Hospice and Emergency Room Use by Disadvantaged Men Dying of Prostate Cancer

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis

BACKGROUND

People who die from cancer (cancer decedents) may experience unpleasant and distressing symptoms which cause them to present to unscheduled care. Unscheduled care is unplanned care delivered by general practitioner out-of-hours and emergency departments. Use of unscheduled care can disrupt treatment plans, leading to a disjointed patient care and suboptimal outcomes.

OBJECTIVES

This systematic review aimed to identify factors associated with unscheduled care use by cancer decedents.

METHOD

Systematic review with narrative synthesis of seven electronic databases (PubMed; Medline; Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Web of Science; Cumulative Index to Nursing and Allied Health Literature) from inception until 01 January 2020. All observational and experimental studies were included, irrespective of their research design.

RESULTS

The search yielded 238 publications included at full-text, of which 47 were included in the final review and synthesis. Unscheduled care use by cancer decedents was influenced by multiple factors, synthesised into themes: demography, clinical and patient, temporal, prescribing and systems. Cancer decedents who were older, men, had comorbidities, or lung cancer, were most likely to use unscheduled care. Unscheduled care presentations were commonly due to pain, breathlessness and gastrointestinal symptoms. Low continuity of care, and oncology-led care were associated with greater unscheduled care use. Access to palliative care, having an up-to-date palliative care plan, and carer education were associated with less unscheduled care use.

CONCLUSION

The review identifies multiple factors associated with unscheduled care use by cancer decedents. Understanding these factors can inform future practice and policy developments, in order to appropriately target future interventions, optimise service delivery and improve the patient journey.

PROSPERO REGISTRATION NUMBER

CRD42016047231.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Caring for the Uninsured with Prostate Cancer: A Comparison of Four Policy Alternatives in California

The IMPACT Program seeks to improve access to prostate cancer care for low-income, uninsured men. The objective of the current study was to compare the cost-effectiveness of four policy alternatives in treating this population. We analyzed the cost-effectiveness of four policy alternatives for providing care to low-income, uninsured men with prostate cancer: (1) IMPACT as originally envisioned, (2) a version of IMPACT with reduced physician fees, (3) a hypothetical Medicaid prostate cancer treatment program, and (4) the existing county safety net. We calculated cost-effectiveness based on incremental cost-effectiveness ratios (ICERs) with the formula ICER = (Cost(alternative strategy) - Cost(baseline strategy)) / (QALY(alternative strategy) - QALY(baseline strategy)). We measured outcomes as quality-adjusted life years (QALYs). "Best-case" scenarios assumed timely access to care in 50% of cases in the county system and 70% of cases in any system that reimbursed providers at Medicaid fee-for-service rates. "Worst-case" scenarios assumed timely access in 35 and 50% of corresponding cases. In fiscal year 2004-2005, IMPACT allocated 11% of total expenditures to administrative functions and 23% to fixed clinical costs, with an overall budget of $5.9 million. The ICERs ($/QALY) assuming "best-case" scenarios for original IMPACT, modified IMPACT, and a hypothetical Medicaid program were $32,091; $64,663; and $10,376; respectively. ICERs assuming "worst-case" scenarios were $27,189; $84,236; and $10,714; respectively. County safety net was used as a baseline. In conclusion, IMPACT provides underserved Californians with prostate cancer care and value-added services with only 11% of funds allocated to administrative fixed costs. Both the original IMPACT program and the hypothetical Medicaid prostate cancer program were cost-effective compared to the county safety net, while the reduced-fees version of IMPACT was not.

An examination of end-of-life care in a safety net hospital system: a decade in review

OBJECTIVES

To examine patterns of use of end-of-life care in patients receiving treatment at a large, urban safety-net hospital from 2000 to 2010.

METHODS

Data from the Parkland Hospital palliative care database, which tracked all consults for this period, were analyzed. Logistic regression was used to identify predictors of hospice use, and Cox proportional hazards modeling to examine survival.

RESULTS

There were 5,083 palliative care consults over the study period. More patients were Black (41%) or White (31%), and younger than 65 years old (75%). Cancer patients or those who received palliative care services longer were more likely to receive hospice; those who had no form of health care assistance were less likely. There were no racial/ethnic differences in hospice use.

CONCLUSION

In this cohort, there were no racial/ethnic disparities in hospice use. Those who had no form of health care assistance were less likely to receive hospice.

Prostate cancer survivorship: lessons from caring for the uninsured

Since 2001, UCLA has operated

IMPACT

Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (CaP). Funded by the California Department of Public Health, with a cumulative budget of over $80 million, the program provides comprehensive care for low-income, uninsured Californian men with biopsy-proven CaP. Health services research conducted with program enrollees, through the UCLA Men's Health Study, yields an opportunity to perform qualitative and quantitative assessments of patient-reported outcomes in these men, all members of historically underserved, primarily minority populations. This review summarizes data from several studies in which validated instruments were administered longitudinally in 727 participants, prospectively measuring health-related quality of life (HRQOL), self-efficacy in interactions with physician interactions, social and emotional health, symptom distress, satisfaction with care, and other patient-reported outcomes.

Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world

CONTEXT

Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important.

OBJECTIVES

To evaluate the literature in the developed world for barriers to access for low SE groups.

METHODS

Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access.

RESULTS

A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access.

CONCLUSION

Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.