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Mitchell RJ, Delaney GP, Arnolda G, Liauw W, Phillips JL, Lystad RP, Harrison R, Braithwaite J. Potentially burdensome care at the end-of-life for cancer decedents: a retrospective population-wide study. BMC Palliat Care 2024; 23:32. [PMID: 38302965 PMCID: PMC10835903 DOI: 10.1186/s12904-024-01358-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Variation persists in the quality of end-of-life-care (EOLC) for people with cancer. This study aims to describe the characteristics of, and examine factors associated with, indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer. METHOD A population-based retrospective cohort study of people aged ≥ 20 years who died with a cancer-related cause of death during 2014-2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, consisting of > 1 ED presentation or > 1 hospital admission or ≥ 1 ICU admission within 30 days of death, or died in acute care. RESULTS Of the 80,005 cancer-related deaths, 86.9% were hospitalised in the 12 months prior to death. Fifteen percent had > 1 ED presentation, 9.9% had > 1 hospital admission, 8.6% spent ≥ 14 days in hospital, 3.6% had ≥ 1 intensive care unit admission, and 1.2% received mechanical ventilation on ≥ 1 occasion in the last 30 days of life. Seventeen percent died in acute care. The potentially burdensome care composite measure identified 20.0% had 1 indicator, and 10.9% had ≥ 2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥ 55 years), females, people with 1 or ≥ 2 Charlson comorbidities, people with neurological cancers, and people who died in 2018-2019 were less likely to experience potentially burdensome care. Compared to people with head and neck cancer, people with all cancer types (except breast and neurological) were more likely to experience ≥ 2 indicators of potentially burdensome care versus none. CONCLUSION This study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Geoffrey P Delaney
- Maridulu Budyari Gumal - Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), UNSW, Sydney, Australia
- Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia
- Collaboration for Cancer Outcomes Research and Evaluation, South-Western Sydney Clinical School, UNSW, Sydney, Australia
- University of New South Wales School of Clinical Medicine, Sydney, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Winston Liauw
- University of New South Wales School of Clinical Medicine, Sydney, Australia
- Cancer Care Centre, St George Hospital, Kogarah, Australia
| | - Jane L Phillips
- Maridulu Budyari Gumal - Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), UNSW, Sydney, Australia
- Faculty of Health, School of Nursing, QUT, Brisbane, Australia
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Reema Harrison
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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Nagarajah S, Powis ML, Fazelzad R, Krzyzanowska MK, Kukreti V. Implementation and Impact of Choosing Wisely Recommendations in Oncology. JCO Oncol Pract 2022; 18:703-712. [DOI: 10.1200/op.22.00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Choosing Wisely (CW) campaign, launched in 2012, includes oncology-specific recommendations to promote evidence-based care and deimplementation of low-value practices. However, it is unclear to what extent the campaign has prompted practice change. We systematically reviewed the literature to evaluate the uptake of cancer-specific CW recommendations focusing on the period before the declaration of the COVID-19 pandemic. We used Grimshaw's deimplementation framework to thematically group the findings and extracted information on implementation strategies, barriers, and facilitators from articles reporting on active implementation. In the 98 articles addressing 32 unique recommendations, most reported on passive changes in adherence pre-post publication of CW recommendations. Use of active surveillance for low-risk prostate cancer and reduction in staging imaging for early breast cancer were the most commonly evaluated recommendations. Most articles assessing passive changes in adherence pre-post CW publication reported improvement. All articles evaluating active implementation (10 of 98) reported improved compliance (range: 3%-73% improvement). Most common implementation strategies included provider education and/or stakeholder engagement. Preconceived views and reluctance to adopt new practices were common barriers; common facilitators included the use of technology and provider education to increase provider buy-in. Given the limited uptake of oncology-specific CW recommendations thus far, more attention toward supporting active implementation is needed. Effective adoption of CW likely requires a multipronged approach that includes building stakeholder buy-in through engagement and education, using technology-enabled forced functions to facilitate change along with policy and reimbursement models that disincentivize low-value care. Professional societies have a role to play in supporting this next phase of CW.
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Affiliation(s)
- Sonieya Nagarajah
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Lynn Powis
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Rouhi Fazelzad
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Monika K. Krzyzanowska
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vishal Kukreti
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Allen MJ, Dunn N, Guan T, Harrington J, Walpole E. End-of-life intravenous chemotherapy administration patterns in the treatment of Queensland lung and pancreas cancer patients: a 10-year retrospective analysis. Intern Med J 2022; 52:623-632. [PMID: 33070428 DOI: 10.1111/imj.15107] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND End-of-life (EOL) chemotherapy administration rates for solid tumours are 12-20% and are associated with a reduced quality of life, increased hospitalisation and incidence of death within an acute care facility. AIM We sought to determine the rate of EOL chemotherapy in government and private hospitals and determine the impact on hospitalisations and location of death in lung and pancreatic cancer patients. METHODS Data were obtained from the Queensland Oncology Repository between 2005 and 2014. Lung (n = 16 501) and pancreatic cancer (n = 4144) deaths were analysed. EOL chemotherapy was determined to be within 30 days of death. Demographics, location of treatment and death are reported. RESULTS Chemotherapy was administered to 6518 (40%) lung cancer and 1694 (41%) pancreatic cancer patients. A total of 1474 (9%) and 477 (12%) patients, respectively, received EOL chemotherapy. EOL chemotherapy was more common in males and those with distant metastatic disease, while less likely in the elderly and those with a lower socioeconomic status. EOL chemotherapy was more prevalent in large hospitals and was more common in private compared with government hospitals for pancreatic cancer (30 vs 26%; P < 0.001), while it was similar for lung cancer (24 vs 22%; P = 0.115). Death after EOL chemotherapy compared with all cancer deaths was more common in an acute care facility (lung cancer: 60 vs 37%; P < 0.001; pancreatic cancer: 53 vs 36%; P < 0.001). CONCLUSIONS EOL chemotherapy rates were similar to Australian yet marginally lower than international rates, with variation dependent on the size and type of facility and increased the rate of deaths within an acute care facility.
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Affiliation(s)
- Michael J Allen
- Division of Cancer Services, Princess Alexandra Hospital, Queensland Health, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nathan Dunn
- Queensland Cancer Control Analysis Team, Cancer Alliance Queensland, Brisbane, Queensland, Australia
| | - Tracey Guan
- Queensland Cancer Control Analysis Team, Cancer Alliance Queensland, Brisbane, Queensland, Australia
| | - John Harrington
- Queensland Cancer Control Analysis Team, Cancer Alliance Queensland, Brisbane, Queensland, Australia
| | - Euan Walpole
- Division of Cancer Services, Princess Alexandra Hospital, Queensland Health, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Pitson G, Matheson L, Garrard B, Eastman P, Rogers M. Population-based analysis of radiotherapy and chemotherapy treatment in the last month of life within regional Australia. Intern Med J 2021; 50:596-602. [PMID: 31161700 DOI: 10.1111/imj.14377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cancer treatment near end of life is not likely to add meaningful benefit and minimising intervention rates has been promoted as an indicator of quality of care. Population-based analysis of treatment allows comparative analysis of treatment rates and provides insight into patterns of care. AIMS To report a population-based analysis of both radiotherapy and active systemic therapy (AST) delivery rates along with patterns of treatment within the last 14 and 30 days of life. METHODS The Evaluation of Cancer Outcomes Registry records clinical information on all newly diagnosed cancer patients for the Barwon South West Region of Victoria, Australia. Diagnosis details, tumour type and stage as well as core treatment details and date of death were extracted for all patients diagnosed from 2009 to 2015 inclusive. RESULTS A total of 12 760 cases cancers were recorded. The median age of all cases was 68.8, and 53% were male. AST was received by 3699 (29%) of patients and radiotherapy by 3811 (30%). Patient deaths within 14 and 30 days of treatment for AST were 4.3 and 8.7%, respectively, and deaths within 14 and 30 days of treatment for radiotherapy 3.8 and 8.0% respectively. Factors associated with death within 30 days of AST and/or radiotherapy were male gender, age greater than 70 years and higher disease stage (all P < 0.01). Treatment rates within 30 days of death were highest for lung cancer (23% of cases) and lowest for breast cancer (2% of cases). CONCLUSIONS This population-based analysis of AST and radiotherapy treatment within the last 30 days of life within a region of Australia has shown overall treatment rates below 10%. Treatment rates appear influenced by both patient and tumour characteristics. Future focus on subgroups with high rates of late intervention may help minimise treatment unlikely to add benefit.
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Affiliation(s)
- Graham Pitson
- Cancer Services, Barwon Health, Geelong, Victoria, Australia.,Barwon South Western Region Integrated Cancer Service, Geelong, Victoria, Australia
| | - Leigh Matheson
- Barwon South Western Region Integrated Cancer Service, Geelong, Victoria, Australia
| | - Brooke Garrard
- Barwon South Western Region Integrated Cancer Service, Geelong, Victoria, Australia
| | - Peter Eastman
- Palliative Care, Barwon Health, Geelong, Victoria, Australia
| | - Margaret Rogers
- Barwon South Western Region Integrated Cancer Service, Geelong, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Chiba M, Negishi M, Miyagawa S, Suzuki S, Sasai E, Sugai K, Hagiwara S. Status and cost analysis of antimicrobial treatment of terminally ill patients with hematological malignancy in an acute hospital. J Infect Chemother 2020; 26:1288-1293. [PMID: 32830046 DOI: 10.1016/j.jiac.2020.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Terminally ill patients with hematological malignancy tend to be treated aggressively. We aimed to clarify the status and costs of antimicrobial treatment of patients dying with hematological malignancies. METHODS This retrospective study was conducted in a Japanese acute hospital between September 2010 and August 2015. A total of 141 patients who stayed for 14 days or longer and died in the hospital were investigated. RESULTS The median patient age was 67 years (range, 22-93). Most patients were treated with antibacterial, antifungal, and antiviral agents (98%, 75%, and 27% of the patients, respectively) in the last 14 days of their lives. The frequency of antibiotics used in the last 7 days did not differ from that of the week before. The median cost of antimicrobials was 245,000 JPY (2227 USD), which reflected 16% of the total medical costs spent over the last 14 days. A subgroup analysis of the patients according to care policy (aggressive care policy (A) and palliative care policy (P), respectively) showed that the total medical cost in group P in the last 7 days decreased from that of the preceding week; however, the cost of antimicrobials did not lessen even in the last 7 days. CONCLUSIONS Most patients dying with hematological malignancy were treated with a broad spectrum of antimicrobials. It appeared to be difficult to reduce, let alone discontinue antimicrobial treatment even in patients treated according to the palliative care policy. The optimal use of antibiotics for hematological patients in their end-of-life should be discussed.
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Affiliation(s)
- Miyuki Chiba
- Department of Nursing, National Center for Global Health and Medicine, Tokyo, Japan
| | - Miyako Negishi
- Department of Nursing, National Hospital Organization Saga Hospital, Saga, Japan
| | - Sanae Miyagawa
- Department of Nursing, National Cancer Center Hospital, Tokyo, Japan
| | - Satoru Suzuki
- Hospital Information Management Office, National Center for Global Health and Medicine, Tokyo, Japan
| | - Emiko Sasai
- Department of Nursing, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazunori Sugai
- Hospital Information Management Office, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shotaro Hagiwara
- Division of Hematology, National Center for Global Health and Medicine, Tokyo, Japan; Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan.
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Scott IA. Audit‐based measures of overuse of medical care in Australian hospital practice. Intern Med J 2019; 49:893-904. [DOI: 10.1111/imj.14346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/07/2018] [Accepted: 12/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ian A. Scott
- Department of Internal Medicine and Clinical EpidemiologyPrincess Alexandra Hospital Brisbane Queensland Australia
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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Janda M, Hayes SC. Time and treatments: It is what you make of it that counts. Asia Pac J Clin Oncol 2017; 13:343-344. [PMID: 29134792 DOI: 10.1111/ajco.12763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Monika Janda
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sandra C Hayes
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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