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Adsersen M, Thygesen LC, Neergaard MA, Sjøgren P, Mondrup L, Nissen JS, Clausen LM, Groenvold M. Higher Admittance to Specialized Palliative Care for Patients with High Education and Income: A Nationwide Register-Based Study. J Palliat Med 2023; 26:57-66. [PMID: 36130182 DOI: 10.1089/jpm.2022.0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: While associations between socioeconomic position, that is, income and education and admittance to specialized palliative care (SPC) have been investigated previously, no prior national studies have examined admittance to all types of SPC, that is, hospital-based palliative care team/units and hospice. Aim: To investigate whether cancer patients' education and income were associated with admittance to SPC (hospital-based palliative care team/unit, hospice). Design: Data sources were several nationwide registers. The association between SPC and education and income, respectively, was investigated using logistic regression analyses. Setting/Participants: Patients dying from cancer in Denmark 2010-12 (n = 41,741). Results: In the study population, 45% had lower secondary school, and 6% had an academic education. Patients with an academic education were more often admitted to SPC than those having lower secondary school (odds ratio [OR] = 1.69; 95% confidence interval [CI]: 1.51-1.89). Patients in the highest income quartile (Q4) were more often admitted than those in the lowest income quartile (Q1) (OR = 1.46; 95% CI: 1.37-1.56). This association was stronger for hospice (OR = 1.67 (95% CI: 1.54-1.81)) than for admittance to hospital-based palliative care team/unit (OR = 1.23 (95% CI: 1.14-1.31)). Compared with patients who had lower secondary school and the lowest income, the OR of admittance to SPC among the most affluent academics was 1.96 (95% CI: 1.71-2.25). Conclusion: This nationwide study indicates that admittance to SPC was clearly associated with education and income. We believe that the associations indicate inequity. Initiatives to improve access for patients with low education or income should be established.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lise Mondrup
- The Palliative Team Esbjerg, Sydvestjysk Hospital, Esbjerg, Denmark
| | | | | | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Jøhnk C, Laigaard HH, Pedersen AK, Bauer EH, Brandt F, Bollig G, Wolff DL. Time to End-of-Life of Patients Starting Specialised Palliative Care in Denmark: A Descriptive Register-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13017. [PMID: 36293593 PMCID: PMC9602996 DOI: 10.3390/ijerph192013017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
Increasing numbers of patients are being referred to specialised palliative care (SPC) which, in order to be beneficial, is recommended to last more than three months. This cohort study aimed to describe time to end-of-life after initiating SPC treatment and to explore potential regional variations. We used national register data from all Danish hospital SPC teams. We included patients who started SPC treatment from 2015-2018 to explore if time to end-of-life was longer than three months. Descriptive statistics were used to summarise the data and a generalised linear model was used to assess variations among the five Danish regions. A total of 27,724 patients were included, of whom 36.7% (95% CI 36.2-37.1%) had over three months to end-of-life. In the Capital Region of Denmark, 40.1% (95% CI 39.0-41.3%) had over three months to end-of-life versus 32.5% (95% CI 30.9-34.0%) in North Denmark Region. We conclude that most patients live for a shorter period of time than the recommended three months after initiating SPC treatment. This is neither optimal for patient care, nor the healthcare system. A geographical variation between regions was shown indicating different practices, patient groups or resources. These results warrant further investigation to promote optimal SPC treatment.
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Affiliation(s)
- Camilla Jøhnk
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
| | - Helene Holm Laigaard
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Department of Clinical Research, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Eithne Hayes Bauer
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Frans Brandt
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
| | - Georg Bollig
- Department of Internal Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Sydvang 1, 6400 Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
- Department of Anesthesiology, Intensive Care, Palliative Medicine and Pain Therapy, HELIOS Klinikum, 24837 Schleswig, Germany
| | - Donna Lykke Wolff
- Department of Regional Health Research, University of Southern Denmark, J. B. Winsløws Vej 19, 5000 Odense, Denmark
- Internal Medicine Research Unit, Hospital Sønderjylland, University Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark
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Bergqvist J, Hedman C, Schultz T, Strang P. Equal receipt of specialized palliative care in breast and prostate cancer: a register study. Support Care Cancer 2022; 30:7721-7730. [PMID: 35697884 PMCID: PMC9385819 DOI: 10.1007/s00520-022-07150-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE There are inequalities in cancer treatment. This study aimed to investigate whether receipt of specialized palliative care (SPC) is affected by typical female and male diagnoses (breast and prostate cancer), age, socioeconomic status (SES), comorbidities as measured by the Charlson Comorbidity Index (CCI), or living arrangements (home vs nursing home residence). Furthermore, we wanted to investigate if receipt of SPC affects the place of death, or correlated with emergency department visits, or hospital admissions. METHODS All breast and prostate cancer patients who died with verified distant metastases during 2015-2019 in the Stockholm Region were included (n = 2516). We used univariable and stepwise (forward) logistic multiple regression models. RESULTS Lower age, lower CCI score, and higher SES significantly predicted receipt of palliative care 3 months before death (p = .007-p < .0001). Patients with prostate cancer, a lower CCI score, receiving palliative care services, or living in a nursing home were admitted to a hospital or visited an emergency room less often during their last month of life (p = .01 to < .0001). Patients receiving palliative care services had a low likelihood of dying in an acute care hospital (p < .001). Those who died in a hospital were younger, had a lower CCI score, and had received less palliative care or nursing home services (p = .02- < .0001). CONCLUSION Age, comorbidities, and nursing home residence affected the likelihood of receiving SPC. However, the diagnosis of breast versus prostate cancer did not. Emergency room visits, hospital admissions, and hospital deaths are registered less often for patients with SPC.
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Affiliation(s)
- Jenny Bergqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
- Breast Center, Department of Surgery, Capio St Gorans Sjukhus, St Görans plan 1, 112 19, Stockholm, Sweden.
| | - Christel Hedman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- R & D Department, Stockholms Sjukhem Foundation, 102 26, P. O. Box 12230, Stockholm, Sweden
| | - Torbjörn Schultz
- R & D Department, Stockholms Sjukhem Foundation, 102 26, P. O. Box 12230, Stockholm, Sweden
| | - Peter Strang
- R & D Department, Stockholms Sjukhem Foundation, 102 26, P. O. Box 12230, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Centre Stockholm-Gotland, Stockholm, Sweden
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4
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Sampedro Pilegaard M, Knold Rossau H, Lejsgaard E, Kjer Møller JJ, Jarlbaek L, Dalton SO, la Cour K. Rehabilitation and palliative care for socioeconomically disadvantaged patients with advanced cancer: a scoping review. Acta Oncol 2021; 60:112-123. [PMID: 33021852 DOI: 10.1080/0284186x.2020.1827156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rehabilitation and palliative care may play an important role in addressing the problems and needs perceived by socioeconomically disadvantaged patients with advanced cancer. However, no study has synthesized existing research on rehabilitation and palliative care for socioeconomically disadvantaged patients with advanced cancer. The study aimed to map existing research of rehabilitation and palliative care for patients with advanced cancer who are socioeconomically disadvantaged. MATERIAL AND METHODS A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was performed in CINAHL, PubMed and EMBASE. Two reviewers independently assessed abstracts and full-text articles for eligibility and performed data extraction. Both qualitative and quantitative studies published between 2010 and 2019 were included if they addressed rehabilitation or palliative care for socioeconomically disadvantaged (adults ≥18 years) patients with advanced cancer. Socioeconomic disadvantage is defined by socioeconomic position (income, educational level and occupational status). RESULTS In total, 11 studies were included in this scoping review (138,152 patients and 45 healthcare providers) of which 10 were quantitative studies and 1 was a qualitative study. All included studies investigated the use of and preferences for palliative care, and none focused on rehabilitation. Two studies explored health professionals' perspectives on the delivery of palliative care. CONCLUSION Existing research within this research field is sparse. Future research should focus more on how best to reach and support socioeconomically disadvantaged people with advanced cancer in community-based rehabilitation and palliative care.
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Affiliation(s)
- Marc Sampedro Pilegaard
- REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Odense, Denmark
- Department of Public Health, Research Unit of General Practice, The Research Initiative of Activity Studies and Occupational Therapy, University of Southern Denmark, Odense, Denmark
| | - Henriette Knold Rossau
- REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Odense, Denmark
| | - Esben Lejsgaard
- Department of Sociology and Social Work, Aalborg University, Denmark, Aalborg, Denmark
| | - Jens-Jakob Kjer Møller
- REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Odense, Denmark
| | - Lene Jarlbaek
- REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Odense, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship & Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department for Clinical Oncology & Palliative Care, Danish Research Center for Equality in Cancer (COMPAS), Zealand University Hospital, Næstved, Denmark
| | - Karen la Cour
- REHPA, the Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Odense, Denmark
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5
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Mondor L, Wodchis WP, Tanuseputro P. Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study. Palliat Med 2020; 34:1393-1401. [PMID: 32772809 DOI: 10.1177/0269216320947964] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing equitable care to patients in need across the life course is a priority for many healthcare systems. AIM To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). DESIGN Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). SETTING/PARTICIPANTS A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. RESULTS In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9-5.1%), which was 8.6% (6.2-10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8-7.8%) absolute gap, 26.3% (22.5-30.0%) relative gap) and for physician encounters (6.8% (5.7-7.9%) absolute gap, 13.2% (11.0-15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). CONCLUSION Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.
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Affiliation(s)
- Luke Mondor
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada
| | - Walter P Wodchis
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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6
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Martinsson L, Lundström S, Sundelöf J. Better quality of end-of-life care for persons with advanced dementia in nursing homes compared to hospitals: a Swedish national register study. BMC Palliat Care 2020; 19:135. [PMID: 32847571 PMCID: PMC7449048 DOI: 10.1186/s12904-020-00639-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022] Open
Abstract
Background Hospitalisation of patients with advanced dementia is generally regarded as less preferable compared to care at home or in a nursing home. For patients with other diagnoses, young age has been associated with better end-of-life care. However, studies comparing the quality of palliative care for persons with advanced dementia in hospitals and nursing homes are scarce. The aim of this study was to investigate whether quality of end-of-life care for patients with dementia depends on age, gender and place of death. Methods The Swedish Register of Palliative Care (SRPC) was used to identify patients who died from dementia in hospitals or nursing homes during a three-year period. The likelihood of death occurring at a hospital, based on age and gender differences, was calculated. Associations between 13 end-of-life care quality indicators collected from the SRPC and age, gender and place of care were examined in a logistic regression model. Results Death at a hospital was associated with poorer quality of end-of-life care for 10 of the 13 measured outcomes when compared to death at a nursing home, and with better quality according to two of the outcomes. Death at a hospital was more common for men compared to women and for younger patients compared to older. Receiving fluids intravenously or via enteral tube in the last 24 h of life was strongly associated with death at a hospital. Women were more likely to have their oral health assessed and less likely to have pressure ulcers at death. Eight of 12 end-of-life care outcomes showed better results for the age group 65 to 84 years compared to those 85 years or older. Conclusions Death in hospitals was associated with poorer quality of end-of-life care compared to death in nursing homes. Our data support the importance of advance care planning and individual assessments in nursing homes to avoid referral to hospitals during end of life. Despite established recommendations to avoid hospitalisation if possible, there were strong associations between younger age, male gender and hospitalisation in the end of life. Further studies are needed to investigate the role of socioeconomic factors in end-of-life care for this patient group.
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Affiliation(s)
- Lisa Martinsson
- Department of Radiation Sciences, Umeå University, SE 907 87, Umeå, Sweden.
| | - Staffan Lundström
- Department of Palliative Medicine, Stockholms Sjukhem Foundation, SE 112 19, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, SE 171 77, Stockholm, Sweden
| | - Johan Sundelöf
- Betaniastiftelsen (non-profit organisation), SE 116 20, Stockholm, Sweden
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Frasca M, Galvin A, Raherison C, Soubeyran P, Burucoa B, Bellera C, Mathoulin-Pelissier S. Palliative versus hospice care in patients with cancer: a systematic review. BMJ Support Palliat Care 2020; 11:188-199. [PMID: 32680891 DOI: 10.1136/bmjspcare-2020-002195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Guidelines recommend an early access to specialised palliative medicine services for patients with cancer, but studies have reported a continued underuse. Palliative care facilities deliver early care, alongside antineoplastic treatments, whereas hospice care structures intervene lately, when cancer-modifying treatments stop. AIM This review identified factors associated with early and late interventions of specialised services, by considering the type of structures studied (palliative vs hospice care). DESIGN We performed a systematic review, prospectively registered on PROSPERO (ID: CRD42018110063). DATA SOURCES We searched Medline and Scopus databases for population-based studies. Two independent reviewers extracted the data and assessed the study quality using Joanna Briggs Institute critical appraisal checklists. RESULTS The 51 included articles performed 67 analyses. Most were based on retrospective cohorts and US populations. The median quality scores were 19/22 for cohorts and 15/16 for cross-sectional studies. Most analyses focused on hospice care (n=37). Older patients, men, people with haematological cancer or treated in small centres had less specialised interventions. Palliative and hospice facilities addressed different populations. Older patients received less palliative care but more hospice care. Patients with high-stage tumours had more palliative care while women and patients with a low comorbidity burden received more hospice care. CONCLUSION Main disparities concerned older patients, men and people with haematological cancer. We highlighted the challenges of early interventions for older patients and of late deliveries for men and highly comorbid patients. Additional data on non-American populations, outpatients and factors related to quality of life and socioeconomic status are needed.
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Affiliation(s)
- Matthieu Frasca
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France .,Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Angeline Galvin
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Chantal Raherison
- Department of Pneumology, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Pierre Soubeyran
- CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
| | - Benoît Burucoa
- Department of Palliative Medicine, CHU of Bordeaux, Bordeaux, Aquitaine, France
| | - Carine Bellera
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,CIC1401, Bergonie institute, Comprehensive Cancer Center, Bordeaux, Aquitaine, France
| | - Simone Mathoulin-Pelissier
- Epicene Team, Inserm UMR 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, Aquitaine, France.,UMR 1218, ACTION, University of Bordeaux, Bordeaux, Aquitaine, France
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8
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Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives. Support Care Cancer 2019; 27:4733-4744. [PMID: 30972644 DOI: 10.1007/s00520-019-04726-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations. PURPOSE To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer. METHODS Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists. RESULTS Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues. CONCLUSION Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.
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9
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Davies JM, Sleeman KE, Leniz J, Wilson R, Higginson IJ, Verne J, Maddocks M, Murtagh FEM. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002782. [PMID: 31013279 PMCID: PMC6478269 DOI: 10.1371/journal.pmed.1002782] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. METHODS AND FINDINGS MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. CONCLUSIONS In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.
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Affiliation(s)
- Joanna M. Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Julia Verne
- Health Intelligence, Public Health England, Bristol, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Fliss E. M. Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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10
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Henson LA, Higginson IJ, Gao W. What factors influence emergency department visits by patients with cancer at the end of life? Analysis of a 124,030 patient cohort. Palliat Med 2018. [PMID: 28631517 DOI: 10.1177/0269216317713428] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency department visits towards the end of life by patients with cancer are increasing over time. This is despite evidence of an association with poor patient and caregiver outcomes and most patients preferring home-based care. AIM To identify socio-demographic and clinical factors associated with end-of-life emergency department visits and determine the relationship between patients' prior emergency department use and risk of multiple (⩾2) visits in the last month of life. DESIGN Population-based cohort study. SETTING/PARTICIPANTS All adults who died from cancer, in England, between 1 April 2011 and 31 March 2012. Our primary outcome was the adjusted odds ratio for multiple emergency department visits in the last month of life, derived using multivariable logistic regression. RESULTS Among 124,030 cancer decedents (52.9% men; mean age: 74.1 years), 30.7% visited the emergency department once in their last month of life and 5.1% visited multiple times. Patients were more likely to visit multiple times if they were men, younger, Asian or Black, of lower socio-economic status, had greater comorbidity, and lung or head and neck cancer. Patients with ⩾4 emergency department visits in the 11 months prior to their last month of life were also more likely to make multiple visits during their last 30 days; this followed a dose-response pattern ( p for trend <0.001). CONCLUSION Patients with greater comorbidity, lung or head and neck cancer and a higher number of previous emergency department visits are more likely to visit the emergency department multiple times in the last month of life. Previously reported socio-demographic factors (men, younger age, Black, low socio-economic status) are also confirmed for the first time in a UK population.
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Affiliation(s)
- Lesley A Henson
- Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
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- Cicely Saunders Institute, Department of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Adsersen M, Thygesen LC, Neergaard MA, Bonde Jensen A, Sjøgren P, Damkier A, Groenvold M. Admittance to specialized palliative care (SPC) of patients with an assessed need: a study from the Danish palliative care database (DPD). Acta Oncol 2017; 56:1210-1217. [PMID: 28557612 DOI: 10.1080/0284186x.2017.1332425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Admittance to specialized palliative care (SPC) has been discussed in the literature, but previous studies examined exclusively those admitted, not those with an assessed need for SPC but not admitted. The aim was to investigate whether admittance to SPC for referred adult patients with cancer was related to sex, age, diagnosis, geographic region or referral unit. MATERIAL AND METHODS A register-based study with data from the Danish Palliative Care Database (DPD). From DPD we identified all adult patients with cancer, who died in 2010-2012 and who were referred to and assessed to have a need for SPC (N = 21,597).The associations were investigated using logistic regression models, which also evaluated whether time from referral to death influenced the associations. RESULTS In the adjusted analysis, we found that admittance was higher for younger patients [e.g., 50-59 versus 80 + years: odds ratio (OR) = 2.03; 1.78-2.33]. There was lower odds of admittance for patients with hematological malignancies and patients from two regions: Capital Region of Denmark and Region of Southern Denmark. Lower admittance among men and patients referred from hospital departments was explained by later referral. CONCLUSIONS In this first nationwide study of admittance to SPC among patients with a SPC need, we found difference in admittance according to age, diagnosis and region. This indicates that prioritization of the limited resources means that certain subgroups with a documented need have reduced likelihood of admission to SPC.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, NV , Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anette Damkier
- The Palliative Care Team Funen, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, NV , Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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12
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Adsersen M, Thygesen LC, Jensen AB, Neergaard MA, Sjøgren P, Groenvold M. Is admittance to specialised palliative care among cancer patients related to sex, age and cancer diagnosis? A nation-wide study from the Danish Palliative Care Database (DPD). BMC Palliat Care 2017; 16:21. [PMID: 28330507 PMCID: PMC5363002 DOI: 10.1186/s12904-017-0194-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were to investigate whether cancer patients' admittance to SPC in Denmark varied in relation to sex, age and diagnosis, and whether the patterns differed by type of institution (hospital-based palliative care team/unit, hospice, or both). METHODS This was a register-based study of adult patients living in Denmark who died from cancer in 2010-2012. Data sources were the Danish Palliative Care Database, Danish Register of Causes of Death and Danish Cancer Registry. The associations between the explanatory variables (sex, age, diagnosis) and admittance to SPC were investigated using logistic regression. RESULTS In the study population (N = 44,548) the overall admittance proportion to SPC was 37%. Higher odds of overall admittance to SPC were found for women (OR = 1.23; 1.17-1.28), younger patients (<40 compared with 80+ years old) (OR = 6.44; 5.19-7.99) and patients with sarcoma, pancreatic and stomach cancers, whereas the lowest were for patients with haematological malignancies. The higher admission found for women was most pronounced for hospices compared to hospital-based palliative care teams/units, whereas higher admission of younger patients was more pronounced for hospital-based palliative care teams/units. Patients with brain cancer were more often admitted to hospices, whereas patients with prostate cancer were more often admitted to hospital-based palliative care teams/units. CONCLUSION It is unlikely that the variations in relation to sex, age and cancer diagnoses can be fully explained by differences in need. Future research should investigate whether the groups having the lowest admittance to SPC receive sufficient palliative care elsewhere.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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13
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Personas enfermas al final de la vida: vivencias en la accesibilidad a recursos sociosanitarios. ENFERMERÍA UNIVERSITARIA 2017. [DOI: 10.1016/j.reu.2016.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Henson LA, Gomes B, Koffman J, Daveson BA, Higginson IJ, Gao W. Factors associated with aggressive end of life cancer care. Support Care Cancer 2015; 24:1079-89. [PMID: 26253587 PMCID: PMC4729799 DOI: 10.1007/s00520-015-2885-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/29/2015] [Indexed: 10/26/2022]
Abstract
BACKGROUND Many patients with cancer experience aggressive care towards the end of life (EOL) despite evidence of an association with poor outcomes such as prolonged pain and overall dissatisfaction with care. PURPOSE To investigate socio-demographic, clinical and community health care service factors associated with aggressive EOL cancer care. METHODS An analysis of pooled data from two mortality follow-back surveys was performed. Aggressive EOL care was defined as greater than or equal to one of the following indicators occurring during the last 3 months of life: greater than or equal to two emergency department visits, ≥30 days in hospital and death in hospital. RESULTS Of the 681 included patients, 50.1% were men and mean age at death was 75 years. The majority of patients (59.3%, 95% confidence interval (CI) 55.6-63.0%) experienced at least one indicator of aggressive EOL care: 29.7% experienced greater than or equal to two ED visits, 17.1% spent ≥30 days in hospital and 37.9% died in hospital. Patients with prostate or haematological cancer were more likely to experience aggressive EOL care (adjusted odds ratio (AOR) 4.36, 95% CI 1.39-13.70, and 4.16, 95% CI 1.38-12.47, respectively, reference group lung cancer). Patients who received greater than five general practitioner (GP) home visits (AOR 0.37, 95% CI 0.17-0.82, reference group no GP visits) or had contact with district nursing (AOR 0.48, 95% CI 0.28-0.83, reference group no contact) or contact with community palliative care services (AOR 0.27, 95% CI 0.15-0.49, reference group no contact) were less likely to experience aggressive EOL care. No association was found between aggressive EOL care and patients' age, gender, marital, financial or health status. CONCLUSIONS Community health care services, in particular contact with community palliative care, are associated with a significant reduction in the odds of cancer patients receiving aggressive EOL care. Expansion of such services may help address the current capacity crises faced by many acute health care systems.
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Affiliation(s)
- Lesley A Henson
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.
| | - Barbara Gomes
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Jonathan Koffman
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Barbara A Daveson
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Irene J Higginson
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Wei Gao
- King's College London, Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
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15
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Old age as risk indicator for poor end-of-life care quality – A population-based study of cancer deaths from the Swedish Register of Palliative Care. Eur J Cancer 2015; 51:1331-9. [DOI: 10.1016/j.ejca.2015.04.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 11/22/2022]
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16
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Urquhart R, Johnston G, Abdolell M, Porter GA. Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis. BMC Palliat Care 2015; 14:2. [PMID: 25674038 PMCID: PMC4324424 DOI: 10.1186/1472-684x-14-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/14/2015] [Indexed: 01/08/2023] Open
Abstract
Background Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis. Methods Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases. Results The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis. Conclusions Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.
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Affiliation(s)
- Robin Urquhart
- Department of Surgery, Dalhousie University, Halifax, NS Canada ; Cancer Outcomes Research Program, Dalhousie University/Capital District Health Authority, Halifax, NS Canada
| | - Grace Johnston
- School of Health Administration, Dalhousie University, Halifax, NS Canada
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS Canada
| | - Geoff A Porter
- Department of Surgery, Dalhousie University, Halifax, NS Canada ; Cancer Outcomes Research Program, Dalhousie University/Capital District Health Authority, Halifax, NS Canada
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Henson LA, Gao W, Higginson IJ, Smith M, Davies JM, Ellis-Smith C, Daveson BA. Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. J Clin Oncol 2014; 33:370-6. [PMID: 25534384 DOI: 10.1200/jco.2014.57.3568] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore factors associated with emergency department (ED) attendance by patients with cancer in their last month of life. METHODS Five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library) were searched through February 2014 for studies investigating ED attendance toward the end of life by adult patients (age 18 years or older) with cancer. No time or language limitations were applied. We performed meta-analysis of factors using a random-effects model, with results expressed as odds ratios (OR) for ED attendance. Sensitivity analyses explored heterogeneity. RESULTS Thirty studies were identified, reporting three demographic, five clinical, and 13 environmental factors, combining data from five countries and 1,181,842 patients. An increased likelihood of ED attendance was found for men (OR, 1.24; 95% CI, 1.19 to 1.29; I(2), 58.2%), black race (OR, 1.45; 95% CI, 1.40 to 1.50; I(2), 0.0%; reference, white race), patients with lung cancer (OR, 1.17; 95% CI, 1.10 to 1.23; I(2), 59.5%; reference, other cancers), and those patients of the lowest socioeconomic status (SES; OR, 1.15; 95% CI, 1.10 to 1.19; I(2), 0.0%; reference, highest SES). Patients receiving palliative care were less likely to attend the ED in their last month of life (OR, 0.43; 95% CI, 0.36 to 0.51; I(2), 59.4%). CONCLUSION We identified demographic (men; black race), clinical (lung cancer), and environmental (low SES; no palliative care) factors associated with an increased risk of ED attendance by patients with cancer in their last month of life. Our findings may be used to develop screening interventions and assist policy-makers to direct resources. Future studies should also investigate previously neglected areas of research, including psychosocial factors, and patients' and caregivers' emergency care preferences.
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Affiliation(s)
- Lesley A Henson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom.
| | - Wei Gao
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Irene J Higginson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Melinda Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Joanna M Davies
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Clare Ellis-Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Barbara A Daveson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
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Sinding C, Warren R, Fitzpatrick-Lewis D, Sussman J. Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours. Support Care Cancer 2014; 22:3101-20. [PMID: 25120008 DOI: 10.1007/s00520-014-2348-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/29/2014] [Indexed: 02/03/2023]
Abstract
The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.
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Affiliation(s)
- Christina Sinding
- School of Social Work & Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada,
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