Palliative care utilization in hospitalized children with cancer

Healthcare costs of cancer among children, adolescents, and young adults: A scoping review

OBJECTIVE

To collate and critically review international evidence on the direct health system costs of children and adolescents and young adults (AYA) with cancer.

METHODS

We conducted searches in PubMed, MEDLINE, CINAHL, and Scopus. Articles were limited to studies involving people aged 0-39 years at cancer diagnosis and published from 2012 to 2022. Two reviewers screened the articles and evaluated the studies using the Consolidated Health Economic Evaluation Reporting Standards checklist. The reviewers synthesized the findings using a narrative approach and presented the costs in 2022 US dollars for comparability.

RESULTS

Overall, the mean healthcare costs for all cancers in the 5 years post diagnosis ranged from US$36,670 among children in Korea to US$127,946 among AYA in the USA. During the first year, the mean costs among children 0-14 years ranged from US$34,953 in Chile to over US$130,000 in Canada. These were higher than the costs for AYA, estimated at US$61,855 in Canada. At the end of life, the mean costs were estimated at over US$300,000 among children and US$235,265 among adolescents in Canada. Leukemia was the most expensive cancer type, estimated at US$50,133 in Chile, to US$152,533 among children in Canada. Overall, more than a third of the total cost is related to hospitalizations. All the included studies were of good quality.

CONCLUSIONS

Healthcare costs associated with cancer are substantial among children, and AYA. More research is needed on the cost of cancer in low- and middle-income countries and harmonization of costs across countries.

Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017

PURPOSE

This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan.

DESIGN

This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan.

METHODS

Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration.

FINDINGS

Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases.

CONCLUSION

This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families.

CLINICAL RELEVANCE

Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.

Palliative care and healthcare utilization among metastatic breast cancer patients in U.S. Hospitals

There is a lack of research focused on understanding the different characteristics and healthcare utilization of metastatic breast cancer patients by palliative care use. This study aims to investigate trend of in-patient palliative care and its association with healthcare utilization among hospitalized metastatic breast cancer patients in the US. National Inpatient Sample (NIS) was used to identify nationwide metastatic breast cancer patients (n = 5209, weighted n = 25,961) from 2010 to 2014. We examined the characteristics of the study sample by palliative care and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariable survey regression models were used to identify predictors. Among 26,961 breast cancer patients, 19.0% had palliative care. Percentage of receiving palliative care during the period were gradually increased. Social factors including race, insurance types were also associated with a receipt of palliative care. Survey linear regression results showed that patients with palliative care were associated with 31% lower hospital charges, however, length of stays were not significantly associated. This study found evidence of who was associated with the receipt of palliative care and its relationship with healthcare utilization. This study also emphasizes the importance of receiving palliative care in patients with breast cancer, paving the way for future research into ways to improve palliative care in cancer patients. This study also found social differences and gave evidence of programs that could be used to help vulnerable groups in future health policy decisions.

Differences in palliative opportunities across diagnosis groups in children with cancer

BACKGROUND

Childhood cancer causes significant physical and emotional stress. Patients and families benefit from palliative care (PC) to reduce symptom burden, improve quality of life, and enhance family-centered care. We evaluated palliative opportunities across leukemia/lymphoma (LL), solid tumors (ST), and central nervous system (CNS) tumor groups.

PROCEDURE

A priori, nine palliative opportunities were defined: disease progression/relapse, hematopoietic stem cell transplant, phase 1 trial enrollment, admission for severe symptoms, social concerns or end-of-life (EOL) care, intensive care admission, do-not-resuscitate (DNR) status, and hospice enrollment. A single-center retrospective review was completed on 0-18-year olds with cancer who died from January 1, 2012 to November 30, 2017. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated from diagnosis to death and across disease groups.

RESULTS

Included patients (n = 296) had LL (n = 87), ST (n = 114), or CNS tumors (n = 95). Palliative opportunities were more frequent in patients with ST (median 8) and CNS tumors (median 7) versus LL (median 5, p = .0005). While patients with ST had more progression/relapse opportunities (p < .0001), patients with CNS tumors had more EOL opportunities (p < .0001), earlier PC consultation, DNR status, and hospice enrollment. Palliative opportunities increased toward the EOL in all diseases (p < .0001). PC was consulted in 108 (36%) patients: LL (48%), ST (30%), and CNS (34%, p = .02).

CONCLUSIONS

All children with cancer incur many events warranting PC support. Patients with ST and CNS tumors had more palliative opportunities than LL, yet received less subspecialty PC. Understanding palliative opportunities within each disease group can guide PC utilization to ease patient and family stress.

Racial disparities in pediatric malignant glioma management: current state of affairs in the United States

BACKGROUND

The diagnosis of malignant glioma confers a poor prognosis in the pediatric population. In the adult demographic, racial disparities exist with respect to access to care and survival. Yet to date no efforts have been made to characterize racial disparities in the care of malignant pediatric gliomas. Correspondingly, the aim of this study was to understand if racial disparities exist in the setting of malignant pediatric gliomas.

METHODS

All pediatric malignant gliomas patients with known race status (White, Black, Other) in the US National Cancer Database (NCDB) between the years 2005-2016 were retrospectively reviewed. Demographic, socioeconomic and clinical data were then abstracted and analyzed by comparison and regression techniques.

RESULTS

A total of 1803 pediatric malignant glioma cases were identified, with 48% female and a median age of 8 years old. Brainstem locations were reported in 48% of cases. Socioeconomically, there were statistically significant differences with respect to insurance status, yearly income, household education level and metropolitan residences between the racial groups (all P < 0.01). With respect to treatment, there was statistical difference in the proportion of patients treated with surgical resection (White 43% vs Black 34% vs Other 37%, P = 0.02). There were no differences between race groups for radiation therapy (P = 0.73) or chemotherapy (P = 0.12). The odds of surgical resection were significantly less in the Black group compared to the White group (OR 0.69, P < 0.01), although there was no difference in overall survival between the two groups in those treated with (P = 0.44) or without (P = 0.27) surgical resection. Primary associations of surgical resection in the Black group were brainstem location (P < 0.05) and lower yearly household income quartiles (P < 0.05).

CONCLUSIONS

Racial disparities exist amongst the management of pediatric malignant gliomas, with undefined impact on survival and quality of life. In this perspective, we identified associations between Black patients and access to surgical treatment. Understanding that there are many elements to patient care, including quality of life, should encourage all clinicians and carers to consider racial disparities appropriately when managing malignant pediatric glioma patients.

Medical Communication during the Transition to Palliative Care in Pediatric Oncology in Hungary-The Parents' Perspective

The transition to palliative care (PC) is a critical aspect of pediatric oncology, and it requires a high level of communication skills from doctors, which could be best judged by the parents of children who have died from cancer. Our aim was to explore the parents' perspectives regarding the timing of the consultation on the implementation of PC, as well as facets of verbal and nonverbal communication in Hungary. Semistructured interviews were conducted with parents who had lost a child to cancer within the past 1-5 years. Interview transcripts (n = 23) were scrutinized with interpretative phenomenological analysis. The parents frequently associated palliation with end-of-life care and they clearly delimited the transition to PC after curative treatments had been exhausted. The parents were ambivalent with regard to the use of the word "death" during this consultation, and they often did not receive information on what to expect (e.g., regarding symptoms) or on who to turn to for further information or support (e.g., concerning bereavement). Although significant progress could be observed in the organization of pediatric palliative care in Hungary, there is still no widely accepted communication method for the transition to sole PC. There is a need for a culturally sensitive approach to refining the recommendations on the word use and communication protocol in pediatric PC in Hungary.

Palliative Care in Paediatric Oncology: an Update

Purpose of this Review

The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology.

Recent Findings

Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources.

Summary

Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.

The Impact of Specialty Palliative Care in Pediatric Oncology: A Systematic Review

CONTEXT

Children with cancer and their families have complex needs related to symptoms, decision-making, care planning, and psychosocial impact extending across the illness trajectory, which for some includes end of life. Whether specialty pediatric palliative care (SPPC) is associated with improved outcomes for children with cancer and their families is unknown.

OBJECTIVE

We conducted a systematic review following PRISMA guidelines to investigate outcomes associated with SPPC in pediatric oncology with a focus on intervention delivery, collaboration, and alignment with National Quality Forum domains.

METHODS

We searched PubMed, Embase, Scopus, Web of Science, and CINAHL databases from inception until April 2020 and reviewed references manually. Eligible articles were published in English, involved pediatric patients aged 0-18 years with cancer, and contained original data regarding patient and family illness and end-of-life experiences, including symptom management, communication, decision-making, quality of life, satisfaction, and healthcare utilization.

RESULTS

We screened 6682 article abstracts and 82 full-text articles; 32 studies met inclusion criteria, representing 15,635 unique children with cancer and 342 parents. Generally, children with cancer who received SPPC had improved symptom burden, pain control, and quality of life with decreased intensive procedures, increased completion of advance care planning and resuscitation status documentation, and fewer end-of-life intensive care stays with higher likelihood of dying at home. Family impact included satisfaction with SPPC and perception of improved communication.

CONCLUSION

SPPC may improve illness experiences for children with cancer and their families. Multisite studies utilizing comparative effectiveness approaches and validated metrics may support further advancement of the field.