Hospice care utilisation among elderly patients who died with hepatocellular carcinoma in the United States

Understanding Experiences of Telehealth in Palliative Care: Photo Interview Study

Background

It is widely accepted that the COVID-19 pandemic has accelerated the era of online health care delivery, including within community palliative care. This study was part of a larger project involving a collaboration between universities, health care services, government agencies, and software developers that sought to enhance an existing telehealth (video call) platform with additional features to improve both patient and health care professional (HCP) experience in a palliative care context.

Objective

The aim of this study was to understand palliative care patients' and HCPs' experiences of telehealth delivery in a palliative care context in Victoria, Australia. For the purposes of this study, telehealth included consultations by both video and telephone calls. By better understanding users' experiences and perceptions of telehealth, we hoped to determine users' preferences for new telehealth enhancement features.

Methods

A total of 6 health care professionals and 6 patients were recruited from a major tertiary hospital network's palliative care unit in Victoria, Australia. Participants were asked to generate 3-5 photographs depicting their telehealth experiences. These photographs were used as visual aids to prompt discussion during subsequent one-on-one interviews. Intertextual analysis was conducted to identify key themes.

Results

A total of 3 overarching themes emerged: comfort (or lack thereof) afforded by telehealth, connection considerations in telehealth, and care quality impacts of telehealth. Patients (n=6) described telehealth as supporting their physical and psychological comfort and maintaining connection with HCPs, yet there were specific situations where it failed to meet their needs or impacted care quality and delayed treatment. HCPs (n=6) recognized the benefit of telehealth for patients but reported several limitations of telehealth, in particular due to lack of physical examination opportunities. Participants indicated that 2 types of connection were imperative for effective telehealth delivery: technical connection (eg, good internet connectivity or clear phone line) and interpersonal connection (ie, good rapport and therapeutic alliance between the HCPs and patients). Often technical connection issues impeded the development of interpersonal connection between the HCPs and patients in telehealth.

Conclusions

The findings presented in this study combined with other co-design activities, which are outside the scope of this paper, indicated the potential value of a telehealth enhancement feature that generates patient-facing clinical consultation summaries. Our team has developed a video telehealth enhancement feature (or "add-on"), which will enable clinicians to distill key actionable advice and self-management guidance discussed during teleconsultations for a take-home summary document for patients. The add-on's prototype has also been subjected to an initial simulation study, which will be reported in a future publication.

Contemporary Patterns of End-of-Life Care Among Medicare Beneficiaries With Advanced Cancer

Importance

Considerable efforts have been dedicated to improving the quality of end-of-life care among patients with advanced cancer in the past decade. Whether the quality has shifted in response to these efforts remains unknown.

Objective

To examine contemporary patterns of end-of-life care among patients with advanced cancer.

Design, Setting, and Participants

This retrospective cohort study used a recent linkage of Surveillance, Epidemiology, and End Results and Medicare data to characterize patterns of end-of-life care. The cohort included fee-for-service Medicare decedents aged 66 years or older who were originally diagnosed with distant-stage breast, prostate, pancreatic, or lung cancers and died between 2014 and 2019. Analyses were conducted between June 1, 2023, and July 31, 2024.

Main Outcomes and Measures

Outcomes included monthly use of acute care, systemic therapy, and supportive care (ie, palliative and hospice care and advanced care planning) in the last 6 months of life. Additionally, a claims-based indicator was evaluated of potentially aggressive care in the last 30 days of life, defined as experiencing more than 1 acute care visit, in-hospital mortality, late receipt of systemic therapy, or hospice entry.

Results

The study included 33 744 Medicare decedents with advanced cancer (mean [SD] age, 75.7 [6.9] years; 52.1% male). From 6 months before death to month of death, there was an increase in the mean (SE) number of acute care visits (from 14.0 [0.5] to 46.2 [0.5] per 100 person-months), hospice use (from 6.6 [0.4] to 73.5 [0.5] per 100 person-months), palliative care (from 2.6 [0.2] to 26.1 [0.6] per 100 person-months), and advanced care planning (from 1.7 [0.6] to 12.8 [1.1] per 100 person-months). Overall, 45.0% of decedents experienced any indicator of potentially aggressive care.

Conclusions and Relevance

This study found persistent patterns of potentially aggressive care, but low uptake of supportive care, among Medicare decedents with advanced cancer. A multifaceted approach targeting patient-, physician-, and system-level factors associated with potentially aggressive care is imperative for improving quality of care at the end of life.

End-of-life in Hepatocellular Carcinoma: How Palliative Care and Social Factors Impact Care and Cost

OBJECTIVE

Investigate the impacts of palliative care consults, race, and socioeconomic status on the prevalence of invasive procedures in patients with hepatocellular carcinoma (HCC).

BACKGROUND

Palliative care, race, and socioeconomic status can all influence end-of-life care preferences, but their roles in HCC have not been adequately explored.

MATERIALS AND METHODS

This is a cross-sectional study of patients with HCC from 2016 to 2019 using the National Inpatient Sample. Terminal and nonterminal hospitalizations were assessed with logistical regression evaluating associations between palliative care, race, income, and procedures along with do-not-resuscitate orders and cost. Procedures included mechanical ventilation, tracheostomy, and cardiopulmonary resuscitation (CPR) among others.

RESULTS

A total of 217,060 hospitalizations in patients with HCC were included, 18.1% of which included a palliative care encounter. The mean age was 65.0 years (SD = 11.3 y), 73.9% were males and 55.5% were white. Procedures were increased in terminal hospitalizations in black [CPR adjusted odds ratio (aOR) = 2.57, P < 0.001] and Hispanic patients (tracheostomy aOR = 3.64, P = 0.018) compared with white patients. Palliative care encounters were associated with reduced procedures during terminal hospitalizations (mechanical ventilation aOR = 0.47, P < 0.001, CPR aOR = 0.24, P < 0.001), but not in nonterminal hospitalizations. No association between income and end-of-life procedures was found. Palliative care was associated with decreased mean cost in terminal ($23,608 vs $31,756, P < 0.001) and nonterminal hospitalizations ($15,786 vs $19,914, P < 0.001).

CONCLUSIONS

Palliative care is associated with less aggressive end-of-life care and decreased costs in patients with HCC. Black and Hispanic race were both associated with more aggressive end-of-life care.

Nonprofit behavior altered by monetary donations: evidence from the U.S. hospice industry

This study investigates whether reliance on monetary donations alters nonprofit firms' behaviors. Specifically, in the hospice industry, a shorter patients' length of stay (LOS) speeds up overall patient turnover, allowing a hospice to serve more patients and expand its donation network. We measure hospices' donation reliance using the donation-revenue ratio, which indicates the importance of donations for revenue structure. By exploiting the supply shifter of donation, we adopt the number of donors as an instrument to control for the potential endogeneity issue. Our result suggests that a one-percentage-point increase in the donation-revenue ratio decreases patient LOS by 8%. Hospices that are more reliant on donations serve patients diagnosed with diseases that have shorter life expectancies to achieve a lower average LOS of all patients' stay. Overall, we find that monetary donations alter the behavior of nonprofit organizations.

Factors Associated With Inpatient Hospice Utilization Among Hospitalized Decedents With Comfort Measures Only Status

Background: Patients with serious illness may elect to transition their care to comfort measures only (CMO) while in the hospital. Although studies have shown that routine hospice care is underutilized, the rate of general inpatient hospice (GIP) use among CMO patients during their terminal admission remains unclear. Objectives: We sought to (1) examine the rate of GIP utilization and (2) identify factors associated with its use among hospitalized CMO decedents. Methods: CMO decedents in two academic, tertiary care hospitals in the United States who died between October 1, 2020 and October 31, 2021, were subgrouped based on their primary medical service (GIP vs. non-GIP) at the time of inpatient death. Data abstracted from the electronic health record included demographics, primary diagnosis codes, Rothman Index (RI), time of CMO order, ordering clinician type, time of death, and length of stay (LOS). Multivariable logistic regression analysis was performed, adjusting for relevant covariates. Results: Of 1475 CMO decedents, only 321 (n = 22%) patients received GIP. On multivariable analysis, CMO patients who died in an ICU were five times less likely (odds ratio [OR] = 0.18, confidence interval [95% CI] 0.11-0.29) to receive GIP. Every 10-point increase in RI raised the likelihood of receiving GIP by 59% (OR = 1.59, 95% CI 1.39-1.80). Conclusions: Most CMO decedents died in the hospital without GIP. Compared with GIP decedents, non-GIP decedents were less acutely ill. There was no difference in total LOS between the two groups. CMO decedents were much less likely to receive GIP in an ICU. The RI may help clinicians identify CMO patients who would benefit from GIP earlier in their terminal admission.

Disparities in Referrals to End-of-Life Care in Eligible Hepatocellular Carcinoma Patients

BACKGROUND

Hepatocellular Carcinoma (HCC) is a malignancy with increasing incidence and morbidity. For patients with a poor prognosis, engagement with advanced care planning and end-of life (EOL) services (I.e., palliative care, hospice) can address physical, financial, and social complications of a terminal diagnosis. Minimal data exist on the demographics of the patients being referred to and enrolling in EOL services for HCC.

AIMS

We aim to report the relationship between demographics and EOL service referral.

METHODS

Retrospective review of a prospectively maintained high-volume liver center registry of patients diagnosed with HCC from 2004 to 2022. EOL services eligible patients were defined as BCLC stage C or D, evidence of metastases, and/or transplant ineligible.

RESULTS

Black patients were more likely to be referred than white patients (OR 1.47 (1.03, 2.11)). Once referred, patients were significantly more likely to be enrolled if they had insurance coverage, though no other factors in models were significant. There were no significant differences in survival among those referred who did or did not enroll, after controlling for other factors.

CONCLUSION

Black patients were more likely to be referred compared to white patients and patients who were insured were more likely to be enrolled. Whether this is indicative of black patients being appropriately referred at a higher rate, being offered EOL care instead of aggressive treatment, or other unknown factors warrants further study.

Early Implementation of Palliative and Supportive Care in Hepatocellular Carcinoma

Early palliative and supportive care referral is the standard of care for many malignancies. This paradigm results in improvements in patients' symptoms and quality of life and decreases the costs of medical care and unnecessary procedures. Leading oncology guidelines have recommended the integration of early referral to palliative and supportive services to care pathways for advanced malignancies. Currently, early referral to palliative care within the hepatocellular carcinoma (HCC) population is not utilized, with gastroenterology guidelines recommending referral of patients with Barcelona Clinic Liver Cancer stage D to these services. This review addresses this topic through analysis of the existing data within the oncology field as well as literature surrounding palliative care intervention in HCC. Early palliative and supportive care in HCC and its impact on patients, caregivers, and health services allow clinicians and researchers to identify management options that improve outcomes within existing service provisions.