Trajectories of Hospitalization Cost Among Patients of End-Stage Lung Cancer: A Retrospective Study in China

This study was conducted to investigate the trajectory of hospitalization costs, and to assess the determinants related to the membership of the identified trajectories, with the view of recommending future research directions. A retrospective study was performed in urban Yichang, China, where a total of 134 end-stage lung cancer patients were selected. The latent class analysis (LCA) model was used to investigate the heterogeneity in the trajectory of hospitalization cost amongst the different groups that were identified. A multi-nominal logit model was applied to explore the attributes of different classes. Three classes were defined as follows: Class 1 represented the trajectory with minimal cost, which had increased over the last two months. Classes 2 and 3 consisted of patients that incurred high costs, which had declined with the impending death of the patient. Patients in class 3 had a higher average cost than those in Class 2. The level of education, hospitalization, and place of death, were the attributes of membership to the different classes. LCA was useful in quantifying heterogeneity amongst the patients. The results showed the attributes were embedded in hospitalization cost trajectories. These findings are applicable to early identification and intervention in palliative care. Future studies should focus on the validation of the proposed model in clinical settings, as well as to identify the determinants of early discharge or aggressive care.

Care Toward the End of Life in Older Populations and Its Implementation Facilitators and Barriers: A Scoping Review

PURPOSE

To inform health system improvements for care of elderly populations approaching the end of life (EOL) by identifying important elements of care and implementation barriers and facilitators.

DESIGN

A scoping review was carried out to identify key themes in EOL care. Articles were identified from MEDLINE, the Cochrane Library, organizational websites, and internet searches. Eligible publications included reviews, reports, and policy documents published between 2005 and 2016. Initially, eligible documents included reviews or reports concerning effective or important models or components of EOL care in older populations, and evidence was thematically synthesized. Later, other documents were identified to contextualize implementation issues.

RESULTS

Thematic synthesis using 35 reports identified key features in EOL care: (1) enabling policies and environments; (2) care pathways and models; (3) assessment and prognostication; (4) advance care planning and advance directives; (5) palliative and hospice care; (6) integrated and multidisciplinary care; (7) effective communication; (8) staff training and experience; (9) emotional and spiritual support; (10) personalized care; and (11) resources. Barriers in implementing EOL care include fragmented services, poor communication, difficult prognostication, difficulty in accepting prognosis, and the curative focus in medical care.

CONCLUSIONS

Quality EOL care for older populations requires many core components but the local context and implementation issues may ultimately determine if these elements can be incorporated into the system to improve care. Changes at the macro-level (system/national), meso-level (organizational), and micro-level (individual) will be required to successfully implement service changes to provide holistic and person-centered EOL care for elderly populations.

An international comparison of costs of end-of-life care for advanced lung cancer patients using health administrative data

BACKGROUND

Patterns of end-of-life cancer care differ in Canada and the United States; yet little is known about differences in service-specific and overall costs.

AIM

The aim of this study was to compare end-of-life costs in Ontario, Canada, and the United States, using administrative health data.

DESIGN

Advanced-stage nonsmall cell lung cancer patients who died from cancer at age ⩾ 65.5 years in 2001-2005 were selected from the US Surveillance, Epidemiology, and End Results-Medicare database (N = 16,858) and the Ontario Cancer Registry (N = 8643). We estimated total and service-specific costs (2009 US dollars) in each of the last 6 months of life from the public payer perspectives for short-term and long-term survivors (lived < 180 and ⩾ 180 days post-diagnosis, respectively). Services were defined for comparisons between systems.

RESULTS

Mean monthly costs increased as death approached, were higher in short-term than long-term survivors, and were generally higher in the United States than in Ontario until the month before death, when they were similar (long-term survivors: US$10,464 and US$10,094 (p = 0.53), short-term survivors US$14,455 and US$12,836 (p = 0.11), in Surveillance, Epidemiology, and End Results-Medicare and Ontario, respectively). Costs for Medicare hospice and Ontario's palliative care components were similar and increased closer to death. Inpatient hospitalization was the main cost driver with similar costs in both cohorts, despite lower utilization in the United States. The compositions of many services and costs differed.

CONCLUSION

Costs for nonsmall cell lung cancer patients were slightly higher in the United States than Ontario until 1 month before death. Administrative data allow exploration and international comparisons of reimbursement policies, health-care delivery, and costs at the end of life.

Palliative care programs for patients with breast cancer: the benefits of home-based care

SUMMARY Improving breast cancer care means enhancing end-of-life care with specialized palliative care services. Palliative care embodies a holistic approach to care that focuses on symptom management of individuals with incurable diseases, whereas end-of-life care specifically focuses on a period of time, such as the last 6 months of life, where a rapid state of decline is often evident. The purpose of this article is to explore the benefits and limitations of end-of-life care provided in the hospital and community settings, with an emphasis on the benefits of home-based care. A key strength of home-based palliative care is the ability to expand the reach of palliative care to more cancer patients beyond residential hospice or hospital settings, which are limited in bed availability. The essential features of quality end-of-life services, regardless of setting, are care that offers seamless transitions, around-the-clock access to the same providers and an interdisciplinary, whole-person approach.

Trend of urban-rural disparities in hospice utilization in Taiwan

AIMS

The palliative care has spread rapidly worldwide in the recent two decades. The development of hospice services in rural areas usually lags behind that in urban areas. The aim of our study was to investigate whether the urban-rural disparity widens in a country with a hospital-based hospice system.

METHODS

From the nationwide claims database within the National Health Insurance in Taiwan, admissions to hospices from 2000 to 2006 were identified. Hospices and patients in each year were analyzed according to geographic location and residence.

RESULTS

A total of 26,292 cancer patients had been admitted to hospices. The proportion of rural patients to all patients increased with time from 17.8% in 2000 to 25.7% in 2006. Although the numbers of beds and the utilizations in both urban and rural hospices expanded rapidly, the increasing trend in rural areas was more marked than that in urban areas. However, still two-thirds (898/1,357) of rural patients were admitted to urban hospices in 2006.

CONCLUSIONS

The gap of hospice utilizations between urban and rural areas in Taiwan did not widen with time. There was room for improvement in sufficient supply of rural hospices or efficient referral of rural patients.

Factors Associated With Favorable Attitudes Toward End-of-Life Planning

Planning for end-of-life (EOL) care can result in better patient outcomes and lowered health care costs. We hypothesized that knowledge and experiences with EOL care would influence patients’ EOL planning (i.e., health care decisions, hospice use). Using an observational, cross-sectional design, we recruited a community sample of 331 South Floridians aged 18 to 84 (M = 44 years, SD = 14.95) to complete a questionnaire examining knowledge and opinions on EOL issues. Regression analyses showed that prior knowledge of living wills and hospice services were associated with more favorable attitudes toward hospice care, preference for limited medical interventions at EOL, and more comfort in communicating about death and dying. Patient education on EOL care may increase hospice use, enhance EOL planning, and improve patient outcomes.

Offering Chemotherapy and Hospice Jointly: One Solution to Hospice Underuse

Purpose . Patients with advanced lung cancer typically receive chemotherapy at the cost of receiving care that may promote quality of life more effectively. The authors examined whether offering chemotherapy and hospice concurrently, a clinically appropriate but often unavailable option, might resolve this problem. Method. Adult smokers (N = 198) completed an Internet-based survey in which they imagined having advanced lung cancer. Participants rated the effectiveness of 4 treatments (supportive care alone, chemotherapy with supportive care, hospice, and chemotherapy with hospice) at achieving 4 goals of treatment (extending survival, controlling symptoms, avoiding side effects, and promoting quality of life at the end of life). Results. Reflecting utilization patterns of lung cancer patients, few respondents preferred supportive care alone (10%) or hospice (19%), and many preferred chemotherapy (29%). The most common choice was concurrent chemotherapy and hospice (42%). Treatments that involved chemotherapy were seen as the most effective at extending survival, whereas treatments that involved hospice were seen as most effective at promoting quality of life. Effectiveness ratings were weakly related to preferences for hospice, moderately related to preferences for chemotherapy with supportive care, and strongly related to preferences for chemotherapy and hospice together. Conclusions. These findings suggest that interest in hospice may be low because, offered without chemotherapy, hospice is perceived as ineffective at controlling symptoms and avoiding side effects. Chemotherapy and hospice together may be a preferred option for treating advanced lung cancer. Furthermore, preferences for chemotherapy and hospice together best reflect the values people placed on the goals of treatment.

Development of the palliative care needs assessment tool (PC-NAT) for use by multi-disciplinary health professionals

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

How should we design supportive cancer care? The patient's perspective

PURPOSE

Hospice services are designed to meet the needs of patients near the end of life. Although so-called open-access hospice programs and bridge programs are beginning to offer these services to patients who are still receiving treatment, it is not known whether they best meet patients' needs.

PATIENTS AND METHODS

Three hundred adult patients receiving treatment for cancer completed interviews in which each patient's value or ability for supportive care services were calculated from the choices that they made among combinations of those services. Preferences for five traditional hospice services and six alternative supportive care services were measured, and patients were followed up for 6 months or until death.

RESULTS

Patients' utilities for alternative services were higher than those for traditional hospice services (0.53 v 0.39; sign-rank test P < .001). Alternative services were also preferred among patients with poor functional status (Eastern Cooperative Oncology Group performance score > 2; n = 54; 0.65 v 0.48; P < .001) and among those who were in the last 6 months of life (0.68 v 0.56; sign-rank test P = .003). Even patients who were willing to forgo cancer treatment (n = 38; 13%) preferred alternative services (3.1 v 1.8; P < .001).

CONCLUSION

Patients who are receiving active treatment for cancer, and even those who are willing to stop treatment, express a clear preference for alternative supportive care services over traditional hospice services. Supportive care programs for patients with advanced cancer should reconsider the services that they offer and might seek to include novel services in addition to, or perhaps instead of, traditional hospice services.

Inequity in the provision of and access to palliative care for cancer patients. Results from the Italian survey of the dying of cancer (ISDOC)

Background

The palliative services and programs have been developed with different intensity and modalities in all countries. Several studies have reported that a geographic variation in the availability and provision of palliative care services between and within countries exists, and that a number of vulnerable groups are excluded from these services. This survey estimates the distribution of places of care for Italian cancer patients during the last three months of their lives, the proportion receiving palliative care support at home and in hospital, and the factors associated with the referral to palliative care services.

Methods

This is a mortality follow-back survey of 2,000 cancer deaths identified with a 2-stage probability sample, representative of the whole country. Information on patients' experience was gathered from the non-professional caregiver through an interview, using an adapted version of the VOICES questionnaire. A section of the interview concerned the places of care and the palliative care services provided to patients. Multivariate logistic regression analyses were conducted to identify the determinants of palliative care service use.

Results

Valid interviews were obtained for 67% of the identified caregivers (n = 1,271). Most Italian cancer patients were cared for at home (91%) or in hospital (63%), but with substantial differences within the country. Only 14% of Italian cancer patients cared for at home against 20% of those admitted to hospital, received palliative care support. The principal determinants identified for receiving these service were: an extended interval between diagnosis and death (P = 0.01) and the caregiver's high educational level (P = 0.01) for patients at home; the low patient's age (P < 0.01) and the caregiver's high educational level (P = 0.01) for patients in hospital.

Conclusion

In Italy palliative care services are not equally available across the country. Moreover, access to the palliative care services is strongly associated with socio demographic characteristics of the patients and their caregivers. Italian Policy-makers need to equalise palliative care provision and access across the country to meet the needs of all cancer patients.