Place of death and its predictors for local patients registered at a comprehensive cancer center

Racial and ethnic disparities in end-of-life care for patients with oesophageal cancer: death trends over time

Background

Given significant morbidity and mortality associated with oesophageal cancer, supportive, high-quality end-of-life care is critical. Most patients with advanced cancer prefer to die at home, but incongruence between preferred and actual place of death is common. Here, we examined trends and disparities in location of death among patients with oesophageal cancer.

Methods

Using the Centers for Disease Control and Prevention Wide-Range Online Data for Epidemiologic Research database, we utilized multinomial logistic regression to assess associations between sociodemographic characteristics and location of death for patients with oesophageal cancer (n = 237,063). Additionally, we utilized linear regression models to evaluate the significance of changes in location of death trends over time and disparities in the relative change in location of death trends across sociodemographic groups.

Findings

From 2003 to 2019, there was a decrease of deaths in hospitals, nursing homes, and outpatient medical facilities/emergency departments and an increase of deaths at home and in hospice. Relative to White decedents, Black and Asian decedents were less likely to die at home (relative risk ratio (RRR): 0.58 [95% confidence interval (CI): 0.56-0.60], RRR: 0.57 [95% CI: 0.53-0.61]) and in hospice (RRR: 0.67 [95% CI: 0.64-0.71], RRR: 0.49 [95% CI: 0.43-0.55]) when compared to the hospital. Similar disparities were noted for American Indian and Alaska Native (AIAN) decedents. These disparities persisted even upon stratifying by the number of listed causes of death, a proxy for severity of illness. Time trend analysis indicated that increases in deaths in hospice over time occurred at a slower rate for AIAN and Asian decedents relative to White decedents.

Interpretation

2 in 5 patients with oesophageal cancer die at home, with an increasing proportion dying at home and in hospice-in line with general patient preferences. However, location of death disparities have largely persisted over time among racial and ethnic minority groups. Our findings suggest the importance of improving access to advance care planning and delivering tailored, person-centred interventions.

Funding

None.

Trends and associated factors in place of death among individuals with cardiovascular disease in China, 2008-2020: A population-based study

Background

Cardiovascular disease (CVD) is the leading cause of death (COD) in China. Understanding the characteristics of place of death (POD) among CVD deaths would be of great importance to evaluate the healthcare service utilization at the end stage of life. Limited studies have reported the POD distribution among CVD deaths, and little was known about the associated factors of hospital CVD deaths.

Methods

By using data from National Mortality Surveillance System (NMSS) in China, this study presented the characteristics of POD distribution during 2008 and 2020. Afterwards, multilevel logistic regression was used to explore associated factors of hospital CVD deaths and quantify the magnitude to which the spatial variations of hospital CVD deaths could be explained by those associated factors.

Findings

During 2008-2020, there was 7101871 CVD deaths collected by NMSS in China, with 77·13% home deaths and 18·49% hospital deaths. Shanghai (59·40%) had the highest percentage of hospital CVD deaths. Age, sex, ethnicity, marital status, education, occupation, underlying COD were significant influential factors of hospital CVD deaths. Spatial variations were shown at provincial level, with 33·88% of them being explained by factors at individual level.

Interpretation

Home was the leading POD among CVD deaths in China, those CVD decedents characterized as the female, the youngest, Han population, the married, the retiree, lived in urban areas, with higher socioeconomic status and died of chronic CVDs had a higher probability of hospital deaths. Providing accessible and available healthcare services were priorities to improve quality of end-of-life care, significant variations among provinces and sub-population also reminded us of the requirements for equal healthcare resources allocation and multiple options for minorities of POD preference at the end stage of life.

Funding

National Key Research & Development Program of China (grant number 2018YFC1315301)

Causes of Death and End-of-Life Care in Patients With Intracranial High-Grade Gliomas: A Retrospective Observational Study

BACKGROUND AND OBJECTIVES

To understand patterns of care and circumstances surrounding end of life in patients with intracranial gliomas.

METHODS

We retrospectively analyzed end-of-life circumstances in patients with intracranial high-grade gliomas at Columbia University Irving Medical Center who died from January 2014 through February 2019, including cause of death, location of death, and implementation of comfort measures and resuscitative efforts.

RESULTS

There were 152 patients (95 men, 57 women; median age at death 61.5 years, range 24-87 years) who died from 1/2014-2/2019 with adequate data surrounding end-of-life circumstances. Clinical tumor progression (n=117, 77.0%) was the most common cause of death with all patients transitioned to comfort measures. Other causes included, but were not limited to, infection (19, 12.5%); intratumoral hemorrhage (5, 3.3%); seizures (8, 5.3%); cerebral edema (4, 2.6%); pulmonary embolism (4, 2.6%); autonomic failure (2, 1.3%); and hemorrhagic shock (2, 1.3%). Multiple mortal events were identified in 10 (8.5%). Seventy-three patients (48.0%) died at home with hospice. Other locations were inpatient hospice (40, 26.3%); acute care hospital (34, 22.4%) including 27 (17.8%) with and 7 (4.6%) without comfort measures; skilled nursing facility (4, 3.3%) including 3 (2.0%) with and 1 (0.7%) without comfort measures; or religious facility (1, 0.7%) with comfort measures. Acute cardiac and/or pulmonary resuscitation was performed in 20 patients (13.2%).

DISCUSSION

Clinical tumor progression was the most common (77.0%) cause of death followed by infection (12.5%). Hospice or comfort measures were ultimately implemented in 94.7% of patients, though resuscitation was performed in 13.2%. Improved understanding of circumstances surrounding death, frequency of use of hospice services, and frequency of resuscitative efforts in patients with gliomas may allow physicians to more accurately discuss end-of-life expectations with patients and caregivers, facilitating informed care planning.

Family Caregiving and Place of Death: Insights From Cross-national Analysis of the Harmonized End-of-Life Data

OBJECTIVES

Family is largely overlooked in research on factors associated with place of death among older adults. We determine if family caregiving at the end of life is associated with place of death in the United States and Europe.

METHOD

We use the Harmonized End of Life data sets developed by the Gateway to Global Aging Data for the Survey of Health, Ageing and Retirement in Europe (SHARE) and the Health and Retirement Study (HRS). We conducted multinomial logistic regression on 7,113 decedents from 18 European countries and 3,031 decedents from the United States to determine if family caregiving, defined based on assistance with activities of daily living, was associated with death at home versus at a hospital or nursing home.

RESULTS

Family caregiving was associated with reduced odds of dying in a hospital and nursing home, relative to dying at home in both the United States and Europe. Care from a spouse/partner or child/grandchild was both more common and more strongly associated with place of death than care from other relatives. Associations between family caregiving and place of death were generally consistent across European welfare regimes.

DISCUSSION

This cross-national examination of family caregiving indicates that family-based support is universally important in determining where older adults die. In both the United States and in Europe, most care provided during a long-term illness or disability is provided by family caregivers, and it is clear families exert tremendous influence on place of death.

Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial

BACKGROUND

While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers.

METHODS

A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate.

RESULTS

In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario.

CONCLUSION

This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs.

TRIAL REGISTRATION

The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

Temporal trends in place of death for end-of-life patients: Evidence from Toronto, Canada

Understanding the temporal trends in the place of death among patients in receipt of home-based palliative care can help direct health policies and planning of health resources. This paper aims to assess the temporal trends in place of death and its determinants over the past decade for patients receiving home-based palliative care. This paper also examines the impact of early referral to home-based palliative care services on patient's place of death. Survey data collected in a home-based end-of-life care program in Toronto, Canada from 2005 to 2015 were analysed using a multivariate logistic model. The results suggest that the place of death for patients in receipt of home-based palliative care has changed over time, with more patients dying at home over 2006-2015 when compared to 2005. Also, early referral to home-based palliative care services may not increase a patient's likelihood of home death. Understanding the temporal shifts of place of death and the associated factors is essential for effective improvements in home-based palliative care programs and the development of end-of-life care policies.

Assessment of changes in place of death of older adults who died from dementia in the United States, 2000-2014: a time-series cross-sectional analysis

BACKGROUND

As the mortality attributable to dementia-related diseases in the United States escalates, providing quality and equitable end-of-life care for dementia patients across care settings has become a major public health challenge. Previous research suggests that place of death may be an indicator of quality of end-of-life care. This study aims to examine the geographical variations and temporal trends in place of death of dementia decedents in the US and the relationships between place of death of dementia decedents and broad structural determinants.

METHODS

Using nationwide death certificates between 2000 and 2014, we described the changes in place of death of dementia decedents across states and over time. Chi-square test for trend in proportions was used to test significant linear trend in the proportion of dementia decedents at difference places. State fixed effects models were estimated to assess the relationships between the proportion of dementia decedents at difference places and state-level factors, particularly availability of care facility resources and public health insurance expenditures.

RESULTS

Dementia decedents were more likely to die at home and other places and less likely to die at institutional settings over the study period. There was wide inter-state and temporal variability in the proportions of deaths at different places. Among state-level factors, availability of nursing home beds was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on institutional long term supports and services was positively associated with rates of nursing home/long term care deaths and negatively associated with rates of home deaths. Medicaid expenditure on home and community based services, however, had a positive association with rates of home deaths.

CONCLUSIONS

There was a persistent shift in the place of death of dementia decedents from institutions to homes and communities. Increased investments in home and community based health services may help dementia patients to die at their homes. As home becomes an increasingly common place of death of dementia patients, it is critical to monitor the quality of end-of-life care at this setting.

End-of-life care among adolescent and young adult patients with cancer living in poverty

BACKGROUND

To the authors' knowledge, end-of-life (EOL) care outcomes among adolescents and young adults (AYAs) with cancer who are living in poverty remain poorly understood. The primary aim of the current study was to examine the effect of poverty on EOL care for AYA patients with cancer.

METHODS

The authors conducted a multisite, retrospective study of AYA patients with cancer aged 15 to 39 years who died between January 2013 and December 2016 at 3 academic sites. Medical record-based EOL care outcomes included hospice referral, palliative care (PC) consultation, cancer treatment within the last month of life, and location of death. Two measures of poverty were applied: 1) zip code with a median income ≤200% of the federal poverty level; and 2) public insurance or lack of insurance. Logistic regression analyses were conducted.

RESULTS

A total of 252 AYA cancer decedents were identified. Approximately 41% lived in a high-poverty zip code and 48% had public insurance or lacked insurance; approximately 70% had at least 1 poverty indicator. Nearly 40% had a hospice referral, 60% had a PC consultation (76% on an inpatient basis), 38% received EOL cancer treatment, and 39% died in the hospital. In bivariable analyses, AYA patients living in low-income zip codes were found to be less likely to enroll in hospice (P ≤ .01), have an early PC referral (P ≤ .01), or receive EOL cancer treatment (P = .03), although only EOL cancer treatment met statistical significance in multivariable models. No differences with regard to location of death (P = .99) were observed.

CONCLUSIONS

AYA patients with cancer experience low rates of hospice referral and high rates of in-hospital death regardless of socioeconomic status. Future studies should evaluate early inpatient PC referrals as a possible method for improving EOL care.

Trends in Place of Death Among Patients With Gynecologic Cancer in the United States

OBJECTIVE

To describe the change over time in place of death (hospital, home, hospice) among all women in the United States who died of gynecologic malignancies and compare them with other leading causes of female cancer deaths.

METHODS

This is a retrospective cross-sectional study using national death certificate data from the Mortality Multiple Cause-of-Death Public Use Record Data. All women who died from gynecologic, breast, lung, and colorectal cancers were identified according to International Classification of Diseases, 10 Revision, cause of death from 2003 to 2015. Regression analyses with ordinary least-squares linear probability modeling were used to test for differences in location of death over time, and differences in trends by cancer type, while controlling for age, race, ethnicity, marital status, and education status.

RESULTS

From 2003 to 2015, 2,133,056 women died from gynecologic, lung, breast, and colorectal malignancies in the United States. A total of 359,340 died from gynecologic malignancies, including ovarian cancer (n=188,366 [52.4%]), uterine cancer (n=106,454 [29.6%]), cervical cancer (n=52,320 [14.6%]), and vulvar cancer (n=12,200 [3.4%]). Overall, 49.2% (n=176,657) of gynecologic cancer deaths occurred at home or in hospice. The relative increase from 2003 to 2015 in the rate of deaths at home or in hospice was 47.2% for gynecologic cancer deaths (40.5% in 2003 to 59.5% in 2015). In adjusted analyses, the trend in the percentage of deaths at home or in hospice increased at a rate of 1.6 percentage points per year for gynecologic cancer deaths (95% CI 1.5-1.6) vs 1.5 (95% CI 1.4-1.5, P<.001), 1.4 (95% CI 1.4-1.5, P<.001), and 1.5 (95% CI 1.4-1.5, P=.09) percentage points per year for lung, breast, and colorectal cancer deaths, respectively.

CONCLUSION

Between 2003 and 2015, there was a 47.2% increase (40.5-59.5%) in the rates of gynecologic cancer deaths occurring at home or in hospice. This trend may represent an increase in advance care planning and value-based treatment decisions.

Place of Death and Use of Health Services in the Last Year of Life

Aim

To investigate whether health service input in the last year of life differs between cancer patients who die at home versus those dying in inpatient care.

Methods

Post hoc exploratory case-control study of 127 home deaths and 200 inpatient deaths. Retrospective electronic record linkage of patients’ community and inpatient care during the last year of life.

Results

Patients who died at home began their home nursing care closer to death than those who died as inpatients. Their first contact with inpatient hospice care began further from death. Before their final month, home death patients also had more specialist and district nursing than patients who died in inpatient care.

Conclusions

Patients who began their home nursing early were less likely to die at home than those who began such care late. This suggests that it may be difficult to sustain end-of-life care at home for an extended period. Further research incorporating assessment of informal care input and disease trajectory is required to investigate this issue.

Disparities in place of death for patients with hematological malignancies, 1999 to 2015

Patients with hematologic malignancies (HMs) often receive aggressive end-of-life care and less frequently use hospice. Comprehensive longitudinal reporting on place of death, a key quality indicator, is lacking. Deidentified death certificate data were obtained via the National Center for Health Statistics for all HM deaths from 1999 to 2015. Multivariate regression analysis (MVA) was used to test for disparities in place of death associated with sociodemographic variables. During the study period, there were 951 435 HM deaths. Hospital deaths decreased from 54.6% in 1999 to 38.2% in 2015, whereas home (25.9% to 32.7%) and hospice facility deaths (0% to 12.1%) increased (all P < .001). On MVA of all cancers, HM patients had the lowest odds of home or hospice facility death (odds ratio [OR], 0.55; 95% confidence interval, 0.54-0.55). Older age (40-64 years: OR, 1.34; ≥65 years: OR, 1.89), being married (OR, 1.62), and having myeloma (OR, 1.34) were associated with home or hospice facility death, whereas being black or African American (OR, 0.68), Asian (OR, 0.58), or Hispanic (OR, 0.84) or having chronic leukemia (OR, 0.83) had decreased odds of dying at home or hospice (all P < .001). In conclusion, despite hospital deaths decreasing over time, patients with HMs remained more likely to die in the hospital than at home.

Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners

Background

Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses.

Methods

This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important).

Results

Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members’ difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients’ capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers.

Conclusions

Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5333-x) contains supplementary material, which is available to authorized users.

Determinants of place of Death for recipients of Home-Based Palliative Care

Introduction: Health system restructuring combined with the preferences of many terminally ill care recipients and their caregivers has led to an increase in home-based palliative care, yet many care recipients die within institutional settings such as hospitals. This study sought to determine the place of death and its predictors among palliative care patients with cancer. Methods: Study participants were re cruited from the Temmy Latner Centre for Palliative Care, a regional palliative care program based in Toronto, Canada. A total of 137 patients and their family caregivers participated in the study; application of various exclusion criteria restricted analysis to a sub-sample of 110. Bivariate (chi-square) and multivariate (logistic regression) analyses were conducted. Results: 66 percent of participants died at home. Chisquare analysis indicated that women were more likely to die at home than men; multivariate analysis indicated that women and those living with others were significantly more likely to die at home than men or those who lived alone. Conclusion: Place of death is influenced by the socio-demographic characteristics of patients, the characteristics of their caregivers, and health service factors. Palliative care programs need to tailor services to men and those living alone in order to reduce institutional deaths.

Racial-Ethnic Disparities in End-of-Life Care Quality among Lung Cancer Patients: A SEER-Medicare-Based Study

INTRODUCTION

Cancer end-of-life care and associated racial-ethnic disparities have been in focus during the last few years due to concerns regarding subjective care variations and poor quality of care. Given the high mortality rate and disease burden of lung cancer, end-of-life care quality is particularly crucial for this disease. This study uses previously validated measures and examines racial-ethnic disparities in lung cancer end-of-life care quality.

METHODS

This study involves retrospective analysis of patients ≥66 years, who were diagnosed with stage I-IV lung cancer, and who died on or before December 31, 2013, using the Surveillance Epidemiology and End Result-Medicare data from 1991-2013. Poor quality of care was measured using three themes: (1) potentially preventable medical encounters, (2) delayed hospice referral, and (3) aggressive chemotherapy provision during end-of-life. The patients were analyzed as two separate cohorts of NSCLC and SCLC patients. Logistic regression analyses were performed to estimate racial-ethnic disparities in the adjusted odds of receiving poor quality end-of-life care.

RESULTS

The study found considerable racial-ethnic disparities in end-of-life care quality. The racial-ethnic minorities had higher odds of experiencing potentially preventable medical encounters in the last month of life as compared with non-Hispanic whites. Odds of delayed hospice referral and aggressive chemotherapy provision during end-of-life were lower in non-Hispanic blacks as compared with non-Hispanic whites.

CONCLUSIONS

The study findings highlight the continued lack of access and care disparity among the minorities, which could precipitate potentially preventable utilizations, and limit access to hospice care during end-of-life. The study suggests the need to develop educational, patient navigational and other interventions that could potentially reduce aggressive utilizations and improve appropriate hospice care provision during end-of-life.

The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies

BACKGROUND

Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer.

OBJECTIVE

To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs.

DESIGN

Prospective cohort study and long-term follow-up.

SETTING/SUBJECTS

From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year.

MEASUREMENTS

We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes.

RESULTS

Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital.

CONCLUSIONS

The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.

Development of Imminent Mortality Predictor for Advanced Cancer (IMPAC), a Tool to Predict Short-Term Mortality in Hospitalized Patients With Advanced Cancer

PURPOSE

End-of-life care for patients with advanced cancer is aggressive and costly. Oncologists inconsistently estimate life expectancy and address goals of care. Currently available prognostication tools are based on subjective clinical assessment. An objective prognostic tool could help oncologists and patients decide on a realistic plan for end-of-life care. We developed a predictive model (Imminent Mortality Predictor in Advanced Cancer [IMPAC]) for short-term mortality in hospitalized patients with advanced cancer.

METHODS

Electronic health record data from 669 patients with advanced cancer who were discharged from Yale Cancer Center/Smilow Cancer Hospital were extracted. Statistical learning techniques were used to develop a tool to estimate survival probabilities. Patients were randomly split into training (70%) and validation (30%) sets 20 times. We tested the predictive properties of IMPAC for mortality at 30, 60, 90, and 180 days past the day of admission.

RESULTS

For mortality within 90 days at a 40% sensitivity level, IMPAC has close to 60% positive predictive value. Patients estimated to have a greater than 50% chance of death within 90 days had a median survival time of 47 days. Patients estimated to have a less than 50% chance of death had a median survival of 290 days. Area under the receiver operating characteristic curve for IMPAC averaged greater than .70 for all time horizons tested. Estimated potential cost savings per patient was $15,413 (95% CI, $9,162 to $21,665) in 2014 constant dollars.

CONCLUSION

IMPAC, a novel prognostic tool, can generate life expectancy probabilities in real time and support oncologists in counseling patients about end-of-life care. Potentially avoidable costs are significant.

Predictors of Death in the Hospital for Patients with Chronic Serious Illness

BACKGROUND

Most people prefer to die at home, yet most do not. Understanding factors associated with terminal hospitalization may inform interventions to improve care.

OBJECTIVE

Among patients with chronic illness receiving care in a multihospital healthcare system, we identified the following: (1) predictors of death in any hospital; (2) predictors of death in a hospital outside the system; and (3) trends from 2010 to 2015.

DESIGN

Retrospective cohort using death certificates and electronic health records. Settings/Subjects: Decedents with one of nine chronic illnesses.

RESULTS

Among 20,486 decedents, those most likely to die in a hospital were younger (odds ratio [OR] 0.977, confidence interval [CI] 0.974-0.980), with more comorbidities (OR 1.188, CI 1.079-1.308), or more outpatient providers (OR 1.031, CI 1.015-1.047); those with cancer or dementia, or more outpatient visits were less likely to die in hospital. Among hospital deaths, patients more likely to die in an outside hospital had lower education (OR 0.952, CI 0.923-0.981), cancer (OR 1.388, CI 1.198-1.608), diabetes (OR 1.507, CI 1.262-1.799), fewer comorbidities (OR 0.745, CI 0.644-0.862), or fewer hospitalizations within the system during the prior year (OR 0.900, CI 0.864-0.938). Deaths in hospital did not change from 2010 to 2015, but the proportion of hospital deaths outside the system increased (p < 0.022).

CONCLUSIONS

Patients dying in the hospital who are more likely to die in an outside hospital, and therefore at greater risk for inaccessibility of advance care planning, were more likely to be less well-educated and have cancer or diabetes, fewer comorbidities, and fewer hospitalizations. These findings may help target interventions to improve end-of-life care.

Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees

BACKGROUND

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice.

OBJECTIVE

To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees.

DESIGN

Longitudinal, observational cohort study (2008-2010).

SETTING/SUBJECTS

Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355).

MEASUREMENTS

We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures.

RESULTS

Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices.

CONCLUSIONS

Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Standardized Criteria for Palliative Care Consultation on a Solid Tumor Oncology Service Reduces Downstream Health Care Use

PURPOSE

Hospitalized patients with advanced cancer have a high symptom burden and need for support. Integration of palliative care (PC) improves symptom control and decreases unwanted health care use, yet many patients are never offered these services. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. To improve the quality of cancer care, we developed standardized criteria, or triggers, for PC consultation on the inpatient solid tumor service.

METHODS

Patients were eligible for this prospective cohort study if they met at least one of the following eligibility criteria: had an advanced solid tumor; prior hospitalization within 30 days; hospitalization > 7 days; and active symptoms. During the intervention, patients who met the criteria received automatic PC consultation.

RESULTS

When we compared patients in the intervention group with control subjects, there were increases in PC consultations (19 of 48 [39%] to 52 of 65 [80%]; P ≤ .001) and hospice referrals (seven of 48 [14%] to 17 of 65 [26%]; P = .03), and there were declines in 30-day readmission rates (17 of 48 [35%] to 13 of 65 [18%]; P = .04) and receipt of chemotherapy after discharge (21 of 48 [44%] to 12 of 65 [18%]; P = .03). There was an overall increase in support measures following discharge ( P = .004). Length of stay was unaffected.

CONCLUSION

To our knowledge, this is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, the standardized use of triggers for PC consultation is associated with substantial impact on 30-day readmission rates, chemotherapy following discharge, hospice referrals, and use of support services following discharge. Expansion of this model to other hospitals and health systems should improve the value of cancer care.

Association of Hospital Admission Risk Profile Score with Mortality in Hospitalized Older Adults

OBJECTIVES

To evaluate the association of the Hospital Admission Risk Profile (HARP) score with mortality after discharge in a population of hospitalized older adults.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Hospitalized patients aged 70 years or older.

MEASUREMENTS

Patient age at the time of admission, modified Folstein Mini-Mental Status Exam score, and self-reported instrumental activities of daily living 2 weeks prior to admission were used to calculate a HARP score. The primary outcome assessed was overall mortality up to 365 days after hospital discharge. Cox proportional hazard analyses evaluated the association between HARP score and mortality adjusting for age, sex, and comorbidities associated with increased mortality.

RESULTS

Of the 474 patients, 165 (34.8%) had a low HARP score, 177 (37.4%) had an intermediate, and 132 (27.8%) had a high score. HARP score was not associated with differences in 30-day readmission rates. High HARP score patients had higher mortality when compared to patients with low HARP scores at all time frames (30 days: 12.9% vs 1.8%, p < .05; 90 days: 19.7% vs 4.8%, p < .05; 365 days: 34.8% vs 16.9%, p < .05). In fully adjusted Cox proportional models, patients with high HARP scores had a 3.5 times higher odds of mortality when compared to low HARP score patients.

CONCLUSION

The HARP score is a simple and easy to use instrument that identifies patients at increased risk for mortality after hospital discharge. Early identification of patients at increased risk for mortality has the potential to help guide treatment decisions following hospital discharge and provides additional information to providers and patients for shared decision making and may help in clarifying and achieving patient and family goals of care.

Capturing the Palliative Home Care Experience From Bereaved Caregivers Through Qualitative Survey Data: Toward Informing Quality Improvement

CONTEXT

Measuring palliative care experience using patient-reported outcomes is becoming important for assessing and improving quality, although most validated outcome tools solely use scaled questions.

OBJECTIVES

We analyzed open-text survey responses from bereaved caregivers to identify strengths and weaknesses in the quality of end-of-life care services and to assess the usefulness of qualitative survey data for quality improvement.

METHODS

This was a retrospective observational study involving bereaved caregivers of decedents who had received palliative home care services in one of six health care regions in Ontario, Canada. Using the U.K.'s validated Views of Informal Carers-Evaluation of Services survey, respondents were asked what was good and what was bad about the services provided in the last three months of life as separate open-text questions. A qualitative constant comparison approach was used to derive themes from the responses.

RESULTS

Among 330 caregivers who completed the survey, 271 (82%) caregivers responded to the open-text questions: 93% of those commented on something that was good about care and 55% on something that was bad. The care experiences were generally positive, with the exception of specific individuals or settings that were perceived as adverse. The qualitative data were more informative about deficiencies in care compared with the quantitative data.

CONCLUSION

The qualitative survey data in this study provided key recommendations toward making care more responsive to the needs of dying patients and their families. Capturing the narrative responses of bereaved caregivers is feasible and informative for palliative care program development.

Retrospective evaluation of palliative care and hospice utilization in hospitalized patients with metastatic breast cancer

BACKGROUND

Hospitalizations in patients with metastatic cancer occur commonly at the end of life but have not been well-described in individuals with metastatic breast cancer.

AIM

To describe the reasons for admission and frequency of palliative care and hospice utilization in hospitalized patients with metastatic breast cancer.

DESIGN

This was a retrospective chart review of patients who had their first hospitalization with a diagnosis of metastatic breast cancer between 1 January 2009 and 31 December 2010. To standardize follow-up time, we collected data for 3 years post the index hospitalization.

SETTING/PARTICIPANTS

We identified 123 consecutive patients who were hospitalized for the first time with a diagnosis of metastatic breast cancer at a single, tertiary care center.

RESULTS

Uncontrolled symptoms accounted for half (50%, 62/123) of index admissions. The majority of patients died during the follow-up period (76%, 94/123), and the median time from index admission to death was 6 months (range: 0-34 months). Approximately half (53%, 50/94) died in the hospital or within 14 days of last hospital discharge, and less than one-third (29%, 27/94) were referred to hospice after their last hospitalization. The inpatient palliative care team evaluated 57% (54/94) of those who died at least once during an admission, but only 17% (16/94) of patients attended an outpatient palliative care appointment.

CONCLUSIONS

Hospitalized patients with metastatic breast cancer are commonly admitted for uncontrolled symptoms and have a poor prognosis. However, only a minority receive outpatient palliative care or are referred to hospice during their last hospitalization prior to death.

Preparing for Value-Based Payment: A Stepwise Approach for Cancer Centers

Most cancer centers are ill-equipped to pursue value-based payment (VBP) because of limited information on their population’s cost of care. Herein, we outline the stepwise approach used by Smilow Cancer Hospital at Yale-New Haven in our pursuit of better value care. First, we addressed institutional barriers. A move toward value required demonstration to Yale-New Haven Health System leadership that OCM would improve patient care, fund new infrastructure, and provide the opportunity to gain experience with VBP without a major threat to the financial stability of the health system. We evaluated patterns of care and found that of patients presenting to the emergency department (ED), 88% were admitted, 62% arrived during the workday, and 50% could have been stabilized with urgent care services. Within 30 days of death, 27% were admitted to the intensive care unit, 38% presented to the ED, and 52% were admitted. To quantify total cost of care, we accessed the 5% Medicare Limited Data Set to map out total cost of care for patients receiving chemotherapy at Smilow Cancer Hospital. Costs increased as patients moved through 6-month episodes, used the ED (patients with two or more visits were twice as expensive as those with one or fewer), or died during an episode (costs were twice as high as episodes in which the patient lived). To determine strategic interventions to improve value, we targeted investments in urgent care to reduce ED utilization, care management to prevent hospital admissions, and referral to palliative care for clarification of goals of care and avoidance of costly futile treatment. Developing internal metrics to evaluate success will require monitoring our interventions by having utilization measures for each site of care and individual provider.

Characteristics Associated with In-Hospital Death among Commercially Insured Decedents with Cancer

BACKGROUND

A majority of patients with poor-prognosis cancer express a preference for in-home death; however, in-hospital deaths are common.

OBJECTIVE

We sought to identify characteristics associated with in-hospital death.

DESIGN

Case series.

SETTING/SUBJECTS

Commercially insured patients with cancer who died between July 2010 and December 2013 and who had at least two outpatient visits at a tertiary cancer center during the last six months of life.

MEASUREMENTS

Patient characteristics, healthcare utilization, and in-hospital death (primary outcome) were ascertained from institutional records and healthcare claims. Bivariate and multivariable analyses were used to evaluate the association of in-hospital death with patient characteristics and end-of-life outcome measures.

RESULTS

We identified 904 decedents, with a median age of 59 years at death. In-hospital death was observed in 254 patients (28%), including 110 (12%) who died in an intensive care unit. Hematologic malignancy was associated with a 2.57 times increased risk of in-hospital death (95% confidence interval [CI] 1.91-3.45, p < 0.001), and nonenrollment in hospice was associated with a 14.5 times increased risk of in-hospital death (95% CI 9.81-21.4, p < 0.001). Time from cancer diagnosis to death was also associated with in-hospital death (p = 0.003), with the greatest risk among patients dying within six months of cancer diagnosis. All significant associations persisted in multivariable analyses that were adjusted for baseline characteristics.

CONCLUSIONS

In-hospital deaths are common among commercially insured cancer patients. Patients with hematologic malignancy and patients who die without receiving hospice services have a substantially higher incidence of in-hospital death.

The Impact of Reported Hospice Preferred Practices on Hospital Utilization at the End of Life

BACKGROUND

The Affordable Care Act requires hospices to report quality measures across a range of processes and practices. Yet uncertainties exist regarding the impact of hospice preferred practices on patient outcomes.

OBJECTIVE

Assess the impact of 6 hospice preferred practices and hospice organizational characteristics on hospital utilization and death using the first national data on hospice preferred practices.

DESIGN

Longitudinal cohort study (2008-2011) of Medicare beneficiaries (N=149,814) newly enrolled in a national random sample of hospices (N=577) from the National Hospice Survey (84% response rate) and followed until death.

OUTCOME MEASURES

The proportion of patients at each hospice admitted to the hospital, emergency department (ED), and intensive care unit (ICU), and who died in the hospital after hospice enrollment.

RESULTS

Hospices that reported assessing patient preferences for site of death at admission had lower odds of being in the highest quartile for hospital death (AOR=0.36; 95% CI, 0.14-0.93) and ED visits (AOR=0.27; 95% CI, 0.10-0.76). Hospices that reported more frequently monitoring symptoms had lower odds of being in the highest quartile for ICU stays (AOR=0.48; 95% CI, 0.24-0.94). In adjusted analyses, a higher proportion of patients at for-profit compared with nonprofit hospices experienced a hospital admission (15.3% vs. 10.9%, P<0.001), ED visit (21.8% vs. 15.6%, P<0.001), and ICU stay (5.1% vs. 3.0%, P<0.001).

CONCLUSIONS

Hospitalization of patients following hospice enrollment varies substantially across hospices. Two of the 6 preferred practices examined were associated with hospitalization rates and for-profit hospices had persistently high hospitalization rates regardless of preferred practice implementation.

Factors Associated With Place of Death Among the Chinese Oldest Old

Based on 6,444 deceased respondents ages 80 to 105 years from the first three waves of the Chinese Longitudinal Healthy Longevity Survey, the authors use multilevel modeling to examine how community development, individual sociodemographic characteristics, health conditions, and health resources affect place of death. Results show that 92% of Chinese oldest old die at home, with 7% dying in hospitals and 1% at institutions. Analyses indicate that residents from relatively developed communities in China tend to have a higher chance of hospital and/or institutional deaths; individuals with higher socioeconomic status (SES) and worsening health are more likely to experience hospital deaths; those who have pension and/or public and/or collective free medical services are more likely to die in hospitals and/or institutions. The authors also propose a theory about place of death consisting of three evolutionary stages, which might explain the disparity in patterns of place of death in different societies.

Perceptions of palliative care among hematologic malignancy specialists: a mixed-methods study

PURPOSE

Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood.

METHODS

This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences.

RESULTS

Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care.

CONCLUSION

Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists.

The influence of familial factors on the choice of the place of death for terminally ill breast cancer patients: a retrospective single-center study

BACKGROUND

The social or familial factors influencing the location chosen for end-of-life (EOL) care for terminally ill breast cancer patients are unknown.

METHODS

We retrospectively analyzed 195 patients with recurrent or progressive breast cancer who received anticancer treatment at the National Cancer Center Hospital between January 2008 and May 2012. Detailed data concerning the patients' demographic, familial, and clinical characteristics were collected, and multivariate and Cox logistic regression analyses were performed to evaluate the impact of these characteristics on the place of EOL care and on survival, respectively.

RESULTS

Sixty-eight patients (34.9 %) died in a hospital, 26 patients (13.3 %) at home, and 101 patients (51.8 %) in hospice. Most of the patients having caregivers received EOL care at palliative care facilities (hospice or home) [odds ratio (OR) 2.57; 95 % confidence interval (CI) 1-6.6; p = 0.05]. In contrast, patients with factors suggesting a clinically severe status (performance status ≥2, use of opioids, delirium, and ascites) more often received EOL care in a hospital. Among patients who received EOL care at hospice or home, patients with minor children received EOL care at home (OR 0.08; 95 % CI 0.02-0.38; p = 0.001). Patients with brain metastases chose hospice (OR 12.37; 95 % CI 2.25-68.13; p = 0.004). Furthermore, having a caregiver was associated with prolonged survival (hazard ratio 0.62; 95 % CI 0.39-0.97; p = 0.035).

CONCLUSION

Familial factors such as having children and caregivers significantly influenced the place of EOL care for terminally ill breast cancer patients.

Does hospital need more hospice beds? Hospital charges and length of stays by lung cancer inpatients at their end of life: A retrospective cohort design of 2002-2012

BACKGROUND

Previous studies found that hospice and palliative care reduces healthcare costs for end-of-life cancer patients.

AIM

To investigate hospital inpatient charges and length-of-stay differences by availability of hospice care beds within hospitals using nationwide data from end-of-life inpatients with lung cancer.

DESIGN

A retrospective cohort study was performed using nationwide lung cancer health insurance claims from 2002 to 2012 in Korea.

SETTING AND PARTICIPANTS

Descriptive and multi-level (patient-level and hospital-level) mixed models were used to compare inpatient charges and lengths of stay. Using 673,122 inpatient health insurance claims, we obtained aggregated hospital inpatient charges and lengths of stay from a total of 114,828 inpatients and 866 hospital records.

RESULTS

Hospital inpatient charges and length of stay drastically increased as patients approached death; a significant portion of hospital inpatient charges and lengths of stay occurred during the end-of-life period. According to our multi-level analysis, hospitals with hospice care beds tend to have significantly lower end-of-life hospital inpatient charges; however, length of stay did not differ. Hospitals with more hospice care beds were associated with reduction in hospital inpatient charges within 3 months before death.

CONCLUSION

Higher end-of-life healthcare hospital charges were found for lung cancer inpatients who were admitted to hospitals without hospice care beds. This study suggests that health policy-makers and the National Health Insurance program need to consider expanding the use of hospice care beds within hospitals and hospice care facilities for end-of-life patients with lung cancer in South Korea, where very limited numbers of resources are currently available.

Does Continuous Hospice Care Help Patients Remain at Home?

CONTEXT

In the U. S., hospices sometimes provide high-intensity "continuous care" in patients' homes. However, little is known about the way that continuous care is used or what impact continuous care has on patient outcomes.

OBJECTIVES

To describe patients who receive continuous care and determine whether continuous care reduces the likelihood that patients will die in an inpatient unit or hospital.

METHODS

Data from 147,137 patients admitted to 11 U.S. hospices between 2008 and 2012 were extracted from the electronic medical records. The hospices are part of a research-focused collaboration. The study used a propensity score-matched cohort design.

RESULTS

A total of 99,687 (67.8%) patients were in a private home or nursing home on the day before death, and of these, 10,140 (10.2%) received continuous care on the day before death. A propensity score-matched sample (n = 24,658) included 8524 patients who received continuous care and 16,134 patients who received routine care on the day before death. Using the two matched groups, patients who received continuous care on the day before death were significantly less likely to die in an inpatient hospice setting (350/8524 vs. 2030/16,134; 4.1% vs. 12.6%) (odds ratio [OR] 0.29; 95% CI 0.27-0.34; P < 0.001). When patients were cared for by a spouse, the use of continuous care was associated with a larger decrease in inpatient deaths (OR 0.12; 95% CI 0.09-0.16; P < 0.001) compared with those patients cared for by other family members (OR 0.37; 95% CI 0.32-0.42; P < 0.001). It is possible that unmeasured covariates were not included in the propensity score match.

CONCLUSION

Use of continuous care on the day before death is associated with a significant reduction in the use of inpatient care on the last day of life, particularly when patients are cared for by a spouse.

Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill

BACKGROUND

Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care.

OBJECTIVE

The study objective was to explore and describe clergy perspectives regarding "good" versus "poor" death within the participant's spiritual tradition.

METHODS

This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a "good death." Principles of grounded theory were used to identify a final set of themes and subthemes.

RESULTS

A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a "poor death" was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a "middle death," or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor.

CONCLUSIONS

Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities.

Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma

OBJECTIVES

To examine the patterns of utilization of radiation therapy, chemotherapy, surgery, and hospice at the end-of-life care for patients diagnosed with metastatic melanoma.

METHODS

We identified 816 Medicare beneficiaries toward who were 65 years of age or older, with pathologically confirmed metastatic malignant melanoma between January 1, 2000, and December 31, 2007. We evaluated trends and associations between sociodemographic and health service characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy.

RESULTS

We found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), and no significant fluctuation in the use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P=0.07 for trend). Enrollment in short-term (1 to 3 d) hospice care use increased, whereas long-term hospice care (≥4 d) remained stable. Patients living in the SEER (Surveillance, Epidemiology and End Results) northeast and south regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery, and radiation therapy.

CONCLUSIONS

Surgery and hospice care use increased over the years of this study, whereas the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma.

The Perspective of Non-oncologist Physicians on Patients with Metastatic Cancer and Palliative Care (ALONE Study): A Study of the Palliative Care Working Committee of the Turkish Oncology Group (TOG)

The aim of our study was to determine the perspective of non-oncologist physicians regarding their attitudes and beliefs associated with palliative care for patients with metastatic cancer. The study was planned as a cross-sectional survey, and non-oncologist physicians were reached via e-mail and social networking sites. The first part of the questionnaire involved demographic properties, the second part inquired as to the perspectives of participants regarding metastatic disease, and the third part was used to determine beliefs and attitudes about palliative care. All of the questions were five-point Likert-type questions. A total of 1734 physicians completed the questionnaire. The majority of participants were general surgeons or internal medicine specialists (21 and 18%, respectively), were male (61%), were younger than 50 years of age (54%), worked in the town center (67%), had more than 11 years of professional experience (57%), and worked in a hospital without an active oncology service (86%). A total of 71% of participants identified all patients with metastatic cancer as being terminal stage, 62% were unaware of palliative care techniques, 64% did not know about common supportive care options, 59% were against hospice, and 63% had no opinion on resuscitation. We determined that non-oncologist physicians believed that all patients with metastatic cancer are at the terminal stage and that palliative/supportive care is the oncologist's task. These data suggest that non-oncologist physicians would benefit from additional graduate and postgraduate courses on these topics.

Place of Death among Hospitalized Patients with Cancer at the End of Life

BACKGROUND

The majority of hospital deaths in the United States occur after ICU admission. The characteristics associated with the place of death within the hospital are not known for patients with cancer.

OBJECTIVE

The study objective was to identify patient characteristics associated with place of death among hospitalized patients with cancer who were at the end of life.

METHODS

A retrospective cohort study design was implemented. Subjects were consecutive patients hospitalized between 2003 and 2007 at a large comprehensive cancer center in the United States. Multinomial logistic regression analysis was used to identify patient characteristics associated with place of death (ICU, hospital following ICU, hospital without ICU) among hospital decedents.

RESULTS

Among 105,157 hospital discharges, 3860 (3.7%) died in the hospital: 42% in the ICU, 14% in the hospital following an ICU stay, and 44% in the hospital without ICU services. Individuals with the following characteristics had an increased risk of dying in the ICU: nonlocal residence, newly diagnosed hematologic or nonmetastatic solid tumor malignancies, elective admission, surgical or pediatric services. A palliative care consultation on admission was associated with dying in the hospital without ICU services.

CONCLUSIONS

Understanding existing patterns of care at the end of life will help guide decisions about resource allocation and palliative care programs. Patients who seek care at dedicated cancer centers may elect more aggressive care; thus the generalizability of this study is limited. Although dying in a hospital may be unavoidable for patients who have uncontrolled symptoms that cannot be managed at home, palliative care consultations with patients and their families in advance regarding end-of-life preferences may prevent unwanted admission to the ICU.

Evaluation of cancer patients admitted to the emergency department within one month before death in Turkey: what are the problems needing attention?

BACKGROUND

Although previously studies have reported that most patients with malignancy prefer to die at home, this is not the real situation in clinical practice.

AIM

In this study, we aimed to determine the characteristics of Turkish cancer patients admitted to the emergency department (ED) within one month before death.

MATERIALS AND METHOD

This descriptive retrospective study focused on questions about how often and why patients with cancer visited the ED before death. A total of 107 individuals with cancer were divided into 2 groups: Group 1, patients with at least one visit in the final 4 weeks; and Group 2, patients with no visit to ED. Demographic and clinical features were compared between the two groups.

STATISTICAL ANALYSES

Descriptive statistical methods, statistical analysis for correlation, Student's t-test, chi-square tests and logistic regression were used.

RESULTS

At least one visit to ED within one month before death was reported for 64 (60%) of the 107 cases. Of these 64 (Group 1), 38% (n=24) were discharged and 9% (n=6) died in the ED. The most common site of the primary tumor was the lung (n=24, 38%) and the most common symptom was dyspnea (92%). With the other 43 (40%) cancer patients not presenting to the ED within one month before death, they were more likely to be female with another type of cancer.

CONCLUSIONS

Guidelines are needed for better management of cancer patients benefiting from visits to ED within the last month of life .

The DOMUS study protocol: a randomized clinical trial of accelerated transition from oncological treatment to specialized palliative care at home

Background

The focus of Specialized Palliative Care (SPC) is to improve care for patients with incurable diseases and their families, which includes the opportunity to make their own choice of place of care and ultimately place of death.

The Danish Palliative Care Trial (DOMUS) aims to investigate whether an accelerated transition process from oncological treatment to continuing SPC at home for patients with incurable cancer results in more patients reaching their preferred place of care and death. The SPC in this trial is enriched with a manualized psychological intervention.

Methods/Design

DOMUS is a controlled randomized clinical trial with a balanced parallel-group randomization (1:1). The planned sample size is 340 in- and outpatients treated at the Department of Oncology at Copenhagen University Hospital. Patients are randomly assigned either to: a) standard care plus SPC enriched with a standardized psychological intervention for patients and caregivers at home or b) standard care alone. Inclusion criteria are incurable cancer with no or limited antineoplastic treatment options.

Discussion

Programs that facilitate transition from hospital treatment to SPC at home for patients with incurable cancer can be a powerful tool to improve patients’ quality of life and support family/caregivers during the disease trajectory. The present study offers a model for achieving optimal delivery of palliative care in the patient’s preferred place of care and attempt to clarify challenges.

Trial registration

Clinicaltrials.gov Identifier: NCT01885637

Exercise training as treatment in cancer cachexia

Cachexia is a wasting syndrome that may accompany a plethora of diseases, including cancer, chronic obstructive pulmonary disease, aids, and rheumatoid arthritis. It is associated with central and systemic increases of pro-inflammatory factors, and with decreased quality of life, response to pharmacological treatment, and survival. At the moment, there is no single therapy able to reverse cachexia many symptoms, which include disruption of intermediary metabolism, endocrine dysfunction, compromised hypothalamic appetite control, and impaired immune function, among other. Growing evidence, nevertheless, shows that chronic exercise, employed as a tool to counteract systemic inflammation, may represent a low-cost, safe alternative for the prevention/attenuation of cancer cachexia. Despite the well-documented capacity of chronic exercise to counteract sustained disease-related inflammation, few studies address the effect of exercise training in cancer cachexia. The aim of the present review was hence to discuss the results of cachexia treatment with endurance training. As opposed to resistance exercise, endurance exercise may be performed devoid of equipment, is well tolerated by patients, and an anti-inflammatory effect may be observed even at low-intensity. The decrease in inflammatory status induced by endurance protocols is paralleled by recovery of various metabolic pathways. The mechanisms underlying the response to the treatment are considered.

The epidemiology of long- and short-term cancer survivors. A population-based cohort study exploring denominators for rehabilitation and palliative care programs

INTRODUCTION

In this study, we present data from a population-based cohort of incident cancer patients separated in long- and short-term survivors. Our aim was to procure denominators for use in the planning of rehabilitation and palliative care programs.

MATERIAL AND METHODS

A registry-linkage cohort study. All cancer patients, diagnosed from 1993 to 2003 from a 470 000 large population, were followed individually from diagnosis to death or until 31 December 2008. Long-term survivors lived five years or more after the time of the cancer diagnosis (TOCD). Short-term survivors died less than five years after TOCD.

RESULTS

The cohort comprised 24 162 incident cancer patients with 41% long-term survivors (N = 9813). Seventy percent of the cohort was 60 + years at TOCD. The 14 349 short-term survivors' median survival was 0.6 year, and 78% died less than two years after TOCD. A 12 years' difference in age at TOCD was seen between long- and short-term survivors, with median ages of 60 versus 72 years, respectively. Females comprised 64% of long-term, and 46% of short-term survivors. The proportion of breast and lung cancers differed between the groups: Long-term survivors: 31% breast cancer, 2.4% lung cancer. Short-term survivors: 21% lung cancer, 7.2% breast cancer. Chemotherapy was provided to 15% of all patients, and to 10% of the 60 + year olds.

DISCUSSION

The epidemiology of long- and short-term survivors shows significant differences with regard to age at TOCD, cancer types and sex. Two-year crude cancer survival seems as a clinically relevant cut point for characterizing potential "denominators" for rehabilitation or palliative care programs. From this cohort of incident cancer patients, and using two-year survival as a cut point, it could be estimated that 54% would candidate to a "care trajectory" focusing on rehabilitation and 46% a "care trajectory" focusing on palliative care at TOCD.

Intensive palliative care for patients with hematological cancer dying in hospice: analysis of the level of medical care in the final week of life

Dying of hematological oncology patients often take place in respective hematology ward or intensive care unit rather than hospice. With the increased attention to quality palliative care for hematology patients, concerns regarding their level of medical care at end-of-life need to be addressed. We conducted a retrospective review of consecutive hematological oncology patients who succumbed in a palliative unit between July 2012 and August 2013. The primary outcome measure was their level of medical care received, including administration of antibiotics, total parenteral nutrition, blood sampling, GCSF injection and blood products transfusion, during their last seven days of life. During the last seven days of life, 85.7 % of patients had blood sampling and 23.8% of patients received G-CSF injection. Total parenteral nutrition was administered in 14.3% of patients. One-third of patients received transfusion of packed cells and nearly half of them received transfusion of platelet concentrates. Almost 90% of patients received antibiotics during their last week of life. Collaboration between hematology and palliative care has resulted in successful transition of hematologic cancer patients into hospice unit in their terminal phase of illness. However, their level of medical care, even approaching last seven days of life, remained intensive. Proper allocation of medical resources and future research regarding optimal end-of-life care for hematology patients are warranted.