to have enough choice about place of death-and more likely to be reported to have had unwanted treatment decisions. Being over 85 years was associated with a reduction in the odds of home death (OR=0.36); failure to ascertain and record preference for place of death contributed to this. CONCLUSIONS Age-associated disparity exists in care provided in the last two days and the realization of preferences.
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Affiliation(s)
- Katherine J Hunt
- 1 Faculty of Health Sciences, University of Southampton , Southampton, United Kingdom
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Abstract
Introduction Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD. Methods We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age–sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated. Results PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age–sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21–2.85) and 1.83 (CI 1.58–2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex. Discussion Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.
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Affiliation(s)
- Lynn Lethbridge
- School of Health Administration, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada
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Fisher J, Urquhart R, Johnston G. Use of opioid analgesics among older persons with colorectal cancer in two health districts with palliative care programs. J Pain Symptom Manage 2013; 46:20-9. [PMID: 23017627 PMCID: PMC3747099 DOI: 10.1016/j.jpainsymman.2012.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 11/30/2022]
Abstract
CONTEXT Prescription of opioid analgesics is a key component of pain management among persons with cancer at the end of life. OBJECTIVES To use a population-based method to assess the use of opioid analgesics within the community among older persons with colorectal cancer (CRC) before death and determine factors associated with the use of opioid analgesics. METHODS Data were derived from a retrospective, linked administrative database study of all persons who were diagnosed with CRC between January 1, 2001 and December 31, 2005 in Nova Scotia, Canada. This study included all persons who 1) were 66 years or older at the date of diagnosis; 2) died between January 1, 2001 and April 1, 2008; and 3) resided in health districts with formal palliative care programs (PCPs) (n=657). Factors associated with having filled at least one prescription for a so-called "strong" opioid analgesic in the six months before death were examined using multivariate logistic regression. RESULTS In all, 36.7% filled at least one prescription for any opioid in the six months before death. Adjusting for all covariates, filling a prescription for a strong opioid was associated with enrollment in a PCP (odds ratio [OR]=3.18, 95% CI=2.05-4.94), residence in a long-term care facility (OR=2.19, 95% CI=1.23-3.89), and a CRC cause of death (OR=1.75, 95% CI=1.14-2.68). Persons were less likely to fill a prescription for a strong opioid if they were older (OR=0.97, 95% CI=0.95-0.99), male (OR=0.59, 95% 0.40-0.86), and diagnosed less than six months before death (OR=0.62, 95% CI=0.41-0.93). CONCLUSION PCPs may play an important role in enabling access to end-of-life care within the community.
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Affiliation(s)
- Judith Fisher
- Pharmaceutical Services, Department of Health and Wellness, Halifax, Nova Scotia, Canada.
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71
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Hui D, Kim SH, Kwon JH, Tanco KC, Zhang T, Kang JH, Rhondali W, Chisholm G, Bruera E. Access to palliative care among patients treated at a comprehensive cancer center. Oncologist 2012; 17:1574-80. [PMID: 23220843 DOI: 10.1634/theoncologist.2012-0192] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral. METHODS We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death. RESULTS In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5-4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6-45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC. CONCLUSIONS We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.
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Affiliation(s)
- David Hui
- The University of Texas MD Anderson Cancer Center, Unit 1414, 1515 Holcombe Boulevard, Houston, Texas 77030, USA.
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Bruera E, Hui D. Conceptual models for integrating palliative care at cancer centers. J Palliat Med 2012; 15:1261-9. [PMID: 22925157 PMCID: PMC3533890 DOI: 10.1089/jpm.2012.0147] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2012] [Indexed: 11/12/2022] Open
Abstract
Palliative care programs are rapidly evolving in acute care facilities. Increased and earlier access has been advocated for patients with life-threatening illnesses. Existing programs would need major growth to accommodate the increased utilization. The objective of this review is to provide an update on the current structures, processes, and outcomes of the Supportive and Palliative Care Program at the University of Texas M.D. Anderson Cancer Center (UTMDACC), and to use the update as a platform to discuss the challenges and opportunities in integrating palliative and supportive services in a tertiary care cancer center. Our interprofessional program consists of a mobile consultation team, an acute palliative care unit, and an outpatient supportive care clinic. We will discuss various metrics including symptom outcomes, quality of end-of-life care, program growth, and financial issues. Despite the growing evidence to support early palliative care involvement, referral to palliative care remains heterogeneous and delayed. To address this issue, we will discuss various conceptual models and practical recommendations to optimize palliative care access.
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Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Lo YT, Chen RY, Wang CN, Chen YS. Discrepant effect of age on hospice utilization by cancer patients in Taiwan: Hospital versus home care services. Palliat Med 2012; 26:766-7. [PMID: 22733964 DOI: 10.1177/0269216311421836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yu-Tai Lo
- Jiannren Hospital, Kaohsiung, Taiwan, ROC
| | - Ru-Yih Chen
- Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
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Abstract
Authors Nieuwenhoven and Klinge (Journal of Women's Health 2010;19:1-6) argue that despite advances, sex and gender are not well treated in the biomedical literature. Many studies in which males and females are represented do not address the similarities or differences between sexes, sometimes adjusting for (thereby obscuring) sex differences and sometimes ignoring sex altogether. Women continue to be underrepresented in randomized drug trials, excluded from some by potential reproductive effects, and perhaps frightened from others by IRB-required warnings. Although recognized, sex disparities in treatment, for example, for acute cardiac syndrome, persist. As electronic abstracts become a prime means of communicating research results, they must adequately and accurately represent a study's findings.
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Downar J, Chou YC, Ouellet D, La Delfa I, Blacker S, Bennett M, Petch C, Cheng SM. Survival duration among patients with a noncancer diagnosis admitted to a palliative care unit: a retrospective study. J Palliat Med 2012; 15:661-6. [PMID: 22432440 DOI: 10.1089/jpm.2011.0401] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Palliative care unit (PCU) beds are a limited resource in Canada, so PCU admission is restricted to patients with a short prognosis. Anecdotally, PCUs further restrict admission of patients with noncancer diagnoses out of fear that they will "oversurvive" and reduce bed availability. This raises concerns that noncancer patients have unequal access to PCU resources. PURPOSE/METHODS To clarify survival duration of patients with a noncancer diagnosis, we conducted a retrospective review of all admissions to four PCUs in Toronto, Canada, over a 1-year period. We measured associations between demographic data, prognosis, Palliative Performance Score (PPS), length of stay (LOS), and waiting time. RESULTS We collected data for 1000 patients, of whom 21% had noncancer diagnoses. Noncancer patients were older, with shorter prognoses and lower PPS scores on admission. Noncancer patients had shorter LOS (14 versus 24, p<0.001) than cancer patients and a similar likelihood of being discharged alive to cancer patients. Noncancer patients had a trend to lower LOS across a broad range of demographic, diagnostic, prognostic, and PPS categories. Multivariable analysis showed that LOS was not associated with the diagnosis of cancer (p=0.36). DISCUSSION/CONCLUSION Noncancer patients have a shorter LOS than cancer patients and a similar likelihood of being discharged alive from a PCU than cancer patients, and the diagnosis of cancer did not correlate with survival in our study population. Our findings demonstrate that noncancer patients are not "oversurviving," and that referring physicians and PCUs should not reject or restrict noncancer referrals out of concern that these patients are having a detrimental impact on PCU bed availability.
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Affiliation(s)
- James Downar
- University Health Network, Toronto, Ontario, Canada.
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76
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Maddison AR, Asada Y, Burge F, Johnston GW, Urquhart R. Inequalities in end-of-life care for colorectal cancer patients in Nova Scotia, Canada. J Palliat Care 2012; 28:90-96. [PMID: 22860381 PMCID: PMC3747104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Access to high-quality end-of-life (EOL) care is critical for all those with incurable cancer. The objective of this study was to examine inequalities in access to, and quality of, EOL care by assessing registration in a palliative care program, emergency room visits in the last 30 days of life, and location of death among individuals who died of colorectal cancer in Nova Scotia, Canada, between 2001 and 2008. We used population-based linked administrative data and performed multivariate logistic regression models to assess the association between socio-economic, geographic, and demographic factors and outcomes related to access to, and quality of, EOL care (n=1201). This study demonstrates that although access to, and quality of, EOL care appears to have improved, there remain significant inequalities throughout the population. Of primary concern is the variation in access to, and quality of, EOL care based on geographic location of residence and patient age.
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Affiliation(s)
- André R Maddison
- Faculty of Medicine, Dalhousie University, 5849 University Avenue, Mailbox No. 257, Halifax, Nova Scotia, Canada.
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77
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Tang ST, Liu TW, Shyu YIL, Huang EW, Koong SL, Hsiao SC. Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006. Palliat Med 2012; 26:80-8. [PMID: 21606128 DOI: 10.1177/0269216311406989] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated. PURPOSE To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients. METHODS Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years. RESULTS Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life. CONCLUSION Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC.
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Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review. Cancer Causes Control 2011; 23:213-20. [PMID: 22101505 DOI: 10.1007/s10552-011-9875-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 11/09/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care. METHODS A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology. RESULTS We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis. CONCLUSIONS The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.
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Bossuyt N, Van den Block L, Cohen J, Meeussen K, Bilsen J, Echteld M, Deliens L, Van Casteren V. Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium. J Palliat Med 2011; 14:1135-41. [PMID: 21815816 DOI: 10.1089/jpm.2011.0045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Educational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use. OBJECTIVES To examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use. RESEARCH DESIGN A retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use. SUBJECTS A Belgian nationwide representative sample of people who died not suddenly in 2005-2007. RESULTS In comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life. CONCLUSIONS Less well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.
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Affiliation(s)
- Nathalie Bossuyt
- Scientific Institute of Public Health, Operational Directorate Public Health & Surveillance, Brussels, Belgium.
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Lavergne MR, Johnston GM, Gao J, Dumont S, Burge FI. Exploring generalizability in a study of costs for community-based palliative care. J Pain Symptom Manage 2011; 41:779-87. [PMID: 21276697 PMCID: PMC3747103 DOI: 10.1016/j.jpainsymman.2010.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 07/08/2010] [Accepted: 07/09/2010] [Indexed: 11/27/2022]
Abstract
CONTEXT Palliative care researchers face challenges recruiting and retaining study subjects. OBJECTIVES This article investigates selection, study site, and participation biases to assess generalizability of a cost analysis of palliative care program (PCP) clients receiving care at home. METHODS Study subjects' sociodemographic, geographic, survival, disease, and treatment characteristics were compared for the same year and region with those of three populations. Comparison I was with nonstudy subjects enrolled in the PCP to assess selection bias. Comparison II was with adults who died of cancer to assess study site bias. Comparison III was with study-eligible persons who declined to participate in order to assess participation bias. RESULTS Comparison I: When compared with the other 1010 PCP clients, the 50 study subjects were on average 3.6 years younger (P=0.03), enrolled 70 days longer in the PCP (P<0.001), lived 6.7 km closer to the PCP (P<0.0001), and were more likely to have cancer (96.0% vs. 86.4%, P=0.05). Comparison II: Compared with all cancer decedents, the 45 study subjects who died of cancer were on average 7.0 years younger (P<0.001), lived 2.7 km closer to the PCP (P<0.001), and were more likely to have had radiotherapy (62.2% vs. 33.8%, P<0.0001) and medical oncology (28.9% vs. 14.8%, P=0.01) consultations. Comparison III: The 50 study subjects lived on average 42 days longer after their diagnosis (P=0.03) and 2.6 km closer to the PCP (P=0.01) than the 110 eligible persons who declined to participate. CONCLUSION If the study findings are applied to populations that differ from the study subjects, inaccurate conclusions are possible.
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Affiliation(s)
- M Ruth Lavergne
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Lavergne MR, Johnston GM, Gao J, Dummer TJ, Rheaume DE. Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study. Palliat Med 2011; 25:101-10. [PMID: 20937613 PMCID: PMC3701583 DOI: 10.1177/0269216310384900] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Palliative radiotherapy (PRT) can improve quality of life for people dying of cancer. Variation in the delivery of PRT by factors unrelated to need may indicate that not all patients who may benefit from PRT receive it. In this study, 13,494 adults who died of cancer between 2000 and 2005 in Nova Scotia, Canada, were linked to radiotherapy records. Multivariate logistic regression was used to examine the relationships among demographic, clinical, service, and geographic variables, and PRT consultation and treatment. Among the decedents, 4188 (31.0%) received PRT consultation and 3032 (22.3%) treatment. PRT declined with increased travel time and community deprivation. Females, older persons, and nursing home residents also had lower PRT rates. Variations were observed by cancer site and previous oncology care. Variations in PRT use should be discussed with referring physicians, and improved means of access to PRT considered. Benchmarks for optimal rates of PRT are needed.
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Affiliation(s)
- M Ruth Lavergne
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Inequity in access to cancer care: a review of the Canadian literature. Cancer Causes Control 2011; 22:359-66. [PMID: 21221758 DOI: 10.1007/s10552-010-9722-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 12/23/2010] [Indexed: 12/24/2022]
Abstract
Despite the policy and research attention on ensuring equitable access--equal access for equal need--to health care, research continues to identify inequities in access to cancer services. We conducted a literature review to identify the current state of knowledge about inequity in access to cancer health services in Canada in terms of the continuum of care, disease sites, and dimensions of inequity (e.g., income). We searched MEDLINE, CINAHL, and Embase for studies published between 1990 and 2009. We retrieved 51 studies, which examine inequity in access to cancer services from screening to end-of-life care, for multiple cancer types, and a variety of socioeconomic, geographic, and demographic factors that may cause concern for inequity in Canada. This review demonstrates that income has the most consistent influence on inequity in access to screening, while age and geography are most influential for treatment services and end-of-life care, even after adjusting for patient need. Our review also reports on methods used in the literature and new techniques to explore. Equitable access to cancer care is vitally important in all health systems. Obtaining information on the current status of inequities in access to cancer care is a critical first step toward action.
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Gao J, Johnston GM, Lavergne MR, McIntyre P. Identifying population groups with low palliative care program enrolment using classification and regression tree analysis. J Palliat Care 2011; 27:98-106. [PMID: 21805944 PMCID: PMC3747101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Classification and regression tree (CART) analysis was used to identify subpopulations with lower palliative care program (PCP) enrolment rates. CART analysis uses recursive partitioning to group predictors. The PCP enrolment rate was 72 percent for the 6,892 adults who died of cancer from 2000 and 2005 in two counties in Nova Scotia, Canada. The lowest PCP enrolment rates were for nursing home residents over 82 years (27 percent), a group residing more than 43 kilometres from the PCP (31 percent), and another group living less than two weeks after their cancer diagnosis (37 percent). The highest rate (86 percent) was for the 2,118 persons who received palliative radiation. Findings from multiple logistic regression (MLR) were provided for comparison. CART findings identified low PCP enrolment subpopulations that were defined by interactions among demographic, social, medical, and health system predictors.
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Affiliation(s)
- Jun Gao
- Health Canada, Centre for Vaccine Evaluation, Biologics and Genetic Therapies Directorate, Ottawa, Ontario, Canada
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Abarshi E, Echteld MA, Van den Block L, Donker G, Deliens L, Onwuteaka-Philipsen B. The oldest old and GP end-of-life care in the Dutch community: a nationwide study. Age Ageing 2010; 39:716-22. [PMID: 20817932 DOI: 10.1093/ageing/afq097] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Provision of adequate care for the oldest old is increasingly crucial, given the current ageing trends. This study explores differences in end-of-life care of the oldest (≥85 years) versus the younger (65-84 years) old; testing the hypothesis that age could be an independent correlate of receiving specialised palliative care services (SPCS), having palliative-centred treatment and dying in a preferred place. METHODS general practitioners (GPs) participating in the nation-wide representative network in the Netherlands were asked to fill in patient, illness and care characteristics of all registered patients ≥65 years, who died non-suddenly in their practices between 2005 and 2008, using standardised forms. Associations with the palliative care variables were tested using multiple logistic regression. RESULTS nine hundred and ninety patients were registered. Among the oldest old, there were more women than men, more patients with heart failure than cancer, less hospital and home deaths and more residential care home deaths compared with the younger old. Of the oldest old, fewer received SPCS and more preferred to die in a residential care home than the younger old. Age was independently associated with palliative care provided: compared with the younger group, the oldest old received SPCS less often (OR = 0.7) and were treated with a palliative-centred goal more often (OR = 2.4); but age was not related to dying in a preferred place, i.e. independent of other characteristics. CONCLUSION this study shows age to be independently associated with receiving SPCS in the Dutch community. Although the GPs do recognise the 'palliative phase' in the oldest old, involvement of specialist teams is somewhat less.
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Affiliation(s)
- Ebun Abarshi
- Department of Public and Occupational Health, The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Barbera L, Sussman J, Viola R, Husain A, Howell D, Librach SL, Walker H, Sutradhar R, Chartier C, Paszat L. Factors Associated with End-of-Life Health Service Use in Patients Dying of Cancer. Healthc Policy 2010; 5:e125-e143. [PMID: 21286260 PMCID: PMC2831738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
This study describes acute care hospital death, physician house calls and home care near the end of life among patients who died of cancer and the factors that are associated with these events and services. It is a population-based retrospective study that uses linked administrative healthcare data. The cohort includes all patients who died of cancer between 2000 and 2004 in Ontario, Canada.Fifty-five per cent of patients died in acute care hospital, 68% received home care in the last 6 months of life and 24% received at least one physician house call in the last 2 weeks of life. Increased age was associated with a decreased likelihood of each event or service. Women were less likely to die in acute care and more likely to receive home care. Residents in low-income neighbourhoods were less likely to receive house calls or home care. Patients who received home care or house calls were less likely to die in acute care.Our observations add to those in the literature, suggesting a need to increase the use of supportive care services at the end of life in hopes of decreasing the need for acute care. They also serve as a baseline for future comparison, which is of particular interest since new government policies directed at end-of-life care were recently introduced.
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Affiliation(s)
- Lisa Barbera
- Radiation Oncologist, Odette Cancer Centre, Adjunct Scientist, Institute for Clinical Evaluative Sciences, Assistant Professor, Department of Radiation Oncology, University of Toronto, Toronto, ON
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