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Gitau K, Huang A, Isenberg SR, Stall N, Ailon J, Bell CM, Quinn KL. Association of patient sex with use of palliative care in Ontario, Canada: a population-based study. CMAJ Open 2023; 11:E1025-E1032. [PMID: 37935486 PMCID: PMC10635704 DOI: 10.9778/cmajo.20220232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. METHODS We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance. RESULTS There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician. INTERPRETATION After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.
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Affiliation(s)
- Kevin Gitau
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Anjie Huang
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Sarina R Isenberg
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Nathan Stall
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Jonathan Ailon
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Chaim M Bell
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Kieran L Quinn
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
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Webber C, Hafid S, Gayowsky A, Howard M, Tanuseputro P, Jones A, Scott MM, Hsu AT, Downar J, Manuel D, Conen K, Isenberg SR. End-of-life interventions in patients with cancer. BMJ Support Palliat Care 2023:spcare-2023-004222. [PMID: 37536756 DOI: 10.1136/spcare-2023-004222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site. METHODS We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site. RESULTS Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates. CONCLUSIONS Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shuaib Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aaron Jones
- ICES, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mary M Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, Walker Family Cancer Centre and Niagara Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Hafid A, Howard M, Webber C, Gayowsky A, Scott M, Jones A, Hsu AT, Tanuseputro P, Downar J, Conen K, Manuel D, Isenberg SR. Describing settings of care in the last 100 days of life for cancer decedents: a population-based descriptive study. Cancer Med 2023; 12:4809-4820. [PMID: 36281530 PMCID: PMC9972173 DOI: 10.1002/cam4.5291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death. METHODS A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada. RESULTS Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home. CONCLUSIONS In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.
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Affiliation(s)
- Abe Hafid
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada
| | | | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada
| | - Aaron Jones
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Katrin Conen
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada.,Department of Family Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Sarina R Isenberg
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
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Webber C, Isenberg SR, Scott M, Hafid A, Hsu AT, Conen K, Jones A, Clarke A, Downar J, Kadu M, Tanuseputro P, Howard M. Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study. J Palliat Med 2022; 25:897-906. [PMID: 35007439 DOI: 10.1089/jpm.2021.0496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abe Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- ICES, Ottawa, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anna Clarke
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Morin L, Onwuteaka-Philipsen BD. The promise of big data for palliative and end-of-life care research. Palliat Med 2021; 35:1638-1640. [PMID: 34636263 DOI: 10.1177/02692163211048307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Lucas Morin
- Inserm CIC 1431, University Hospital of Besançon, Besançon, France.,Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam University Medical Center, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, the Netherlands
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