Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review

Objectives

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients.

Methods

A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients.

Results

Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities.

Conclusion

This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

Palliative Care Utilization Among Hospitalized Patients With Hepatocellular Cancer: A Nationwide Study in the Pandemic Era (2019-2021)

Background: Palliative care addresses a range of needs, from symptom management to providing support to patients with hepatocellular cancer (HCC) and their families throughout the illness. However, research on palliative care in HCC remains limited, particularly during the COVID-19 pandemic. This study investigates the healthcare utilization associated with palliative care referral among patients with HCC. Methods: This is a retrospective cross-sectional analysis conducted using the National Inpatient Sample (NIS) database from 2019 to 2021 among patients with HCC age ≥18 years. Results: Among the 35,220 hospitalizations with HCC as the principal diagnosis, 18.7% received inpatient palliative care referrals. Factors associated with increased palliative care referrals included age ≥65 years, Midwest region, Charlson Comorbidity Index (CCI) score ≥3, and end-of-life care, as reflected by discharge resulting in death. No racial or insurance disparities were observed. Palliative care consultations were associated with lower total hospital costs ($20,573 vs $26,035, <0.0001). A higher prevalence of "do-not-resuscitate" status was also found among patients with palliative care referrals. Conclusion: The study provides an understanding of palliative care utilization across pre-pandemic and pandemic periods. Factors such as advanced age, hospital region, and underlying comorbidities influenced the likelihood of referral, with no discernible racial or insurance disparities identified. Palliative care involvement has also been shown to provide cost-effective supportive care with lower hospital costs. These findings provide invaluable guidance for optimizing the integration of palliative care alongside HCC management.

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

BACKGROUND

Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.

METHODS

Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.

RESULTS

Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001).

CONCLUSIONS

There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.

Surrogate Perception of Disability after Hospitalization for Traumatic Brain Injury

BACKGROUND

The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability.

STUDY DESIGN

We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling.

RESULTS

Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034).

CONCLUSIONS

In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.

Utilization of medical interventions in hospitalized Mexican adults with cancer at the end of life in a referral hospital: The importance of early palliative care

OBJECTIVES

To investigate the impact of early vs. late palliative care (PC) on the frequency of admissions to acute hospital settings and the utilization of end-of-life (EoL) interventions in cancer decedents.

METHODS

In this single-center, cross-sectional study, we examined the frequency of intensive care unit (ICU) and emergency department (ED) admissions among adult cancer decedents between 2018 and 2022 in a referral hospital in México. Additionally, we assessed EoL medical interventions, categorizing patients into 3 groups: those who received early PC (EPC), late PC (LPC), and those who did not receive PC (NPC).

RESULTS

We analyzed data from 1762 patients, averaging 56 ± 16.3 years old, with a predominant representation of women (56.8%). PC was administered to 45.2% of patients, but EPC was limited to only 12.3%. The median time from the initiation of PC to death was 5 days (interquartile range: 2.0-31.5). Hematological malignancies were the most prevalent, affecting 21.5% of patients. EPC recipients demonstrated notable reductions in ICU and ED admissions, as well as diminished utilization of chemotherapy, radiotherapy (RT), antibiotics, blood transfusions, and surgery when compared to both LPC and NPC groups. EPC also exhibited fewer medical interventions in the last 14 days of life, except for RT.

SIGNIFICANCE OF RESULTS

The findings of this study indicate that a significant proportion of EoL cancer patients receive PC; however, few receive EPC, emphasizing the need to improve accessibility to these services. Moreover, the results underscore the importance of thoughtful deliberation regarding the application of EoL medical interventions in cancer patients.

Effects of Specialist Palliative Care for Patients Undergoing Major Abdominal Surgery for Cancer: A Randomized Clinical Trial

Importance

Specialist palliative care benefits patients undergoing medical treatment of cancer; however, data are lacking on whether patients undergoing surgery for cancer similarly benefit from specialist palliative care.

Objective

To determine the effect of a specialist palliative care intervention on patients undergoing surgery for cure or durable control of cancer.

Design, Setting, and Participants

This was a single-center randomized clinical trial conducted from March 1, 2018, to October 28, 2021. Patients scheduled for specified intra-abdominal cancer operations were recruited from an academic urban referral center in the Southeastern US.

Intervention

Preoperative consultation with palliative care specialists and postoperative inpatient and outpatient palliative care follow-up for 90 days.

Main Outcomes and Measures

The prespecified primary end point was physical and functional quality of life (QoL) at postoperative day (POD) 90, measured by the Functional Assessment of Cancer Therapy-General (FACT-G) Trial Outcome Index (TOI), which is scored on a range of 0 to 56 with higher scores representing higher physical and functional QoL. Prespecified secondary end points included overall QoL at POD 90 measured by FACT-G, days alive at home until POD 90, and 1-year overall survival. Multivariable proportional odds logistic regression and Cox proportional hazards regression models were used to test the hypothesis that the intervention improved each of these end points relative to usual care in an intention-to-treat analysis.

Results

A total of 235 eligible patients (median [IQR] age, 65.0 [56.8-71.1] years; 141 male [60.0%]) were randomly assigned to the intervention or usual care group in a 1:1 ratio. Specialist palliative care was received by 114 patients (97%) in the intervention group and 1 patient (1%) in the usual care group. Adjusted median scores on the FACT-G TOI measure of physical and functional QoL did not differ between groups (intervention score, 46.77; 95% CI, 44.18-49.04; usual care score, 46.23; 95% CI, 43.08-48.14; P = .46). Intervention vs usual care group odds ratio (OR) was 1.17 (95% CI, 0.77-1.80). Palliative care did not improve overall QoL measured by the FACT-G score (intervention vs usual care OR, 1.09; 95% CI, 0.75-1.58), days alive at home (OR, 0.87; 95% CI, 0.69-1.11), or 1-year overall survival (hazard ratio, 0.97; 95% CI, 0.50-1.88).

Conclusions and Relevance

This randomized clinical trial showed no evidence that early specialist palliative care improves the QoL of patients undergoing nonpalliative cancer operations.

Trial Registration

ClinicalTrials.gov Identifier: NCT03436290.

Informed Consent and Shared Decision Making in the Perioperative Environment

Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.

Trends, Sociodemographic and Hospital-Level Factors Associated With Palliative Care Utilization Among Multiple Myeloma Patients Using the National Inpatient Sample (2016-2018)

BACKGROUND

Several factors are reported to be associated with palliative care utilization among patients with various cancers, but literature is lacking on multiple myeloma (MM) specific factors. MM patients have a high symptom burden and early involvement of palliative could increase their quality of life. We examined factors associated with palliative care utilization among MM patients and explored prevalence trends in palliative care utilization among patients with MM.

METHODS

Cross-sectional analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore prevalence trends in palliative care utilization over time. Multivariable logistic regression models were used to examine sociodemographic and hospital-level factors associated with palliative care utilization in MM patients.

RESULTS

Overall prevalence of palliative care utilization in our population was 7.7% with a trend of increasing use of palliative care from 7.3% in 2016 to 8.2% in 2018. MM patients aged 70 years and above had 1.30 times higher odds (95% CI: 1.20-1.42) of receiving palliative care relative to those younger than 70 years. Compared to non-Hispanic whites, non-Hispanic blacks (Adjusted odds ratio (AOR): 0.86; 95% CI: 0.79-0.94) were less likely to utilize palliative care. Patients on Medicaid (AOR: 1.27; 95% CI: 1.08-1.49), private insurance (AOR: 1.27; 95% CI: 1.16-1.39) and other insurance types (AOR: 2.10; 95% CI: 1.79-2.47) had significantly higher odds of receiving palliative care when compared to those on Medicare. Other factors identified were hospital region, location, patient disposition, admission type, length of stay, and number of comorbidities.

CONCLUSION

Our findings highlight the urgent need for education of hospital physicians on the need for early palliative care involvement in the care of hospitalized MM patients. Messaging interventions such as the delivery of pop-up messages in electronic medical records to serve as reminders for physicians can be explored as a potential way to increase palliative care consultations for patients who need them.

Decade-Long Nationwide Trends and Disparities in Use of Comfort Care Interventions for Patients With Ischemic Stroke

Background Stroke remains one of the leading causes of disability and death in the United States. We characterized 10-year nationwide trends in use of comfort care interventions (CCIs) among patients with ischemic stroke, particularly pertaining to acute thrombolytic therapy with intravenous tissue-type plasminogen activator and endovascular thrombectomy, and describe in-hospital outcomes and costs. Methods and Results We analyzed the National Inpatient Sample from 2006 to 2015 and identified adult patients with ischemic stroke with or without thrombolytic therapy and CCIs using validated International Classification of Diseases, Ninth Revision (ICD-9) codes. We report adjusted odds ratios (ORs) and 95% CI of CCI usage across five 2-year periods. Of 4 249 201 ischemic stroke encounters, 3.8% had CCI use. CCI use increased over time (adjusted OR, 4.80; 95% CI, 4.15-5.55) regardless of acute treatment type. Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity, comorbidity burden, and discharge from non-northeastern teaching hospitals were independently associated with receiving CCIs. In the fully adjusted model, thrombolytic therapy and endovascular thrombectomy, respectively, conferred a 6% and 10% greater likelihood of receiving CCIs. Among CCI users, there was a significant decline in in-hospital mortality compared with all other dispositions over time (adjusted OR, 0.46; 95% CI, 0.38-0.56). Despite longer length of stay, CCI hospitalizations incurred 16% lower adjusted costs. Conclusions CCI use among patients with ischemic stroke has increased regardless of acute treatment type. Nonetheless, considerable disparities persist. Closing the disparities gap and optimizing access, outcomes, and costs for CCIs among patients with stroke are important avenues for further research.

Palliative Care and End-of-Life Outcomes Following High-risk Surgery

Importance

Palliative care has the potential to improve care for patients and families undergoing high-risk surgery.

Objective

To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation.

Design, Setting, and Participants

This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included.

Exposures

Palliative-care consultation within 30 days before or 90 days after surgery.

Main Outcomes and Measures

The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes.

Results

A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery.

Conclusions and Relevance

Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.