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Kim S, Chervu N, Premji A, Mallick S, Verma A, Ali K, Benharash P, Donahue T. Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer. Ann Surg Oncol 2024; 31:1328-1335. [PMID: 37957512 DOI: 10.1245/s10434-023-14528-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/14/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available. METHODS The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations. RESULTS Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [β: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (β: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (β: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (β: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001). DISCUSSION PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.
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Affiliation(s)
- Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alykhan Premji
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Timothy Donahue
- Division of Surgical Oncology, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
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Osagiede O, Nayar K, Raimondo M, Kumbhari V, Lukens FJ. The Determinants of Inpatient Palliative Care Use in Patients With Pancreatic Cancer. Am J Hosp Palliat Care 2023:10499091231218257. [PMID: 37991926 DOI: 10.1177/10499091231218257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Symptom burden management is a major goal of pancreatic cancer care given that most patients are diagnosed late. Early palliative care is recommended in addition to concurrent active treatment; however, disparities exist. We sought to determine the factors associated with inpatient palliative treatment among pancreatic cancer patients and compare treatment outcomes in terms of mortality, discharge disposition and resource utilization. METHODS We conducted a retrospective study of 22,053 pancreatic cancers using the National Inpatient Sample (NIS) database (January - December 2020). Patient and hospital characteristics, mortality, discharge disposition, length of stay (LOS), hospital costs and charges were compared between pancreatic cancer patients based on palliative treatment. Multivariate regression was used to evaluate patient and hospital characteristics and outcomes associated with palliative treatment. RESULTS A total number of 3839 (17.4%) patients received palliative care. Patients who received palliative care were more likely to be older, Medicaid insured, and nonobese. Patients were less likely to receive palliative care if they are males, Medicare insured, had a lower Charlson comorbidity score, or treated in Urban nonteaching hospitals. Patients who received palliative care displayed higher odds of in-hospital mortality and prolonged LOS. The adjusted additional mean hospital cost and charges in patients who received palliative care were lower by $1459, and $4222 respectively. CONCLUSIONS Inpatient palliative treatment in pancreatic cancer patients is associated with an older age, a higher comorbidity burden, non-obesity, insurance status and urban teaching hospitals. Our study suggests that inpatient palliative treatment decreased hospital resource utilization without prolonging survival.
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Affiliation(s)
- Osayande Osagiede
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kapil Nayar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Frank J Lukens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Ramkumar N, Wang Q, Brooks GA, Tosteson AN, Wong SL, Loehrer AP. Association of rurality with utilization of palliative care and hospice among Medicare beneficiaries who died from pancreatic cancer: A cohort study. J Rural Health 2023; 39:557-564. [PMID: 36631820 PMCID: PMC10293103 DOI: 10.1111/jrh.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pancreatic cancer has a 5-year survival of just 10%. Services such as palliative care and hospice are thus crucial in this population, yet their geographic accessibility and utilization remains unknown. AIM We studied the association between rurality of patient residence and the use of palliative care and hospice. DESIGN, SETTING, AND PARTICIPANTS Cohort study of continuously enrolled fee-for-service Medicare beneficiaries aged ≥65 diagnosed with incident pancreatic cancer between 04/01/2016-08/31/2018 and who died by 12/31/2018. RESULTS In this decedent cohort of 31,460 patients, 77% lived in metropolitan areas, 11% in micropolitan areas, 7% in small towns, and 5% in rural areas. Patient demographics were largely similar across rurality; however, the proportion of White, non-Hispanic patients and social deprivation was highest in rural areas and lowest in metropolitan areas. Overall, 33% of patients used any palliative care and 77% received hospice services. After risk adjustment, there were no statistically significant differences in the use of palliative care for patients residing in metropolitan versus micropolitan, small town, or rural areas. Patients in small town (OR = 0.77, 95% CI: 0.69-0.86) and rural areas (OR = 0.75, 95% CI: 0.66-0.85) had lower adjusted odds of receiving hospice care compared to patients in metropolitan areas. CONCLUSIONS The use of palliative care services captured in Medicare was low, representing either underutilization or failure to accurately measure the extent of services used. While the overall level of hospice enrollment was high, patients in rural communities had relatively lower use of hospice services compared to those in metropolitan areas.
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Affiliation(s)
- Niveditta Ramkumar
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | - Gabriel A. Brooks
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
| | - Anna N.A. Tosteson
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
| | - Sandra L. Wong
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
| | - Andrew P. Loehrer
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
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Brugel M, Dupont M, Carlier C, Botsen D, Essi DE, Sanchez V, Slimano F, Perrier M, Bouché O. Association of palliative care management and survival after chemotherapy discontinuation in patients with advanced pancreatic adenocarcinoma: A retrospective single-centre observational study. Pancreatology 2023:S1424-3903(23)00069-8. [PMID: 37037682 DOI: 10.1016/j.pan.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/20/2023] [Accepted: 03/16/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Palliative care (PC) is integrated into standard oncology care. However, its clinical impact at the end of life remains unclear in pancreatic adenocarcinoma (PA). We aimed to describe the end-of-life care pathway and to assess whether PC referral influences survival after chemotherapy discontinuation (CD) among advanced PA patients. METHODS This retrospective single-centre observational study was conducted among deceased patients with advanced PA who had received chemotherapy between January 1, 2016, and December 31, 2021. Baseline characteristics, the timing of PC referral and events after CD were collected. The primary outcome was time from CD to death. RESULTS Among the 148 included patients, 53.4% (n = 79) received PC, mostly late after the CD (n = 133, 89.9%), 16.9% (n = 25) received chemotherapy in the last 14 days of life and 75.6% died at the hospital. None received PC in the 8 weeks following the diagnosis. PC referral significantly increased PC department admissions (p < 0.001) and decreased medical unit admissions (p < 0.001). The median survival after the CD was 35 days (IQR: 19-64.5). PC referral was associated with increased survival after CD (HR: 0.65 [0.47-0.90], p = 0.010, Cox) and after adjusting (HR: 0.65 [0.42-0.99], p = 0.045, Cox). CONCLUSION The study suggests that PC may be associated with longer survival after CD in advanced PA patients. However, PC is underused, and patients are referred late in their care pathway.
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Affiliation(s)
- M Brugel
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France.
| | - M Dupont
- Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - C Carlier
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France; Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - D Botsen
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France; Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - D Edoh Essi
- Department of Medical Oncology, Institut Jean Godinot, Reims, France
| | - V Sanchez
- Department of Palliative Care, CHU Reims, Reims, France
| | - F Slimano
- Université de Reims Champagne-Ardenne, Department of Pharmacy, CHU Reims, Reims, France
| | - M Perrier
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France
| | - O Bouché
- Université de Reims Champagne-Ardenne, Department of Ambulatory Oncology Care Unit, CHU Reims, Reims, France
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Madsen UR, Biesbjerg CB, Mikkelsen TB, Marsaa K, Olsen Zwisler AD, Vedste Aagaard T. Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey. Scand J Caring Sci 2023; 37:595-607. [PMID: 36727432 DOI: 10.1111/scs.13144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 11/14/2022] [Accepted: 01/05/2023] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations. METHODS With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark. RESULTS Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall. CONCLUSIONS This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.
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Affiliation(s)
- Ulla Riis Madsen
- Department of Orthopedic Surgery, Holbaek Hospital, Holbaek, Denmark.,REHPA, Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Holbaek, Denmark
| | | | - Tina Broby Mikkelsen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Ann-Dorthe Olsen Zwisler
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Thomas Vedste Aagaard
- Department of Orthopedic Surgery, Holbaek Hospital, Holbaek, Denmark.,Department of Physiotherapy and Occupational Therapy, Holbaek Hospital, Holbaek, Denmark.,Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
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Mohyuddin GR, Sinnarajah A, Gayowsky A, Chan KKW, Seow H, Mian H. Quality of end-of-life care in multiple myeloma: A 13-year analysis of a population-based cohort in Ontario, Canada. Br J Haematol 2022; 199:688-695. [PMID: 35949180 DOI: 10.1111/bjh.18401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
Optimizing end-of-life (EOL) care for multiple myeloma (MM) represents an unmet need. An administrative cohort in Ontario, Canada was analysed between 2006 and 2018. Aggressive care was defined as two or more emergency-department visits in the last 30 days before death, or at least two new hospitalizations within 30 days of death, or an intensive care unit (ICU) admission within the last 30 days of life. Supportive care was defined as a physician house-call in the last two weeks before death, or a palliative nursing or personal support visit at home in the last 30 days before death. Among 5095 patients, 23.2% of patients received chemotherapy at EOL and 55.6% of patients died as inpatient. A minority received aggressive care at EOL [28.3%: autologous stem cell transplant (ASCT), 20.4%: non-ASCT], and a majority received supportive care at EOL (65.4%: ASCT, 61.5%: non-ASCT). Supportive care was less likely to be received by those aged over 80 years and in lower-income neighbourhoods. Supportive care at EOL increased from 56.0% in 2006 to 70.3% in 2018. Despite improvements, many patients with MM experience aggressive care at EOL. Even in a publicly funded health care system, disparities based on age, income and community size are present.
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Affiliation(s)
| | | | | | - Kelvin K W Chan
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Canadian Centre for Applied Research in Cancer Control, Vancouver, British Columbia, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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