Hospice admissions for cancer in the final days of life: independent predictors and implications for quality measures

Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life

INTRODUCTION

Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation.

RESULTS

Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89).

CONCLUSIONS

Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.

Palliative and End-of-Life Care in Hematologic Malignancies: Progress and Opportunities

@JCOOP_ASCO editorial on unique needs of end-of-life care for different blood cancers discusses: #pallheme improves QOL but less utilized in cancers. Contextualize Weisse et al study. More #pallheme research needed for lymphoma and myeloma in era of cell therapy.

Mixed-Methods Study of End-of-Life Experiences of Patients With Hematologic Malignancies in Social Hospice Residential Home Care Settings

PURPOSE

Hospice is underutilized by patients with hematologic malignancies (HM), and when patients are referred, they are typically more ill, hospitalized, and with shorter length of stay (LOS) than patients with solid tumors (ST), limiting research about home hospice care experiences of patients with HM. In this mixed-methods study, we examined the hospice experiences of patients with HM who died at residential care homes (RCHs), home-based settings in which volunteer caregivers and hospice staff provide end-of-life (EOL) care under the social hospice model.

METHODS

We queried a registry of 535 hospice patients who died at RCHs between 2005 and 2020 that included quantitative medication administration data as well as qualitative data from hospice intake forms and written volunteer caregiver narratives. Qualitative data were analyzed by collective case study methodology. Quantitative comparisons of LOS and liquid morphine use were performed with matched patients with ST.

RESULTS

The registry yielded 29 patients with HM, of whom qualitative data were available for 18 patients. Patients with HM exhibited common EOL symptoms (pain, dyspnea, and agitation). Instances of bleeding were low (22%), and notable HM-specific care concerns were described regarding bone fractures, skin integrity, and delirium. Most (78%) experienced good symptom management and peaceful or comfortable deaths. In only one case were symptoms described as severe and poorly managed. Patients with HM had comparable LOS on hospice and at the RCHs to patients with ST, with no group differences in liquid morphine use.

CONCLUSION

In this registry cohort, most patients with HM achieved good symptom management in home care settings with volunteer caregivers and hospice support. Caregivers may require additional counseling and palliative medications for HM-specific EOL symptoms.

Compassionate Communication and Advance Care Planning to improve End-of-life Care in Treatment of Haematological Disease 'ACT': Study Protocol for a Cluster-randomized trial

INTRODUCTION

To support the implementation of advance care planning and serious illness conversations in haematology, a previously developed conversation intervention titled 'Advance Consultations Concerning your Life and Treatment' (ACT) was found feasible. This study aims to investigate the effect of ACT on the quality of end-of-life care in patients with haematological malignancy and their informal caregivers.

METHODS AND ANALYSIS

The study is a nationwide 2-arm cluster randomised trial randomising 40 physician-nurse clusters across seven haematological departments in Denmark to provide standard care or ACT intervention. A total of 400 patients with haematological malignancies and their informal caregivers will be included. The ACT intervention includes an ACT conversation that centres on discussing the patient's prognosis, worries, hopes and preferences for future treatment. The intervention is supported by clinician training and supervision, preparatory materials for patients and informal caregivers, and system changes including dedicated ACT-conversation timeslots and templates for documentation in medical records.This study includes two primary outcomes: (1) the proportion of patients receiving chemotherapy within the last 30 days of death and (2) patients' and informal caregivers' symptoms of anxiety (General Anxiety Disorder-7) at 3 6, 9, 12 and 18 months follow-up. Mixed effects models accounting for clusters will be used.

ETHICS AND DISSEMINATION

The Declaration of Helsinki and the European GDPR regulations as practised in Denmark are followed through all aspects of the study. Findings will be made available to the participants, patient organisations, funding bodies, healthcare professionals and researchers at national and international conferences and through publication in peer-reviewed international journals.

REGISTRATION DETAILS

The study is registered at ClinicalTrials.gov (NCT05444348). The Regional Ethics Committee of the Capital Region of Denmark (record no: 21067634) has decided that approval is not necessary as per Danish legislation. Study approval has been obtained from The Capital Region of Denmark Data Protection Agency (record no: P-2022-93).

TRIAL REGISTRATION NUMBER

NCT05444348.

The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective

BACKGROUND

Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population.

AIM

To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives.

METHODS

A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach.

RESULTS

Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith.

CONCLUSION

Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.

Perspectives on Transfusions for Hospice Patients With Blood Cancers: A Survey of Hospice Providers

CONTEXT

Patients with blood cancers have low rates of hospice use. While lack of transfusion access in hospice is posited to substantially contribute to these low rates, little is known about the perspectives of hospice providers regarding transfusion access in hospice.

OBJECTIVES

To characterize hospice providers' perspectives regarding care for patients with blood cancers and transfusions in the hospice setting.

METHODS

In 2022, we conducted a cross-sectional survey of a sample of hospices in the United States regarding their experience caring for patients with blood cancers, perceived barriers to hospice use, and interventions to increase enrollment.

RESULTS

We received 113 completed surveys (response rate = 23.5%). Of the cohort, 2.7% reported that their agency always offers transfusions, 40.7% reported sometimes offering transfusions, and 54.9% reported never offering transfusions. In multivariable analyses, factors associated with offering transfusions included nonprofit ownership (OR 5.93, 95% CI, 2.2-15.2) and daily census >50 patients (OR 3.06, 95% CI, 1.19-7.87). Most respondents (76.6%) identified lack of transfusion access in hospice as a barrier to hospice enrollment for blood cancer patients. The top intervention considered as "very helpful" for increasing enrollment was additional reimbursement for transfusions (72.1%).

CONCLUSION

In this national sample of hospices, access to palliative transfusions was severely limited and was considered a significant barrier to hospice use for blood cancer patients. Moreover, hospices felt increased reimbursement for transfusions would be an important intervention. These data suggest that hospice providers are supportive of increasing transfusion access and highlight the critical need for innovative hospice payment models to improve end-of-life care for patients with blood cancers.

Factors Affecting Hospice Use Among Adolescents and Young Adult Cancer Patients

Background/Objective: Compared to existing studies on end-of-life care of mid- to older-aged patients diagnosed with cancer, there is a paucity of research on adolescents and young adult (AYA) patients. Guided by the Anderson's Behavioral Model for Healthcare Utilization, this study examined predisposing/enabling/need factors associated with hospice referral/enrollment among AYA patients diagnosed with cancer. Methods: Data were drawn from medical records of AYA patients who died of cancer between January 2013 and December 2016 at three academic sites in the United States and were 15-39 years old at the time of death. Logistic regression was conducted (N = 224). Results: Findings showed that hospice referral was strongly associated with hospice enrollment (odds ratio [OR] = 69.68, p < 0.0001). White patients were more likely to be referred to hospice care than non-White patients; the effect was, however, significant only among patients with private insurance (OR = 3.44, p = 0.040). Patients with public insurance were more likely to be referred to hospice than those with private insurance; the effect was, however, significant only among non-White patients (OR = 5.66, p = 0.005). Among those not receiving cancer treatment in the last month of life (LML), patients with hematologic malignancies were less likely to be referred to hospice than those with solid tumors (OR = 0.19). Among patients with solid tumors, receiving cancer treatment in the LML lowered the odds of hospice referral (OR = 0.50, p = 0.043). Conclusion: Further research efforts are needed to investigate the role of race, insurance, cancer types, and treatments in hospice use among bigger samples of AYA patients diagnosed with cancer.

Effect of the COVID-19 Pandemic on Place of Death Among Medicaid and Commercially Insured Patients With Cancer in Washington State

PURPOSE

The COVID-19 pandemic-related disruptions in health care delivery might have affected end-of-life care in patients with cancer. We examined changes in place of death and hospice support for Medicaid and commercially insured patients during the pandemic.

PATIENTS AND METHODS

We linked Washington State cancer registry records with claims from Medicaid and two commercial insurers for patients with solid tumor age 18-64 years. The study included 322 Medicaid and 162 commercial patients who died between March 2017 and June 2019 (pre-COVID-19), along with 90 Medicaid and 47 commercial patients who died between March and June 2020 (COVID-19). Place of death was categorized as hospital, hospice (home or nonhospital facility), and home without hospice. Place of death was compared using adjusted multinomial logistic regressions stratified by payer and time period (pre-COVID-19 v COVID-19). The clinical and sociodemographic factors associated with dying at home without hospice were examined, and adjusted marginal effects (ME) are reported.

RESULTS

In the adjusted pre-COVID-19 analysis, Medicaid patients were more likely than commercially insured patients to die in hospital (48% v 36%; adjusted ME, 11%; P = .02). In the pre-COVID-19/COVID-19 analysis, Medicaid patients' place of death shifted from hospital (48% v 32%; ME, -16%; P < .01) to home without hospice (19.9% v 38.0%; ME, 16.5%; P < .01). However, there were no statistically significant changes pre-COVID-19/COVID-19 for commercial patients. As a result, during COVID-19, Medicaid patients were more likely than commercial patients to die at home without hospice (38% v 22%; ME, 16%; P = .04) as were male versus female patients (ME, 16%; P < .01).

CONCLUSION

The pandemic might have disproportionately worsened the end-of-life experience for Medicaid enrollees with cancer. Attention should be paid to societal and health system factors that decrease access to care for Medicaid patients.

Goals of care documentation by medical oncologists and oncology patient end-of-life care outcomes

BACKGROUND

Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end-of-life (EOL) care.

METHODS

In April 2020, our cancer center launched a GOC note template, including optional fields for documenting discussion with the patient about: cancer natural history, goals, and/or EOL (resuscitation preferences, hospice receptivity). Associations between GOC notes and EOL care were evaluated.

RESULTS

Among 1721 patients dying between June 1, 2020 and June 30, 2021, median days from first GOC note (± with documentation of EOL discussion) to death was 92, whereas a GOC note including EOL discussion ("GOC EOL note"), specifically, was 31. Patients with a first GOC note >60 days before death spent fewer days inpatient (6.7 vs 10.6 days, p < .001). Among patients with GOC EOL notes, those with such documentation >30 days before death had fewer inpatient (5 vs 11, p < .001) and intensive care unit days (0.5 vs 1.5, p < .001), more hospice referrals (57% vs 44%, p = .003), and less chemotherapy ≤14 days before death (6% vs 11%, p = .010). Of 925 admissions of patients dying within ≤30 days, those with GOC EOL notes were shorter (7 vs 9 days, p = .013) but not associated with more hospice discharge (30% vs 25%, p = .163). Oncologist (vs nononcologist) GOC documentation and earlier documentation of EOL discussion were associated in subset analyses with less inpatient care and more hospice referrals.

CONCLUSIONS

Documentation of GOC, including EOL discussions, is associated with favorable performance on accepted indicators of quality EOL care.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population

Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes.

Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions.

Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables.

Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions.

Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Importance

Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse.

Objective

To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer.

Design, Setting, and Participants

This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019.

Exposure

Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis.

Main Outcomes and Measures

The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling.

Results

Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care.

Conclusions and Relevance

The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

Bereaved Informal Caregivers Rarely Recall a Relationship Between Transfusions and Hospice in Acute Myeloid Leukemia

AIMS

The inability to prescribe blood transfusions is a potential barrier to timely hospice enrollment for patients with blood cancers. The benefits and harms of transfusions near the end of life (EOL), however, are poorly characterized and patients' preferences are unknown. We sought to characterize the recollections of bereaved caregivers about the relationships between transfusions and hospice enrollment decisions.

METHODS

We recruited 18 bereaved caregivers of 15 decedents who died within 6-18 months of the interview. Interviews focused on caregivers' recollections of transfusion and hospice enrollment decisions. Transcripts were analyzed for themes.

RESULTS

We identified 2 themes. First, caregivers described that transfusions were necessary and the decisions to receive transfusions or not were deferred to the clinicians. Second, only 1 caregiver recalled transfusions as relevant to hospice decisions. In that instance there was a delay. Caregivers identified difficulties recognizing death was imminent, hope for miracles, and the necessity of accepting life was ending as more relevant barriers.

CONCLUSIONS

The results indicate clinicians' beliefs in transfusion at EOL may be a more relevant barrier to hospice enrollment than patients' preferences. Strategies to evaluate accurately and discuss the actual benefits and harms of transfusions at the EOL are necessary to advise patients and integrate their preferences into decisions.

Hospice Utilization in Elderly Patients With Brain Metastases

BACKGROUND

Brain metastases are associated with considerable morbidity and mortality. Integration of hospice at the end of life offers patients symptom relief and improves quality of life, particularly for elderly patients who are less able to tolerate brain-directed therapy. Population-level investigations of hospice utilization among elderly patients with brain metastases are limited.

METHODS

Using the Surveillance, Epidemiology and End Results-Medicare database for primary cancer sites that commonly metastasize to the brain, we identified 50 148 patients (aged 66 years and older) diagnosed with brain metastases between 2005 and 2016. We calculated the incidence, timing, and predictors of hospice enrollment using descriptive techniques and multivariable logistic regression. All statistical tests were 2-sided.

RESULTS

The incidence of hospice enrollment was 71.4% (95% confidence interval [CI] = 71.0 to 71.9; P < .001), a rate that increased over the study period (P < .001). The odds of enrollment for black (odds ratio [OR] = 0.76, 95% CI = 0.71 to 0.82; P < .001), Hispanic (OR = 0.80, 95% CI = 0.72 to 0.87; P < .001), and Asian patients (OR = 0.52, 95% CI = 0.48 to 0.57; P < .001) were substantially lower than white patients; men were less likely to be enrolled in hospice than women (OR = 0.78, 95% CI = 0.74 to 0.81; P < .001). Among patients enrolled in hospice, 32.6% (95% CI = 32.1 to 33.1; P < .001) were enrolled less than 7 days prior to death, a rate that was stable over the study period.

CONCLUSIONS

Hospice is used for a majority of elderly patients with brain metastases although a considerable percentage of patients die without hospice services. Many patients enroll in hospice late and, concerningly, statistically significant sociodemographic disparities exist in hospice utilization. Further investigations to facilitate targeted interventions addressing such disparities are warranted.

Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close?

PURPOSE OF REVIEW

The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death.

RECENT FINDINGS

Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.

Disparities in end-of-life care, expenditures, and place of death by health insurance among cancer patients in China: a population-based, retrospective study

Background

Disparities in the utilization, expenditures, and quality of care by insurance types have been well documented. Such comparisons have yet to be investigated in end-of-life (EOL) settings in China, where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.

Methods

A total of 398 patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China, were included. Descriptive analysis and multivariate regression models were used to investigate the bivariate and independent associations, respectively, between health insurance with EOL healthcare utilization, expenditures and place of death.

Results

Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.15 [1.81–2.48] and 1.92 [1.59–2.26], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.01 [0.38–1.64] and 0.71 [0.20–1.22], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥15,722 and ¥43,241 higher expenditures. Similarly, UEBMI beneficiaries were most likely to die in hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.23 [0.11–0.36]) and URBMI (UEBMI vs. URBMI: 0.67 [0.57–0.78]) beneficiaries.

Conclusions

The disproportionately lower utilization of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Purposive hospice care intervention might be warranted to address EOL care for these beneficiaries in China.

End-of-Life Trajectories of Patients With Hematological Malignancies and Patients With Advanced Solid Tumors Visiting the Emergency Department: The Need for a Proactive Integrated Care Approach

Purpose:

Patients with hematological malignancies (HM) have more unpredictable disease trajectories compared to patients with advanced solid tumors (STs) and miss opportunities for a palliative care approach. They often undergo intensive disease-directed treatments until the end of life with frequent emergency department (ED) visits and in-hospital deaths. Insight into end-of-life trajectories and quality of end-of-life care can support arranging appropriate care according to patients’ wishes.

Method:

Mortality follow-back study to compare of end-of-life trajectories of HM and ST patients who died <3 months after their ED visit. Five indicators based on Earle et al. for quality of end-of-life care were assessed: intensive anticancer treatment <3 months, ED visits <6 months, in-hospital death, death in the intensive care unit (ICU), and in-hospice death.

Results:

We included 78 HM patients and 420 ST patients, with a median age of 63 years; 35% had Eastern Cooperative Oncology Group performance status 3-4. At the ED, common symptoms were dyspnea (22%), pain (18%), and fever (11%). After ED visit, 91% of HM patients versus 76% of ST patients were hospitalized (P = .001). Median survival was 17 days (95% confidence interval [CI]: 15-19): 15 days in HM patients (95% CI: 10-20) versus 18 days in ST patients (95% CI: 15-21), P = .028. Compared to ST patients, HM patients more often died in hospital (68% vs 30%, P < .0001) and in the ICU or ED (30% vs 3%, P < .0001).

Conclusion:

Because end-of-life care is more aggressive in HM patients compared to ST patients, a proactive integrated care approach with early start of palliative care alongside curative care is warranted. Timely discussions with patients and family about advance care planning and end-of-life choices can avoid inappropriate care at the end of life.

End of life care for the most common women cancers in Taiwan

OBJECTIVES

Women with terminal cancer are assumed to choose hospice care over aggressive treatment at the end of life. With new chemotherapy and target therapy options, it becomes more difficult to decide between hospice care and aggressive management. It is also crucial to consider the cost increases leading to severe financial burdens on healthcare systems. To better understand treatment options at the individual level, this study set out to describe trends in end-of-life care for the four leading cancers in women in Taiwan.

STUDY DESIGN

This was a population-based retrospective cohort study.

METHODS

The data source was obtained between January 1, 2000, and December 31, 2013, from Taiwan's National Health Insurance Research Database. We identified 98,575 women with a diagnosis of breast (18,596), colorectal (23,734), liver and biliary (28,795) or lung (27,450) cancer who had died during the study period. Hospital data for services provided in the last 6 months of life, including hospice services and aggressive managements (chemotherapy, frequent hospitalisation, emergency room [ER] visits, intensive care unit [ICU] admission and endotracheal intubation), were collected.

RESULTS

Hospice utilisation increased over the study period, with 25.85%, 25.34%, 21.23% and 26.55% of female patients with breast, colorectal, liver and biliary, and lung cancer receiving hospice care, respectively. However, the number of women undergoing aggressive treatments in the last 6 months of life remained high, with the breast cancer group having the highest chemotherapy rate, the colorectal cancer group having frequent hospitalisation and the liver and biliary cancer group having frequent ER visits and ICU admissions.

CONCLUSIONS

Increasing hospice utilisation among women with the four most common cancers in Taiwan indicates that hospice services have gradually become well accepted over the past 13 years; however, the real focus is on the ineffective treatment preceding hospice care, and late referral was also a notable problem.

Hospice or Hospital: The Costs of Dying of Cancer in the Oncology Care Model

Background: End-of-life management is a difficult aspect of cancer care. With the oncology care model (OCM), we have data to assess both clinical outcomes and total cost of care (TCOC). Objective: To measure and characterize the TCOC for those who received less than three days of hospice care (HC) at the end of life compared with those who received three days or more. Design: Assess data on costs and site and date of death from Medicare claims on patients identified in the OCM who received chemotherapy in the six months before death. Standard statistical methods were used to characterize both populations. Setting/Subjects: Subjects were Medicare patients with cancer who died while managed by U.S. oncology practices in the OCM. Measurements were TCOC in 30-day intervals for the last months of life, cost by site of care at the end of life, and demographic characteristics of the population and association with HC. Results: There were 7329 deaths. Dying in the hospital was twice the cost of dying at home under HC ($20,113 vs. $10,803). Of demographic groups measured, only black race and a lymphoma diagnosis had <50% hospice enrollment for three days or more before death. Conclusions: This study reinforces previous studies regarding costs in the last 30 days of life. The graphic representation highlights the dollar cost and the costs of lost opportunity. Using these data to improve communication, addressing socioeconomic support, and formal palliative care integration are potential strategies to improve care.

Perspectives Regarding Hospice Services and Transfusion Access: Focus Groups With Blood Cancer Patients and Bereaved Caregivers

CONTEXT

Patients with blood cancers have low rates of timely hospice use. Barriers to hospice use for this population are not well understood. Lack of transfusion access in most hospice settings is posited as a potential reason for low and late enrollment rates.

OBJECTIVES

We explored the perspectives of patients with blood cancers and their bereaved caregivers regarding the value of hospice services and transfusions.

METHODS

Between June 2018 and January 2019, we conducted three focus groups with blood cancer patients with an estimated life expectancy of six months or less and two focus groups with bereaved caregivers of patients with blood cancers. We asked participants their perspectives regarding quality of life (QOL) and about the potential association of traditional hospice services and transfusions with QOL. A hematologic oncologist, sociologist, and qualitatively trained research assistant conducted thematic analysis of the data.

RESULTS

Twenty-seven individuals (18 patients and nine bereaved caregivers) participated in the five focus groups. Participants identified various QOL domains that were important to them but focused largely on a desire for energy to maintain physical/functional well-being. Participants considered transfusions a high-priority service for their QOL. They also felt that standard hospice services were important for QOL. Bereaved caregivers reported overall positive experiences with hospice.

CONCLUSION

Our analysis suggests that although patients with blood cancers value hospice services, they also consider transfusions vital to their QOL. Innovative care delivery models that combine the elements of standard hospice services with other patient-valued services like transfusions are most likely to optimize end-of-life care for patients with blood cancers.

Patients with haematological malignancies should not have to choose between transfusions and hospice care

Hospice programmes are important for providing end-of-life care to patients with life-limiting illnesses. Hospice enrolment improves quality of life for patients with advanced cancer and reduces the risk of depression for caregivers. Despite the clear benefits of hospice care, patients with haematological malignancies have the lowest rates of enrolment among patients with any tumour subtype. Furthermore, when patients with haematological disorders do enrol into hospice care, they are more likely to do so within 3 days of death than are patients with non-haematological malignancies. Although reasons for low and late hospice use in this population are multifactorial, a key barrier is limited access to blood transfusions in hospice programmes. In this Viewpoint, we discuss the relationship between transfusion dependence and hospice use for patients with blood cancers. We suggest that rather than constraining patients into either transfusion or hospice models, policies that promote combining palliative transfusions with hospice services are likely to optimise end-of-life care for patients with haematological malignancies.

Hospitalizations and length of stay of cancer patients: A cohort study in the Brazilian Public Health System

The hospitalizations are part of cancer care and has been studied by researchers worldwide. A better understanding about their associated factors may help to achieve improvements on this area. The aims of this study were to investigate the association between demographic and clinical characteristics and hospitalizations, as well as between these characteristics and the length of stay (LOS), within the first year of outpatient treatment, for the most incident cancers in the Brazilian population. In this cohort study, we investigated 417,477 patients aged 19 years or more, who started outpatient cancer treatment, from 2010-2014, for breast, prostate, colorectal, cervix, lung and stomach cancers. The outcomes evaluated were: i) Hospitalizations within the first year of outpatient cancer treatment; and ii) LOS of the hospitalized patients. It was performed a binary logistic regression to evaluate the association between the explanatory variables and the hospitalizations and a negative binomial regression to evaluate their influence on the length of hospital stay. The hospitalizations occurred for 34% of patients, with a median of LOS of 6 days (IQR: 2-15). Female patients were 16% less likely to be hospitalized (OR: 0.84; 95% CI: 0.82-0.86), with lower average of LOS (AR: 0.98; 95% CI: 0.97-0.99), each additional year of age reduced in 2% the hospitalization odds (OR: 0.98; 95% CI: 0.98-0.99) and in 1% the average of LOS (AR: 0.99; 95% CI: 0.98-0.99), patients from South region had twice more chances of hospitalization than from North region (OR: 2.01; 95% CI: 1.93-2.10) and patients with colorectal cancer had greater probability of hospitalization (OR: 4.42; 95% CI: 4.27-4.48), with the highest average of LOS (AR: 1.37; 95% CI: 1.35-1.40). In view of our results, we consider that the government must expand the policies with potential to reduce the number of hospitalizations.

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

Goals of care discussions for patients with blood cancers: Association of person, place, and time with end-of-life care utilization

BACKGROUND

Patients with blood cancers experience high-intensity medical care near the end of life (EOL) and low rates of hospice use; attributes of goals of care (GOC) discussions may partly explain these outcomes.

METHODS

By using a retrospective cohort of patients with blood cancer who received care at Dana-Farber Cancer Institute and died in 2014, the authors assessed the potential relationship between timing, location, and the involvement of hematologic oncologists in the first GOC discussion with intensity of care near the EOL and timely hospice use.

RESULTS

Among 383 patients, 39.2% had leukemia/myelodysplastic syndromes, 37.1% had lymphoma, and 23.7% had myeloma. Overall, 65.3% of patients had a documented GOC discussion. Of the first discussions, 33.2% occurred >30 days before death, 34.8% occurred in the outpatient setting, and 46.4% included a hematologic oncologist. In multivariable analyses, having the first discussion >30 days before death (odds ratio [OR], 0.37; 95% CI, 0.17-0.81), in the outpatient setting (OR, 0.21; 95% CI, 0.09-0.50), and having a hematologic oncologist present (OR, 0.40; 95% CI, 0.21-0.77) were associated with lower odds of intensive care unit admission ≤30 days before death. The presence of a hematologic oncologist at the first discussion (OR, 3.07; 95% CI, 1.58-5.96) also was associated with earlier hospice use (>3 days before death).

CONCLUSIONS

In this large cohort of blood cancer decedents, most initial GOC discussions occurred close to death and in the inpatient setting. When discussions were timely, outpatient, or involved hematologic oncologists, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.

Disparities in Hospice Utilization for Older Cancer Patients Living in the Deep South

CONTEXT

Hospice utilization is an end-of-life quality indicator. The Deep South has known disparities in palliative care that may affect hospice utilization.

OBJECTIVES

The objective of this study was to evaluate the association among Deep South patient and hospital characteristics and hospice utilization.

METHODS

This retrospective cohort study evaluated patient and hospital characteristics associated with hospice among Medicare cancer decedents aged ≥65 years in 12 southeastern cancer centers between 2012 and 2015. We examined patient-level characteristics (age, race, gender, cancer type, and received patient navigation) and hospital-level characteristics (board-certified palliative physician, inpatient palliative care beds, and hospice ownership). Outcomes included hospice (within 90 vs. three days of death). Relative risks (RRs) and 95% CIs evaluated the association between patient- and hospital-level characteristics and hospice outcomes using generalized log-linear models with Poisson distribution and robust variance estimates.

RESULTS

Of 12,725 cancer decedents, 4142 (33%) did not utilize hospice. "No hospice" was associated with nonwhite (RR 1.24, 95% CI 1.17-1.32) and nonnavigated patients (RR 1.17, 95% CI 1.10-1.25), and those at a hospital with inpatient palliative care beds (RR 1.15, 95% CI 1.10-1.21). "Late hospice" (20%; n = 1458) was associated with being male (RR 1.31, 95% CI 1.19-1.44) and seen at a hospital without inpatient palliative care beds (RR 0.82, 95% CI 0.75-0.90).

CONCLUSIONS

Hospice utilization differed by patient and hospital characteristics. Patients who were nonwhite, and nonnavigated, and hospitals with inpatient palliative care beds, were associated with no hospice. Research should focus on ways to improve hospice utilization in Deep South older cancer patients.

End-of-Life Costs and Hospice Utilization in Patients with Head and Neck Cancer

The Quality Oncology Practice Initiative has several metrics related to end-of life (EOL) care, including hospice enrollment ≤3 days, with lower scores signaling better performance. Of privately insured patients with head and neck cancer, 3.5% were enrolled in hospice prior to death and 21.3% spent ≤3 days in hospice, indicating aggressive EOL care. Patients with late hospice enrollment had higher spending in the last 30 days of life (DOL). Patients in hospice ≤3 days spent $37,426, while those in hospice >3 days spent $24,418 ( P = .002). The largest portion of this difference was attributable to inpatient services. Patients in hospice ≤3 days spent $22,089 on inpatient services in the last 30 DOL, while those in hospice >3 days spent $8361 ( P < .001). Further research is needed to determine if more high-value care can be provided with earlier hospice enrollment and to ensure that goal concordance is included in defining high-value care.

Patterns of end-of-life hospital care for patients with non-Hodgkin lymphoma: exploring the landscape

Rapid change, treatment responsiveness, and prognostication difficulties present challenges for palliative care integration for hematology patients. This Australian study aimed to document end-of-life hospital care for patients with non-Hodgkin lymphoma (NHL) to consider opportunities for palliative care integration. A retrospective population cohort design examining existing linked datasets of health service utilization and death registration. The results revealed 4380 NHL patients, majority male (58%) and aged 70+ years (70%), spent 32 days (median) in hospital in final 6 months of life, and in the last month, 56% had more than 1 hospital admission, and 57% stayed more than 14 days. Forty-one percent accessed palliative care, with first contact 23 days (median) before death, and for 77% in final admission. Early palliative care was more likely for patients with greater symptom burden. This study mapping patterns of care for patients who die from NHL establishes a baseline enabling comparisons for future care innovations.

Timely Referral to Hospice Care for Oncology Patients: A Retrospective Review

Hospice care is medical care provided to terminally ill patients with a life expectancy of 6 months or less. Hospice services include symptom control, pain management, palliative care, and other supportive services such as providing for home equipment or oxygen; however, it does not provide for life-prolonging therapies such as chemotherapy. Although oncologic benchmarks suggest patients should be enrolled in hospice 3 months prior to death, studies show that most hospice referrals are being made too late. These shorter stays in hospice result in increased cost of care especially at the end of life with most patients dying on aggressive treatments in the hospital. Thus, identifying barriers to hospice placement is critical in improving the referral process and enhancing the quality of end-of-life care. This retrospective study collected data on 418 oncologic patients who passed in 2015 and categorized patients based on hospice status at the time of death. Our study found that the demographics between hospice and nonhospice patients were not significantly different. Hospice patients spent a median of 10 days in hospice and 71% (n = 161) of patients were in hospice 30 days or less. Additionally, 56% of patients were in hospice 10 days or less. Increased education for patients and health-care providers along with better utilization of palliative care services and incorporating a nurse navigator to help with transitioning patients to hospice would improve earlier referral to hospice care and enhance patients' quality of life.

Utilization of Prostate Cancer Quality Metrics for Research and Quality Improvement: A Structured Review

BACKGROUND

The shift toward value-based care in the United States emphasizes the role of quality measures in payment models. Many diseases, such as prostate cancer, have a proliferation of quality measures, resulting in resource burden and physician burnout. This study aimed to identify and summarize proposed prostate cancer quality measures and describe their frequency and use in peer-reviewed literature.

METHODS

The PubMed database was used to identify quality measures relevant to prostate cancer care, and included articles in English through April 2018. A gray literature search for other documents was also conducted. After the selection process of the pertinent articles, measure characteristics were abstracted, and uses were summarized for the 10 most frequently utilized measures in the literature.

RESULTS

A total of 26 articles were identified for review. Of the 71 proposed prostate cancer quality measures, only 47 were used, and less than 10% of these were endorsed by the National Quality Forum. Process measures were most frequently reported (84.5%). Only 6 outcome measures (8.5%) were proposed-none of which were among the most frequently utilized.

CONCLUSION

Although a high number of proposed prostate cancer quality measures are reported in the literature, few were assessed, and the majority of these were non-endorsed process measures. Process measures were most commonly assessed; outcome measures were rarely evaluated. In a step to close the quality chasm, a "top 5" core set of quality measures for prostate cancer care, including structure, process, and outcomes measures, is suggested. Future studies should consider this comprehensive set of quality measures.

Meaningful changes in end-of-life care among patients with myeloma

Patients with advanced myeloma experience a high symptom burden particularly near the end of life, making timely hospice use crucial. Little is known about the quality and determinants of end-of-life care for this population, including whether potential increases in hospice use are also accompanied by “late” enrollment (≤ 3 days before death). Using the Surveillance, Epidemiology, and End-Results-Medicare database, we identified patients ≥ 65 years diagnosed with myeloma between 2000 and 2013 who died by December 31, 2013. We assessed prevalence and trends in hospice use, including late enrollment. We also examined six established measures of potentially aggressive medical care at the end of life. Independent predictors of late hospice enrollment and aggressive end-of-life care were assessed using multivariable logistic regression analyses. Of 12,686 myeloma decedents, 48.2% enrolled in hospice. Among the 6111 who enrolled, 17.2% spent ≤ 3 days there. There was a significant trend in increasing hospice use, from 28.5% in 2000 to 56.5% by 2013 (P_trend <0.001), no significant rise in late enrollment (12.2% in 2000 to 16.3% in 2013, P_trend =0.19), and a slight decrease in aggressive end-of-life care (59.2% in 2000 to 56.7% in 2013, P_trend =0.01). Patients who were transfusion-dependent, on dialysis, or survived for less than one year were more likely to enroll late in hospice and experience aggressive medical care at the end of life. Gains in hospice use for myeloma decedents were not accompanied by increases in late enrollment or aggressive medical care. These findings suggest meaningful improvements in end-of-life care for this population.

Strange Bedfellows No More: How Integrated Stem-Cell Transplantation and Palliative Care Programs Can Together Improve End-of-Life Care

In the intense, cure-oriented setting of hematopoietic stem-cell transplantation (HSCT), delivery of high-quality palliative and end-of-life care is a unique challenge. Although HSCT affords patients a chance for cure, it carries a significant risk of morbidity and mortality. During HSCT, patients usually experience high symptom burden and a significant decrease in quality of life that can persist for long periods. When morbidity is high and the chance of cure remote, the tendency after HSCT is to continue intensive medical interventions with curative intent. The nature of the complications and overall condition of some patients may render survival an unrealistic goal and, as such, continuation of artificial life-sustaining measures in these patients may prolong suffering and preclude patient and family preparation for end of life. Palliative care focuses on the well-being of patients with life-threatening conditions and their families, irrespective of the goals of care or anticipated outcome. Although not inherently at odds with HSCT, palliative care historically has been rarely offered to HSCT recipients. Recent evidence suggests that HSCT recipients would benefit from collaborative efforts between HSCT and palliative care services, particularly when initiated early in the transplantation course. We review palliative and end-of-life care in HSCT and present models for integrating palliative care into HSCT care. With open communication, respect for roles, and a spirit of collaboration, HSCT and palliative care can effectively join forces to provide high-quality, multidisciplinary care for these highly vulnerable patients and their families.

Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma

CONTEXT

Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma.

OBJECTIVES

We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined.

RESULTS

Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice.

CONCLUSION

Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.

Hospice utilization in patients with malignant gliomas

Background

Despite recommendations from professional organizations supporting early hospice enrollment for patients with cancer, little research exists regarding end-of-life (EOL) practices for patients with malignant glioma (MG). We evaluated rates and correlates of hospice enrollment and hospice length of stay (LOS) among patients with MG.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified adult patients who were diagnosed with MG from January 1, 2002 to December 31, 2011 and who died before December 31, 2012. We extracted sociodemographic and clinical data and used univariate logistic regression analyses to compare characteristics of hospice recipients versus nonrecipients. We performed multivariable logistic regression analyses to examine predictors of hospice enrollment >3 or >7 days prior to death.

Results

We identified 12437 eligible patients (46% female), of whom 7849 (63%) were enrolled in hospice before death. On multivariable regression analysis, older age, female sex, higher level of education, white race, and lower median household income predicted hospice enrollment. Of those enrolled in hospice, 6996 (89%) were enrolled for >3 days, and 6047 (77%) were enrolled for >7 days. Older age, female sex, and urban residence were predictors of longer LOS (3- or 7-day minimum) on multivariable analysis. Median LOS on hospice for all enrolled patients was 21 days (interquartile range, 8-45 days).

Conclusions

We identified important disparities in hospice utilization among patients with MG, with differences by race, sex, age, level of education, and rural versus urban residence. Further investigation of these barriers to earlier and more widespread hospice utilization is needed.

Palliative care in patients with haematological neoplasms: An integrative systematic review

BACKGROUND

Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies.

AIM

To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments.

DESIGN

Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240).

DATA SOURCES

PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies.

RESULTS

The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking.

CONCLUSION

Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Improving End-of-Life Care: Palliative Care Embedded in an Oncology Clinic Specializing in Targeted and Immune-Based Therapies

Purpose:

Patients with advanced cancer benefit from early involvement of palliative care. The ideal method of palliative care integration remains to be determined, as does its effectiveness for patients treated with targeted and immune-based therapies.

Materials and Methods:

We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic specializing in targeted and immune-based therapies. Patients seen on a specific day accessed the embedded model, on the basis of automatic criteria; patients seen other days could be referred to a separate palliative care clinic (usual care). We abstracted data from the medical records of 114 patients who died during the 3 years after this model’s implementation.

Results:

Compared with usual care (n = 88), patients with access to the embedded model (n = 26) encountered palliative care as outpatients more often ( P = .003) and earlier (mean, 231 v 109 days before death; P < .001). Hospice enrollment rates were similar ( P = .303), but duration was doubled (mean, 57 v 25 days; P = .006), and enrollment > 7 days before death—a core Quality Oncology Practice Initiative metric—was higher in the embedded model (odds ratio, 5.60; P = .034). Place of death ( P = .505) and end-of-life chemotherapy (odds ratio, 0.361; P = .204) did not differ between the two arms.

Conclusion:

A model of embedded and automatically triggered palliative care among patients treated exclusively with targeted and immune-based therapies was associated with significant improvements in use and timing of palliative care and hospice, compared with usual practice.

Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life

Purpose Little is known about the patterns and predictors of the use of end-of-life health care among patients with acute myeloid leukemia (AML). End-of-life care is particularly relevant for older adults with AML because of their poor prognosis. Methods We performed a population-based, retrospective cohort study of patients with AML who were ≥ 66 years of age at diagnosis and diagnosed during the period from 1999 to 2011 and died before December 31, 2012. Medicare claims were used to assess patterns of hospice care and use of aggressive treatment. Predictors of these end points were evaluated using multivariable logistic regression analyses. Results In the overall cohort (N = 13,156), hospice care after AML diagnosis increased from 31.3% in 1999 to 56.4% in 2012, but the increase was primarily driven by late hospice enrollment that occurred in the last 7 days of life. Among the 5,847 patients who enrolled in hospice, 47.4% and 28.8% started their first hospice enrollment in the last 7 and 3 days of life, respectively. Among patients who transferred in and out of hospice care, 62% received transfusions outside hospice. Additionally, the use of chemotherapy within the last 14 days of life increased from 7.7% in 1999 to 18.8% in 2012. Patients who were male and nonwhite were less likely to enroll in hospice and more likely to receive chemotherapy or be admitted to intensive care units at the end of life. Conversely, older patients were less likely to receive chemotherapy or have intensive care unit admission at the end of life, and were more likely to enroll in hospice. Conclusion End-of-life care for older patients with AML is suboptimal. Additional research is warranted to identify reasons for their low use of hospice services and strategies to enhance end-of-life care for these patients.

Goals-of-care discussions

Goals-of-care conversations led by the oncologist are key to advancing the prognostic awareness of the patient and family, but too frequently do not occur or are ineffective in leading to advance care planning and appropriate planning for end-of-life care. At our institution, a phase 3 trial of palliative care added to usual care of phase 1 clinical trial patients gave us the opportunity to develop an electronic medical record-based goals-of-care template for discussions. We can complete all or parts of the form with patients, use it to ensure full coverage of important tasks such as planning for transition to hospice and legacy work, and make sure all the providers are "on the same page" about treatment plans. We have this within our EMR as a SmartPhrase that can be brought up for completion, and have found that it helps to clarify patient understanding. The form can also be used to document advance care planning for both clinical care and billing. Although this tool has not been formally tested, we have found that it is effective in day-to-day practice as well as in research, and we share it here.

End-of-Life Services Among Patients With Cancer: Evidence From Cancer Registry Records Linked With Commercial Health Insurance Claims

PURPOSE

Despite guidelines emphasizing symptom management over aggressive treatment, end-of-life care for persons with cancer in the United States is highly variable. In consultation with a regional collaboration of patients, providers, and payers, we investigated indicators of high-quality end-of-life care to describe patterns of care, identify areas for improvement, and inform future interventions to enhance end-of-life care for patients with cancer.

METHODS

We linked insurance claims to clinical information from the western Washington SEER database. We included persons ≥ 18 years of age who had been diagnosed with an invasive solid tumor between January 1, 2007, and December 31, 2015, and who had a recorded death date, were enrolled in a commercial plan for the last month of life, and made at least one insurance claim in the last 90 days of life.

RESULTS

In the last month of life, among 6,568 commercially insured patients, 56.3% were hospitalized and 48.6% underwent at least one imaging scan. Among patients younger than 65 years of age, 31.4% were enrolled in hospice; of those younger than 65 years of age who were not enrolled in hospice, 40.5% had received an opioid prescription. Over time, opioid use in the last 30 days of life among young adults not enrolled in hospice dropped from 44.7% in the period 2007 to 2009 to 42.5% in the period 2010 to 2012 and to 36.7% in the period 2013 to 2015.

CONCLUSION

Hospitalization and high-cost imaging scans are burdensome to patients and caregivers at the end of life. Our findings suggest that policies that facilitate appropriate imaging, opioid, and hospice use and that encourage supportive care may improve end-of-life care and quality of life.

Why are patients with blood cancers more likely to die without hospice?

BACKGROUND

Although patients with blood cancers have significantly lower rates of hospice use than those with solid malignancies, data explaining this gap in end-of-life care are sparse.

METHODS

In 2015, we conducted a mailed survey of a randomly selected sample of hematologic oncologists in the United States to characterize their perspectives regarding the utility and adequacy of hospice for blood cancer patients, as well as factors that might impact referral patterns. Simultaneous provision of care for patients with solid malignancies was permitted.

RESULTS

We received 349 surveys (response rate, 57.3%). The majority of respondents (68.1%) strongly agreed that hospice care is helpful for patients with hematologic cancers; those with practices including greater numbers of solid tumor patients (at least 25%) were more likely to strongly agree (odds ratio, 2.10; 95% confidence interval, 1.26-3.52). Despite high levels of support for hospice in general, 46.0% felt that home hospice is inadequate for their patients' needs (as compared to inpatient hospice with round-the-clock care). Although more than half of the respondents reported that they would be more likely to refer patients to hospice if red cell and/or platelet transfusions were available, those who considered home hospice inadequate were even more likely to report that they would (67.3% vs 55.3% for red cells [P = .03] and 52.9% vs 39.7% for platelets [P = .02]).

CONCLUSIONS

These data suggest that although hematologic oncologists value hospice, concerns about the adequacy of services for blood cancer patients limit hospice referrals. To increase hospice enrollment for blood cancer patients, interventions tailoring hospice services to their specific needs are warranted. Cancer 2017;123:3377-84. © 2017 American Cancer Society.

Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer

PURPOSE

The benefits of hospice for patients with end-stage disease are well established. Although hospice use is increasing, a growing number of patients are enrolled for ≤ 7 days, a marker of poor quality of care and patient and family dissatisfaction. In this study, we examined variations in referrals among individuals and groups of physicians to assess a potential source of suboptimal hospice use.

METHODS

We conducted a retrospective chart review of 452 patients with advanced cancer referred to hospice from a comprehensive cancer center. We analyzed patient length of service (LOS) under hospice care, looking specifically at median LOS and percent of short enrollments (%LOS ≤ 7), to examine the variation between individual oncologists and divisions of oncologists.

RESULTS

Of 394 successfully referred patients, median LOS was 14.5 days and %LOS ≤ 7 was 32.5%, consistent with national data. There was significant interdivisional variation in LOS, both by overall distribution and %LOS ≤ 7 ( P < .01). In addition, there was dramatic variation in median LOS by individual physician (range, 4 to 88 days for physicians with five or more patients), indicating differences in hospice referral practices between providers (coefficient of variation > 125%). As one example, median LOS of physicians in the Division of Thoracic Malignancies varied from 4 to 33 days, despite similarities in patient population.

CONCLUSION

Nearly one in three patients with cancer who used hospice had LOS ≤ 7 days, a marker of poor quality. There was significant LOS variability among different divisions and different individual physicians, suggesting a need for increased education and training to meet recommended guidelines.

Treatment targeted at underlying disease versus palliative care in terminally ill patients: a systematic review

OBJECTIVE

To assess the efficacy of active treatment targeted at underlying disease (TTD)/potentially curative treatments versus palliative care (PC) in improving overall survival (OS) in terminally ill patients.

DESIGN

We performed a systematic review and meta-analysis of randomised controlled trials (RCT). Methodological quality of included RCTs was assessed using the Cochrane risk of bias tool.

DATA SOURCES

Medline and Cochrane databases were searched, with no language restriction, from inception to 19 October 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Any RCT assessing the efficacy of any active TTD versus PC in adult patients with terminal illness with a prognosis of <6-month survival were eligible for inclusion.

RESULTS

Initial search identified 8252 citations of which 10 RCTs (15 comparisons, 1549 patients) met inclusion criteria. All RCTs included patients with cancer. OS was reported in 7 RCTs (8 comparisons, 1158 patients). The pooled results showed no statistically significant difference in OS between TTD and PC (HR (95% CI) 0.85 (0.71 to 1.02)). The heterogeneity between pooled studies was high (I²=62.1%). Overall rates of adverse events were higher in the TTD arm.

CONCLUSIONS

Our systematic review of available RCTs in patients with terminal illness due to cancer shows that TTD compared with PC did not demonstrably impact OS and is associated with increased toxicity. The results provide assurance to physicians, patients and family that the patients' survival will not be compromised by referral to hospice with focus on PC.

Family Perspectives on Hospice Care Experiences of Patients with Cancer

Purpose To determine whether hospice use by patients with cancer is associated with their families' perceptions of patients' symptoms, goal attainment, and quality of end-of-life (EOL) care. Methods We interviewed 2,307 families of deceased patients with advanced lung or colorectal cancer who were enrolled in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) and died by 2011. We used propensity-score matching to compare family-reported outcomes for patients who did and did not receive hospice care, including the presence and relief of common symptoms (ie, pain, dyspnea), concordance with patients' wishes for EOL care and place of death, and quality of EOL care. We also examined associations between hospice length of stay and these outcomes among hospice enrollees. Results In a propensity-score-matched sample of 1,970 individuals, families of patients enrolled in hospice reported more pain in their patient compared with those not enrolled in hospice. However, families of patients enrolled in hospice more often reported that patients received "just the right amount" of pain medicine (80% v 73%; adjusted difference, 7 percentage points; 95% confidence interval [CI], 1 to 12 percentage points) and help with dyspnea (78% v 70%; adjusted difference, 8 percentage points; 95% CI, 2 to 13 percentage points). Families of patients enrolled in hospice also more often reported that patients' EOL wishes were followed (80% v 74%; adjusted difference, 6 percentage points; 95% CI, 2 to 11 percentage points) and "excellent" quality EOL care (57% v 42%; adjusted difference, 15 percentage points; 95% CI, 11 to 20). Families of patients who received > 30 days of hospice care reported the highest quality EOL outcomes. Conclusion Hospice care is associated with better symptom relief, patient-goal attainment, and quality of EOL care. Encouraging earlier and increased hospice enrollment may improve EOL experiences for patients with cancer and their families.

Barriers to Quality End-of-Life Care for Patients With Blood Cancers

Purpose

Patients with blood cancers have been shown to receive suboptimal care at the end of life (EOL) when assessed with standard oncology quality measures (eg, no chemotherapy ≤ 14 days before death). As they were developed primarily for solid tumors, it is unclear if these measures are appropriate for patients with hematologic malignancies. Moreover, barriers to high-quality EOL care for this specific patient population are largely unknown.

Methods

In 2015, we asked a national cohort of hematologic oncologists about the acceptability of eight standard EOL quality measures. Building on prior qualitative work, we prespecified that measures achieving agreement among at least 55% of respondents would be considered acceptable. We also explored perspectives regarding barriers to quality EOL care.

Results

We received 349 surveys (response rate = 57.3%). Six of the standard measures met the threshold of acceptability, and four were acceptable to > 75% of respondents: hospice admission > 7 days before death, no chemotherapy ≤ 14 days before death, no intubation in the last 30 days of life, and no cardiopulmonary resuscitation in the last 30 days of life. The highest-ranked barriers to quality EOL care reported were “unrealistic patient expectations” (97.3%), “clinician concern about taking away hope” (71.3%), and “unrealistic clinician expectations” (59.0%).

Conclusion

In this large national cohort of hematologic oncologists, standard EOL quality measures were highly acceptable. The top barrier to quality EOL care reported was unrealistic patient expectations, which may be best addressed with more timely and effective advance care discussions.

Exploring the association of hospice care on patient experience and outcomes of care

OBJECTIVE

To examine the association of the use of hospice care on patient experience and outcomes of care. Promoting high-value, safe and effective care is an international healthcare imperative. However, the extent to which hospice care may improve the value of care is not well characterised.

METHODS

A secondary analysis of variations in care was conducted using the Dartmouth Atlas Report, matched to the American Hospital Association Annual Survey Database to abstract organisational characteristics for 236 US hospitals to examine the relationship between hospice usage and a number of variables that represent care value, including hospital care intensity index, hospital deaths, intensive care unit (ICU) deaths, patient satisfaction and a number of patient quality indicators. Structural equation modelling was used to demonstrate the effect of hospice use on patient experience, clinical and efficiency outcomes.

RESULTS

Hospice admissions in the last 6 months of life were correlated with a number of variables, including increases in patient satisfaction ratings (r=0.448, p=0.01) and better pain control (r=0.491, p=0.01), and reductions in hospital days (r=-0.517, p=0.01), fewer hospital deaths (r=-0.842, p=0.01) and fewer deaths occurring with an ICU admission during hospitalisation (r=-0.358, p=0.01). The structural equation model identified that use of hospice care was inversely related to hospital mortality (-0.885) and ICU mortality (-0.457).

CONCLUSIONS

The results of this investigation demonstrate that greater use of hospice care during the last 6 months of life is associated with improved patient experience, including satisfaction and pain control, as well as clinical outcomes of care, including decreased ICU and hospital mortality.

Geriatric assessment factors are associated with mortality after hospitalization in older adults with cancer

PURPOSE

Survival in older adults with cancer varies given differences in functional status, comorbidities, and nutrition. Prediction of factors associated with mortality, especially in hospitalized patients, allows physicians to better inform their patients about prognosis during treatment decisions. Our objective was to analyze factors associated with survival in older adults with cancer following hospitalization.

METHODS

Through a retrospective cohort study, we reviewed 803 patients who were admitted to Barnes-Jewish Hospital's Oncology Acute Care of Elders (OACE) unit from 2000 to 2008. Data collected included geriatric assessments from OACE screening questionnaires as well as demographic and medical history data from chart review. The primary end point was time from index admission to death. The Cox proportional hazard modeling was performed.

RESULTS

The median age was 72.5 years old. Geriatric syndromes and functional impairment were common. Half of the patients (50.4 %) were dependent in one or more activities of daily living (ADLs), and 74 % were dependent in at least one instrumental activity of daily living (IADLs). On multivariate analysis, the following factors were significantly associated with worse overall survival: male gender; a total score <20 on Lawton's IADL assessment; reason for admission being cardiac, pulmonary, neurologic, inadequate pain control, or failure to thrive; cancer type being thoracic, hepatobiliary, or genitourinary; readmission within 30 days; receiving cancer treatment with palliative rather than curative intent; cognitive impairment; and discharge with hospice services.

CONCLUSIONS

In older adults with cancer, certain geriatric parameters are associated with shorter survival after hospitalization. Assessment of functional status, necessity for readmission, and cognitive impairment may provide prognostic information so that oncologists and their patients make more informed, individualized decisions.

Development of a Spanish-Language Hospice Video

The nation faces a persistent issue of delayed access to hospice care. Even though hospice enrollment is considered to be one of the most difficult medical decisions, physician clinics and hospitals lack tools for helping patients/families faced with making decisions about enrollment. Health-care literature lacks discussion of development of decision-making aids in the context of hospice decisions for minority ethnic groups, even though those groups have decisional needs that may differ from those of non-Hispanic whites. To fill the gap, we developed a video of a Latino hospice patient with footages showing how the patient was being taken care of by her family with support from a hospice disciplinary team. A primary objective of this article is to describe how focus groups, existing decision aids, and individual interviews were used to develop and improve a Spanish-language hospice educational video targeting Latino subgroups with linguistic, cultural, and educational barriers. These steps may provide guidelines for developing and revising health-related videos targeting other minority ethnic groups.

A Longitudinal Analysis of Site of Death: The Effects of Continuous Enrollment in Medicare Advantage Versus Conventional Medicare

This study assessed the odds of dying in hospital associated with enrollment in Medicare Advantage (M-A) versus conventional Medicare Fee-for-Service (M-FFS). Data were derived from the 2008 and 2010 waves of the Health and Retirement Study ( n = 1,030). The sample consisted of elderly Medicare beneficiaries who died in 2008–2010 (34% died in hospital, and 66% died at home, in long-term senior care, a hospice facility, or other setting). Logistic regression estimated the odds of dying in hospital for those continuously enrolled in M-A from 2008 until death compared to those continuously enrolled in M-FFS and those switching between the two plans. Results indicate that decedents continuously enrolled in M-A had 43% lower odds of dying in hospital compared to those continuously enrolled in M-FFS. Financial incentives in M-A contracts may reduce the odds of dying in hospital.