Physician Experience Caring for Dying Patients and Its Relationship to Patient Outcomes

Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study

One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life.Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models.Over one-third (average [range]: 36.11% [33.07%-37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96-32.22%), MRI (4.34-6.70%), and PET (0.00-0.62%), but decreased for BS (9.47-6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity.To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems.

Determinants of ICU care in the last month of life for Taiwanese cancer decedents, 2001 to 2006

BACKGROUND

Use of the hospital ICU is rising rapidly for end-of-life care. The purpose of this population-based study was to determine the prevalence of ICU care in the last month of life of patients with cancer and the associations between ICU care and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of health-care resources at the hospital and regional levels in Taiwan.

METHODS

This retrospective cohort study used administrative data for 204,850 cancer decedents from 2001 to 2006.

RESULTS

Rates of hospital ICU care in the last month of life did not change significantly from 2001 to 2006 (11.27%-12.71%). ICU use in the last month of life was more likely for single male patients aged < 65 years who had hematologic malignancies or esophageal cancer and more comorbidities or a nononcologist as primary-care physician. Patients with cancer were one-third less likely to use ICU care in their last month of life if they received care in a private hospital than if they were cared for in a public hospital. Patient propensity to receive ICU care in the last month of life was positively associated with increasing quartile of total hospital beds in their primary hospital's region.

CONCLUSIONS

Slightly more than one-tenth of Taiwanese patients with cancer received ICU care in their last month of life. ICU use was strongly influenced by receiving care in hospitals and regions with abundant health-care resources. Resources should be devoted to ensure that ICU care at the end of life best meets patients' individual needs and interests.

Use of a palliative care order set to improve resident comfort with symptom management in palliative care

Although one-fourth of all medicare dollars are spent during the last year of life, symptom management for terminal hospitalized patients has continued to be inadequate. Quality end-of-life care is often overlooked, seldom taught and rarely measured within Internal Medicine Residency Programmes. We studied the effects of a palliative care order set and educational e-mail on resident comfort. Survey of residents showed that only 54% were comfortable across nine aspects of palliative care. Three months after release, 88% of residents were using the order set and 63% believed it increased their comfort with palliative care. Resident comfort managing palliative symptoms increased an average 10% (P = 0.02). First-year residents exposed to this order set increased in comfort from 40% to 65% (P < 0.0001), which significantly surpassed the 48% of second-year residents who reported being comfortable (P = 0.002). Introducing a palliative care order set improves resident comfort with symptom management in dying patients.