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Murmann M, Manuel DG, Tanuseputro P, Bennett C, Pugliese M, Li W, Roberts R, Hsu AT. Estimated mortality risk and use of palliative care services among home care clients during the last 6 months of life: a retrospective cohort study. CMAJ 2024; 196:E209-E221. [PMID: 38408785 PMCID: PMC10896599 DOI: 10.1503/cmaj.221513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND In Canada, only 15% of patients requiring palliative care receive such services in the year before death. We describe health care utilization patterns among home care users in their last 6 months of life to inform care planning for older people with varying mortality risks and evolving care needs as they decline. METHODS Using population health administrative data from Ontario, we performed a retrospective cohort study involving home care clients aged 50 years and older who received at least 1 interRAI (Resident Assessment Instrument) Home Care assessment between April 2018 and September 2019. We report the proportion of clients who used acute care, long-term care, and palliative home care services within 6 months of their assessment, stratified by their predicted 6-month mortality risk using a prognostic tool called the Risk Evaluation for Support: Predictions for Elder-life in their Communities Tool (RESPECT) and vital status. RESULTS The cohort included 247 377 adults, 11.9% of whom died within 6 months of an assessment. Among decedents, 50.6% of those with a RESPECT-estimated median survival of fewer than 3 months received at least 1 nonphysician palliative home care visit before death. This proportion declined to 38.7% and 29.5% among decedents with an estimated median survival between 3 and 6 months and between 6 and 12 months, respectively. INTERPRETATION Many older adults in Ontario do not receive any palliative home care before death. Prognostic tools such as RESPECT may improve recognition of reduced life expectancies and palliative care needs of individuals in their final years of life.
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Affiliation(s)
- Maya Murmann
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Douglas G Manuel
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Carol Bennett
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Michael Pugliese
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Wenshan Li
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Rhiannon Roberts
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Bruyère Research Institute (Murmann, Tanuseputro, Hsu); Clinical Epidemiology Program (Manuel, Tanuseputro, Bennett, Pugliese, Li, Roberts, Hsu), Ottawa Hospital Research Institute; Department of Family Medicine (Manuel, Hsu), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro, Pugliese); Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont.
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Li W, Qureshi D, Rhodes E, Imsirovic H, Isenberg SR, Tanuseputro P. Place of Death and Place of Care at the End of Life: Are They Correlated? A Retrospective Cohort Study of Ontario Decedents. J Palliat Med 2024; 27:224-230. [PMID: 37967408 DOI: 10.1089/jpm.2023.0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background: Dying in nonpalliative acute care is generally considered inappropriate and avoidable. Place of death, a commonly reported big-dot indicator of end-of-life care quality, is often used as a proxy for place of care despite no empirical evidence for their correlations. Thus, we examined the correlations between place of death and place of care in the last month of life. We also investigated anecdotal claims that individuals cared in acute care often get discharged to die at home, and vice versa. Methods: We conducted a retrospective cohort study of Ontario decedents (18+) who died between January 1, 2015 and December 31, 2017. We identified individuals who died in nonpalliative acute care, palliative care unit, subacute care, long-term care (LTC), and the community. We calculated the number of days decedents spent in each setting in their last month of life, and used descriptive analyses to investigate their correlations. Results: Decedent's place of death generally correlated with their place of care in the last month of life-individuals who died in a particular setting spent more time in that setting than individuals who died elsewhere. Furthermore, 75.0% of individuals who spent more than two weeks of their last month in acute care died in acute care. Among individuals who died in the community and in LTC, 65.4% and 75.0%, respectively, spent zero days in acute care. Interpretation: We showed that place of death can be a useful high-level performance indicator, by itself and as a proxy for place of care, to gauge end-of-life quality and service provision/implementation.
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Affiliation(s)
- Wenshan Li
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Emily Rhodes
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Haris Imsirovic
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Croxford S, Miller RF, Post FA, Harding R, Lucas SB, Figueroa J, Harrison I, Delpech VC, Dhoot S, Sullivan AK. Cause of death among HIV patients in London in 2016. HIV Med 2019; 20:628-633. [PMID: 31274241 DOI: 10.1111/hiv.12761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Since 2013, the London HIV Mortality Review Group has conducted annual reviews of deaths among people with HIV to reduce avoidable mortality. METHODS All London HIV care Trusts reported data on 2016 patient deaths in 2017. Deaths were submitted using a modified Causes of Death in HIV reporting form and categorized by a specialist HIV pathologist and two HIV clinicians. RESULTS There were 206 deaths reported; 77% were among men. Median age at death was 56 years. Cause was established for 82% of deaths, with non-AIDS-related malignancies and AIDS-defining illnesses being the most common causes reported. Risk factors in the year before death included: tobacco smoking (37%), excessive alcohol consumption (19%), non-injecting drug use (10%), injecting drug use (7%) and opioid substitution therapy (6%). Thirty-nine per cent of patients had a history of depression, 33% chronic hypertension, 27% dyslipidaemia, 17% coinfection with hepatitis B virus and/or hepatitis C virus and 14% diabetes mellitus. At the time of death, 81% of patients were on antiretroviral therapy (ART), 61% had a CD4 count < 350 cells/μL, and 24% had a viral load ≥ 200 HIV-1 RNA copies/mL. Thirty-six per cent of deaths were unexpected; 61% of expected deaths were in hospital. Two-thirds of expected deaths had a prior end-of-life care discussion documented. CONCLUSIONS In 2016, most deaths were attributable to non-AIDS-related conditions and the majority of patients were on ART and virally suppressed. However, several potentially preventable deaths were identified and underlying risk factors were common. As London HIV patients are not representative of people with HIV in the UK, a national mortality review is warranted.
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Affiliation(s)
- S Croxford
- National Infection Service, Public Health England, London, UK
| | - R F Miller
- Central and North West London NHS Foundation Trust, Mortimer Market Centre, London, UK
| | - F A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - R Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
| | - S B Lucas
- Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - J Figueroa
- National Infection Service, Public Health England, London, UK.,NHS England London, London, UK
| | | | - V C Delpech
- National Infection Service, Public Health England, London, UK
| | - S Dhoot
- Directorate of HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - A K Sullivan
- National Infection Service, Public Health England, London, UK.,Directorate of HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Harding R. Palliative care as an essential component of the HIV care continuum. Lancet HIV 2018; 5:e524-e530. [PMID: 30025682 DOI: 10.1016/s2352-3018(18)30110-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/11/2018] [Accepted: 05/17/2018] [Indexed: 11/26/2022]
Abstract
Although antiretroviral therapy has reduced mortality among people with HIV, inadequate treatment coverage, ageing, and the increasing incidence of organ failure and malignancies mean that high-quality care should include care at the end of life. This Review summarises the epidemiology of HIV in relation to mortality, and the symptoms and concerns of people with AIDS and those living with HIV who have either related or unrelated advanced comorbidities. In response to the evidence of a need for palliative care, the principles and practice of palliative care are described, and the evidence for its effectiveness and cost-effectiveness is appraised. The core practices of palliative care offer a mechanism to enhance the person-centred nature of HIV care; I identify the gaps in this type of care, and present evidence for effective models of care to address these. I detail the policies that prompt governments and health systems to respond to the palliative care needs of their population. Finally, I conclude this Review with evidence-based recommendations to improve the delivery of, and access to, high-quality HIV care until the end of life, reducing unnecessary suffering while optimising person-centred outcomes.
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Affiliation(s)
- Richard Harding
- Department of Palliative Care, Policy, and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, Cicely Saunders Institute, King's College London, London, UK.
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