Health-services utilisation amongst older persons during the last year of life: a population-based study

Gerontological educational interventions for student nurses: a systematic review of qualitative findings

OBJECTIVES

This systematic review of qualitative studies explored interventions to improve student nurses' knowledge, attitudes or willingness to work with older people. Student nurses are likely to encounter older people in all health and aged care settings, however, research demonstrates that few have career aspirations in gerontological nursing.

METHODS

Qualitative systematic review method based on the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Search of Medline, Embase, PsycINFO, EBSCOhost and Scopus yielded 1841 articles which were screened to include primary research about educational interventions to improve student nurses' knowledge, attitudes and/or willingness to work with older people. Data extraction was performed on the 14 included studies, and data were analysed using directed content analysis. The Mixed Methods Appraisal Tool (MMAT) was used the assess the quality of the studies.

CONCLUSIONS

Educational interventions included theory or practice courses, or a combination of theory and practice. While most interventions changed nursing students' negative attitudes towards older people, few increased their willingness to work with them. Practice courses had the most significant impact on willingness to work with older people. Quality assessment revealed methodical limitations. More research is needed to better understand the elements of practice interventions that enhance student nurses' knowledge, attitudes, and willingness to work with older people, so that they can be replicated.

Screening for End-of-Life in Acute Hospitals: A Cross-Sectional Survey

BACKGROUND

Patients are frequently admitted to hospital in the last year of life. Actively recognising patients at this stage gives the opportunity to plan future care.

METHODS

We performed a cross-sectional survey of all acute medical and surgical inpatients at one tertiary hospital. Two simple screening tools, the indicators for a palliative approach and the surprise question identified a group of patients at greatly increased risk of dying over the next year.

RESULTS

The one-year mortality of the study group was 27%, however was 52% and 65% for those identified at risk by the indicators for a palliative approach and surprise question tools. The surprise question had an area under the receiver operator curve value of .84.

CONCLUSION

These screening tools could be used to help clinicians identify hospital inpatients that would benefit from advance care planning and a tailored approach to their care.

Exploring End-of-Life Care for Patients with Breast Cancer, Dementia or Heart Failure: A Register-Based Study of Individual and Institutional Factors

OBJECTIVE

To examine variations in end-of-life care for breast cancer, heart failure, and dementia patients.

DATA AND METHODS

Data from four Norwegian health registries were linked using a personal identification number. Longitudinal trends over 365 days and the type of care on the final day of life were analyzed using descriptive techniques and logistic regression analysis.

RESULTS

Patients with dementia were more commonly placed in nursing homes than patients in the two other groups, while patients with heart failure and breast cancer were more frequently hospitalized than the dementia patients. Breast cancer and heart failure patients had a higher likelihood of dying at home than dementia patients. The higher the number of general practitioners, the higher was the probability of home-based end-of-life care for cancer patients, while an increasing non-physician healthcare workers increased the likelihood of home-based care for the other patient groups.

CONCLUSIONS

Diagnoses, individual characteristics, and service availability are all associated with the place of death in end-of-life care. The higher the availability of health care services, the higher also is the probability of ending the life at home.

Potentially burdensome care at the end-of-life for cancer decedents: a retrospective population-wide study

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.

The impact of travel time to cancer treatment centre on post-diagnosis care and mortality among cancer patients in Scotland

Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations.

Older high-cost patients in Norwegian somatic hospitals: a register-based study of patient characteristics

OBJECTIVE

Two-thirds of the economic resources in Norwegian hospitals are used on 10% of the patients. Most of these high-cost patients are older adults, which experience more unplanned hospital admissions, longer hospital stays and higher readmission rates than other patients. This study aims to examine the individual and clinical characteristics of older patients with unplanned admissions to Norwegian somatic hospitals and how these characteristics differ between high-cost and low-cost older patients.

DESIGN

Observational cross-sectional study.

SETTING

Norwegian somatic hospitals.

PARTICIPANTS

National registry data of older Norwegian patients (≥65 years) with ≥1 unplanned contact with somatic hospitals in 2019 (n=2 11 738).

PRIMARY OUTCOME MEASURE

High-cost older patients were defined as those within the 10% of the highest diagnosis-related group weights in 2019 (n=21 179). We compared high-cost to low-cost older patients using bivariate analyses and logistic regression analysis.

RESULTS

Men were more likely to be high-cost older patients than women (OR=1.25, 95% CI 1.21 to 1.29) and the oldest (90+ years) compared with the youngest older adults (65-69 years) were less likely to cause high costs (OR=0.47, 95% CI 0.43 to 0.51). Those with the highest level of education were less likely to cause high costs than those with primary school degrees (OR=0.74, 95% CI 0.69 to 0.80). Main diagnosis group (OR=3.50, 95% CI 3.37 to 3.63) and dying (OR=4.13, 95% CI 3.96 to 4.30) were the clinical characteristics most strongly associated with the likelihood of being a high-cost older patient.

CONCLUSION

Several of the observed patient characteristics in this study may warrant further investigation as they might contribute to high healthcare costs. For example, MDGs, reflecting comprehensive healthcare needs and lower education, which is associated with poorer health status, increase the likelihood of being high-cost older patients. Our results indicate that Norwegian hospitals function according to the intentions of those having the highest needs receiving most services.

Healthcare Resources Utilization throughout the Last Year of Life after Acute Myocardial Infarction

Healthcare resource utilization (HRU) peaks in the last year-of-life, and accounts for a substantial share of healthcare expenditure. We evaluated changes in HRU and costs throughout the last year-of-life among AMI survivors and investigated whether such changes can predict imminent mortality. This retrospective analysis included patients who survived at least one year following an AMI. Mortality and HRU data during the 10-year follow-up period were collected. Analyses were performed according to follow-up years that were classified into mortality years (one year prior to death) and survival years. Overall, 10,992 patients (44,099 patients-years) were investigated. Throughout the follow-up period, 2,885 (26.3%) patients died. The HRU parameters and total costs were strong independent predictors of mortality during a subsequent year. While a direct association between mortality and hospital services (length of in-hospital stay and emergency department visits) was observed, the association with ambulatory services utilization was reversed. The discriminative ability (c-statistics) of a multivariable model including the HRU parameters for predicting the mortality in the subsequent year, was 0.88. In conclusion, throughout the last year of life, hospital-centered HRU and costs of AMI survivors increase while utilization of ambulatory services decrease. HRUs are strong and independent predictors of an imminent mortality year among these patients.

Patterns of health service use before and after a statewide fall prevention initiative for older adults at risk of falls

OBJECTIVE

To understand health-care burden from fall-related injury, we investigated patterns of health service use in participants of the Australian statewide Stepping On fall prevention program.

METHODS

Routinely collected ambulance, emergency, hospital and mortality data for 9163 participants across NSW Local Health Districts between 2009 and 2015 were analysed for patterns in fall-related health service use three years before and after the Stepping On program using negative binomial regression analyses.

RESULTS

Overall fall-related health service use increased over the 6-year study period. There was a high period of usage prior to program participation, which decreased postprogram, then appeared to increase again after 12-15 months. Subgroup analysis showed strongest postprogram reductions for women.

CONCLUSIONS

Patterns of service usage suggest initial program benefits that taper off over time. The results of this observational study need to be interpreted with caution. Investment in ongoing fall prevention programs may be needed for lasting impacts.

Emergency department and intensive care unit health professionals' knowledge and application of the law that applies to end-of-life decision-making for adults: A scoping review of the literature

BACKGROUND

Laws that regulate healthcare practice at the end of life reflect the values of the society where they apply. Traditionally, healthcare professionals rely on their clinical knowledge to inform treatment decisions, but the extent to which the law also informs health professionals' decision-making at the end of life is uncertain.

OBJECTIVE

The objective of this study was to describe what healthcare professionals working in emergency departments and intensive care units know about the law that relates to end-of-life decision-making for hospitalised adults and what affects its application.

REVIEW METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

DATA SOURCES

Data were sourced by searching the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL [via EBSCOhost]), Nursing and Allied Health and Health and Medical Collection (via ProQuest Central), Excerpta Medica dataBASE (Embase), PubMed, PsycINFO, and HeinOnline.

RESULTS

Systematic screening of the search results and application of inclusion criteria resulted in the identification of 18 quantitative and three qualitative articles that were reviewed, summarised, and reported. Ten of the quantitative studies assessed knowledge and attitudes to law or end-of-life decision-making using hypothetical scenarios or vignettes. Qualitative studies focussed on how the law was applied when end-of-life decisions were made. End-of-life decision-making is mostly based on the clinical needs of the patient, with the law having a secondary role.

CONCLUSION

Around the world, there are significant gaps in healthcare professionals' legal knowledge. Clinical factors are considered more important to end-of-life decision-making than legal factors. End-of-life decision-making is perceived to carry legal risk, and this results in the provision of nonbeneficial end-of-life care. Further qualitative research is needed to ascertain the clinician-related factors that affect the integration of law with end-of-life decision-making.

Socioeconomic differences in inpatient care expenditure in the last year of life among older people: a retrospective population-based study in Stockholm County

OBJECTIVES

To investigate the association between inpatient care expenditure (ICE) and income group and the effect of demographic factors, health status, healthcare and social care utilisation on ICE in the last year of life.

DESIGN

Retrospective population-based study.

SETTING

Stockholm County.

PARTICIPANTS

Decedents ≥65 years in 2015 (N=13 538).

OUTCOME

ICE was calculated individually for the month of, and 12 months preceding death using healthcare register data from 2014 and 2015. ICE included the costs of admission and treatment in inpatient care adjusted for the price level in 2018.

RESULTS

There were difference between income groups and ICE incurred at the 75th percentile, while a social gradient was found at the 95th percentile where the highest income group incurred higher ICE (SEK45 307, 95% CI SEK12 055 to SEK79 559) compared with the lowest income groups. Incurring higher ICE at the 95th percentile was driven by greater morbidity (SEK20 333, 95% CI SEK12 673 to SEK29 993) and emergency department care visits (SEK77 995, 95% CI SEK64 442 to SEK79 549), while lower ICE across the distribution was associated with older age and residing in institutional care.

CONCLUSION

Gaining insight into patterns of healthcare expenditure in the last year of life has important implications for policy, particularly as socioeconomic differences were visible in ICE at a time of greater care need for all. Future policies should focus on engaging in advanced care planning and strengthening the coordination of care for older people.

Factors that influence older patients’ participation in clinical communication within developed country hospitals and GP clinics: A systematic review of current literature

Background

Engaging older adults in clinical communication is an essential aspect of high-quality elder care, patient safety and satisfaction in hospitals and GP clinics. However, the factors that influence older adults’ participation during their appointments with health professionals from the older patient’s perspective remain under-investigated.

Objectives

We aimed to fill this knowledge gap by reviewing research articles that have examined older patients’ involvement in clinical communication. In doing so, we hope to assist healthcare professionals and institutions in developing new strategies to improve older patients’ participation and engagement in clinical communication.

Methods

A systematic review of nine databases was conducted for studies reporting identified influences on older patients’ participation in clinical communication published from 2010. These studies were then subjected to thematic analysis for stratification.

Results

Twenty-one articles with a total of 36,797 participants were included and highlighted three major themes that influenced older patients’ participation in the clinical communication. The first theme identified includes accessibility to appointments, support, health information and person-centred care, highlighting that access to appointments, person centred care and health information significantly influences clinical communication participation. Relevant and understandable healthcare information identified that communication factors [i.e. tailored health information, health literacy and patient language barriers, and communication impairments] influences older patients’ participation. Older Patient perceptions of HCP credibility and trustworthiness highlighted how patient’s perceptions of health professionals influence their willingness to participate in clinical communications.

Conclusions and implications

This review demonstrates that there are several factors that contribute to insufficient or no participation of older patients in clinical communication in hospitals and GP clinics. These include accessibility to relevant and understandable health information, and the perceived health professional credibility and trustworthiness. Identifying ways to address these factors may improve patient participation, doctor-patient collaboration and overall health outcomes for older patients.

Heterogeneity in Longitudinal Healthcare Utilisation by Older Adults: A Latent Transition Analysis of the Irish Longitudinal Study on Ageing

BACKGROUND

Older adults likely exhibit considerable differences in healthcare need and usage. Identifying differences in healthcare utilisation both between and within individuals over time may support future service development.

OBJECTIVES

To characterise temporal changes in healthcare utilisation among a nationally representative sample of community-dwelling older adults.

METHODS

A latent transition analysis of the first three waves of The Irish Longitudinal Study on Ageing (TILDA) (N = 6128) was conducted.

RESULTS

Three latent classes of healthcare utilisation were identified, 'primary care only'; 'primary care and outpatient visits' and 'multiple utilisation'. The classes were invariant across all three waves. Transition probabilities indicated dynamic changes over time, particularly for the 'primary care and outpatient visits' and 'multiple utilisation' statuses.

DISCUSSION

Older adults exhibit temporal changes in healthcare utilisation which may reflect changes in healthcare need and disease progression. Further research is required to identify the factors which influence movement between healthcare utilisation patterns.

Inpatient admissions and outpatient appointments in the first year post cancer diagnosis: A population based study from England

BACKGROUND

Time spent in hospital (length of stay) is an important component of patient experience and the financial cost of cancer care. This study documents the length of stay across English cancer diagnoses at a national level and reports on variation by patient demographics and tumour characteristics.

METHODS

Data on all diagnoses of malignant neoplasms from the English National Cancer Registration and Analysis Service for 252,202 patients first diagnosed in 2015 was linked with NHS Digital's Admitted Patient Care and Outpatient Hospital Episode Statistics datasets to quantify length of stay within one year following diagnosis. Length of stay was modelled using linear regression adjusted for sex, age, tumour type, stage, time spent alive during the study period, vital status at end of study period, region, deprivation and ethnicity.

RESULTS

Patients spend a mean of 25 days (median = 17 days; IQR = 8-34 days) in hospital in their first year. Tumour type, stage, age and vital status corrections had the strongest effects in the model adjusting for other independent variables. Younger patients tended towards longer stays.

CONCLUSION

Length of stay varies among patients by tumour type, age and stage. Estimating future health service demands should account for changes in incident tumour characteristics.

Costs for Statutorily Insured Dental Services in Older Germans 2012-2017

OBJECTIVES

We assessed the costs of dental services in statutorily insured, very old (geriatric) Germans.

METHODS

A comprehensive sample of very old (≥75 years) people insured at a large Northeastern statutory insurer was followed over 6 years (2012-2017). We assessed dental services costs for: (1) examination, assessments and advice, (2) operative, (3) surgical, (4) prosthetic, (5) periodontal, (6) preventive and (7) outreach services. Association of utilization with: (1) sex, (2) age, (3) region, (4) social hardship status, (5) International Disease Classification (ICD-10) diagnoses and (6) Diagnoses Related Groups (DRGs) was explored.

RESULTS

404,610 individuals with a mean (standard deviation, SD) age 81.9 (5.4 years) were followed, 173,733 did not survive follow-up. Total mean costs were 129.61 (310.97) euro per capita; the highest costs were for prosthetic (54.40, SD 242.89 euro) and operative services (28.40, SD 68.38 euro), examination/advice (21.15, SD 28.77 euro), prevention (13.31, SD 49.79 euro), surgery (5.91, SD 23.91 euro), outreach (4.81, SD 28.56 euro) and periodontal services (1.64, SD 7.39 euro). The introduction of new fee items for outreach and preventive services between 2012 and 2017 was reflected in costs. Total costs decreased with increasing age, and this was also found for all service blocks except outreach and preventive services. Costs were higher in those with social hardship status, and in Berlin than Brandenburg and Mecklenburg-Western Pomerania. Certain general health conditions were associated with increased or decreased costs.

CONCLUSIONS

Costs were associated with sex, social hardship status, place of living and general health conditions.

CLINICAL SIGNIFICANCE

Dental services costs for the elderly in Germany are unequally distributed and, up to a certain age or health status, generated by invasive interventions mainly. Policy makers should incentivize preventive services earlier on and aim to distribute expenses more equally.

Emergency Department Use by Terminally Ill Patients: A Systematic Review

CONTEXT

Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.

OBJECTIVE

To determine the prevalence of TIP visiting the ED.

METHODS

Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I²).

RESULTS

We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries, and none from low-income countries. Most were from 2015. We found that 45% of patients with cancer visited the ED in the last month of life [95% CI 37-54%] and 75% in the last six months of life [95% CI 62-83%]; I² = 100%. Overall, 17% of patients who visited the ED had a terminal illness [95% CI 12-23%]; I² = 98%. Few studies reported terminal nononcologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or nonresuscitation, or other criteria that could be used for grouping.

CONCLUSIONS

Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with nononcologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.

Clinical Frailty Scale em idosos atendidos no Serviço Hospitalar de Emergência: a fragilidade basal é um bom preditor de mortalidade em 90 dias?

Resumo Objetivo Avaliar a capacidade da Clinical Frailty Scale (CFS) em predizer a mortalidade em até 90 dias e outros desfechos desfavoráveis em idosos admitidos em um Serviço Hospitalar de Emergência (SHE). Método Estudo de coorte prospectivo que incluiu idosos admitidos e que permaneceram por pelo menos uma noite no SHE de um hospital público terciário. O grau de fragilidade basal foi avaliado através da CFS e sua pontuação, o preditor estudado, por meio da curva Receiver Operator Characteristics (ROC). Analisou-se como desfecho primário a mortalidade em 90 dias. Considerou-se como desfechos secundários: mortalidade em 180 dias, declínio funcional, readmissão no SHE, reinternação e necessidade de atenção domiciliar. Resultados 206 participantes foram incluídos. Dos 127 idosos frágeis, 40 (31,5%) faleceram até o 90º dia comparado a 5 (6,3%) do grupo não frágil (p<0,001). Após ajuste para variáveis demográficas e clínicas, a fragilidade manteve-se no modelo como um preditor independente de mortalidade em 90 dias da admissão. A acurácia obtida pela curva ROC (AUROC) para predição de mortalidade em 90 dias foi de 0,81. Para mortalidade em 180 dias foi 0,80; para necessidade de atenção domiciliar, 0,77; e para reinternação, 0,65. Para os demais desfechos estudados, a acurácia não foi significativa. Conclusão A fragilidade basal medida pela CFS é um bom preditor de mortalidade em 90 e 180 dias e de necessidade de atenção domiciliar em idosos admitidos no SHE. Sua aplicação nesse cenário pode auxiliar na tomada de decisões clínicas.

Patient-centered care during the last year of life: adaptation and validation of the German PACIC short form for bereaved persons as proxies (PACIC-S9-proxy)

BACKGROUND

Providing patient-centered care (PCC) during the last year of life (LYOL) can be challenging due to the complexity of the patients' medical, social and psychological needs, especially in case of chronic illnesses. Assessing PCC can be helpful in identifying areas for improvements. Since not all patients can be surveyed, a questionnaire for proxy informants was developed in order to retrospectively assess patient-centeredness in care during the whole LYOL. This study aimed to evaluate the feasibility and validity of an adapted version of the German Patient Assessment of Chronic Illness Care (PACIC) for surveying bereaved persons in order to assess PCC during the decedents' LYOL.

METHODS

The German PACIC short form (11 items) was adapted to a nine-item version for surveying bereaved persons on the decedent's LYOL (PACIC-S9-Proxy). Items were rated on a five-point Likert scale. The PACIC adaptation and validation was part of a cross-sectional survey in the region of Cologne. Participants were recruited through self-selection and active recruitment by practice partners. Sociodemographic characteristics and missing data were analyzed using descriptive statistics. An exploratory factor analysis was conducted in order to assess the structure of the PACIC-S9-Proxy. Internal consistency was estimated using Cronbach's alpha.

RESULTS

Of the 351 informants who participated in the survey, 230 (65.52%) considered their decedent to have suffered from chronic illness prior to death. 193 of these informants (83.91%) completed ≥5 items of the questionnaire and were included in the analysis. The least answered item was item (74.09%) was item 4 (encouragement to group & classes for coping). The most frequently answered item (96.89%) was item 2 (satisfaction with care organization). Informants rated the item" Given a copy of their treatment plan" highest (mean 3.96), whereas "encouragement to get to a specific group or class to cope with the condition" (mean 1.74) was rated lowest. Cronbach's alpha was 0.84. A unidimensional structure of the questionnaire was found (Kaiser-Meyer-Olkin 0.86, Bartlett's test for sphericity p < 0.001), with items' factor loadings ranging from 0.46 to 0.82.

CONCLUSIONS

The nine-item questionnaire can be used as efficient tool for assessing PCC during the LYOL retrospectively and by proxies.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register ( DRKS00011925 ) on 13 June 2017.

Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets

OBJECTIVES

To analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.

DESIGN

Retrospective cohort analysis of national datasets with application of standard UK costings.

PARTICIPANTS AND SETTING

All people who died in Scotland in 2016 aged 18 or older (N=56 407).

MAIN OUTCOME MEASURES

Frequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs.

RESULTS

53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ² (4)=1004, p<0.001) or primary care out-of-hours (62%) (χ² (4)=1924,p<0.001) and have hospital admissions (88%) (χ² (4)=2644, p<0.001). People with organ failure (79%) contacted the ambulance service most frequently (χ² (4)=584, p<0.001). Demographic factors associated with more unscheduled care were older age, social deprivation, living in own home and dying of cancer. People dying with organ failure formed the largest group in the cohort and had the highest NHS costs as a group. The cost of providing services in the community was estimated at 3.9% of total unscheduled care costs despite handling most out-of-hours calls.

CONCLUSIONS

Over 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.

Low Socioeconomic Status Associated With Lower Utilization of Hospice Care Services During End-of-Life Treatment in Patients With Cancer: A Population-Based Cohort Study

CONTEXT

Socioeconomic status (SES) is an important determinant of disparities in health services and may affect the utilization of hospice care services during end-of-life (EOL) treatment in patients with cancer. However, previous studies evaluating the association between SES and utilization of hospice care services among patients with cancer revealed inconsistent findings.

OBJECTIVES

This study aimed to determine the association between SES and utilization of hospice care services during the last year of life in patients with cancer.

METHODS

From January 1, 2006 to December 31, 2016, we identified adults with cancer diagnoses from the Registry for Catastrophic Illness in Taiwan. The cancer diagnoses in study subjects were proved by the pathohistological reports. The utilization of hospice care services during the last year of life in patients with cancer included hospice inpatient care, hospice-shared care, and hospice home care.

RESULTS

In the follow-up period, 28.6% of 516,409 patients with cancer used hospice care services during the last year of life. After adjusting for other covariates, low SES significantly reduced the utilization of hospice care services by 18% during the last year of life in patients with cancer. Moreover, a positive trend between decreasing levels of SES and lower utilization of hospice care during EOL treatment was noted (P < 0.001).

CONCLUSION

Low SES was associated with lower utilization of hospice care services during EOL care in patients with cancer. Our data support the need to target low SES patients with cancer in efforts to optimally increase hospice care services during EOL care.

Preferences for End-of-Life Care and Decision Making Among Older and Seriously Ill Inpatients: A Cross-Sectional Study

CONTEXT

Older and seriously ill Australians are often admitted to hospital in the last year of their life. The extent to which these individuals have considered important aspects of end-of-life (EOL) care, including location in which care is provided, goals of care, and involvement of others in decision making, is unclear.

OBJECTIVES

To determine, in a sample of older and seriously ill Australian inpatients, preferences regarding location in which they receive EOL care and reasons for their choice; who is involved in EOL decisions; disclosure of life expectancy; goals of care; and voluntary-assisted dying.

METHODS

Cross-sectional face-to-face survey interviews conducted with 186 (80% consent) inpatients in a tertiary referral center aged 80 years and older; or aged 55 years and older with progressive chronic disease(s); or with physician-estimated life expectancy of less than 12 months.

RESULTS

Home care was preferred (69%), given the perceived availability of family/friends, familiarity of environment, and likelihood of having wishes respected. If unable to make decisions themselves, inpatients wanted family to decide care alone (31%) or with a doctor (49%). Of those who had not discussed life expectancy, 23% wished to. Most (76%) preferred care that maintained quality of life and relieved symptoms. There was some agreement for being sedated at the EOL (63%) and able to access medication to end life (43%).

CONCLUSION

Most inpatients would prefer EOL care that maintains quality and relieves suffering compared with life extension and to receive this care at home. Family involvement in resolution and documentation of EOL decisions should be prioritized.

Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis

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.