Long-term health-care utilisation in older patients with cancer and the association with the Geriatric 8 screening tool: a retrospective analysis using linked clinical and population-based data in Belgium

BACKGROUND

Little evidence is available on the long-term health-care utilisation of older patients with cancer and whether this is associated with geriatric screening results. We aimed to evaluate long-term health-care utilisation among older patients after cancer diagnosis and the association with baseline Geriatric 8 (G8) screening results.

METHODS

For this retrospective analysis, we included data from three cohort studies for patients (aged ≥70 years) with a new cancer diagnosis who underwent G8 screening between Oct 19, 2009 and Feb 27, 2015, and who survived more than 3 months after G8 screening. The clinical data were linked to cancer registry and health-care reimbursement data for long-term follow-up. The occurrence of outcomes (inpatient hospital admissions, emergency department visits, use of intensive care, contacts with general practitioner [GP], contacts with a specialist, use of home care, and nursing home admissions) was assessed in the 3 years after G8 screening. We assessed the association between outcomes and baseline G8 score (normal score [>14] or abnormal [≤14]) using adjusted rate ratios (aRRs) calculated from Poisson regression and using cumulative incidence calculated as a time-to-event analysis with the Kaplan-Meier method.

FINDINGS

7556 patients had a new cancer diagnosis, of whom 6391 patients (median age 77 years [IQR 74-82]) met inclusion criteria and were included. 4110 (64·3%) of 6391 patients had an abnormal baseline G8 score (≤14 of 17 points). In the first 3 months after G8 screening, health-care utilisation peaked and then decreased over time, with the exception of GP contacts and home care days, which remained high throughout the 3-year follow-up period. Compared with patients with a normal baseline G8 score, patients with an abnormal baseline G8 score had more hospital admissions (aRR 1·20 [95% CI 1·15-1·25]; p<0·0001), hospital days (1·66 [1·64-1·68]; p<0·0001), emergency department visits (1·42 [1·34-1·52]; p<0·0001), intensive care days (1·49 [1·39-1·60]; p<0·0001), general practitioner contacts (1·19 [1·17-1·20]; p<0·0001), home care days (1·59 [1·58-1·60]; p<0·0001), and nursing home admissions (16·7% vs 3·1%; p<0·0001) in the 3-year follow-up period. At 3 years, of the 2281 patients with a normal baseline G8 score, 1421 (62·3%) continued to live at home independently and 503 (22·0%) had died. Of the 4110 patients with an abnormal baseline G8 score, 1057 (25·7%) continued to live at home independently and 2191 (53·3%) had died.

INTERPRETATION

An abnormal G8 score at cancer diagnosis was associated with increased health-care utilisation in the subsequent 3 years among patients who survived longer than 3 months.

FUNDING

Stand up to Cancer, the Flemish Cancer Society.

End-of-Life Care in the Last Three Months before Death in Older Patients with Cancer in Belgium: A Large Retrospective Cohort Study Using Data Linkage

This study aims to describe end-of-life (EOL) care in older patients with cancer and investigate the association between geriatric assessment (GA) results and specialized palliative care (SPC) use. Older patients with a new cancer diagnosis (2009-2015) originally included in a previous multicentric study were selected if they died before the end of follow-up (2019). At the time of cancer diagnosis, patients underwent geriatric screening with Geriatric 8 (G8) followed by GA in case of a G8 score ≤14/17. These data were linked to the cancer registry and healthcare reimbursement data for follow-up. EOL care was assessed in the last three months before death, and associations were analyzed using logistic regression. A total of 3546 deceased older patients with cancer with a median age of 79 years at diagnosis were included. Breast, colon, and lung cancer were the most common diagnoses. In the last three months of life, 76.3% were hospitalized, 49.1% had an emergency department visit, and 43.5% received SPC. In total, 55.0% died in the hospital (38.5% in a non-palliative care unit and 16.4% in a palliative care unit). In multivariable analyses, functional and cognitive impairment at cancer diagnosis was associated with less SPC. Further research on optimizing EOL healthcare utilization and broadening access to SPC is needed.

Linking clinical and population-based data in older patients with cancer in Belgium: Feasibility and clinical outcomes

INTRODUCTION

Geriatric screening and geriatric assessment (GS/GA) have proven their benefits in the care for older patients with cancer. However, less is known about the predictive value of GS/GA for outcomes. To research this, clinical data on GS/GA can be enriched with population-based data. In this article we describe the methods and feasibility of data linkage, and first clinical outcomes (GS/GA results and overall survival).

MATERIALS AND METHODS

A large cohort study consisting of patients aged ≥70 years with a new cancer diagnosis was established using linked data from clinical and population-based databases. Clinical data were derived from a previous prospective study where older patients with cancer were screened with G8, followed by GA in case of an abnormal result (GS/GA study; 2009-2015). These data were linked to cancer registration data from the Belgian Cancer Registry (BCR), reimbursement data of the health insurance companies (InterMutualistic Agency, IMA), and hospital discharge data (Technical Cell, TCT). Cox regression analyses were conducted to evaluate the prognostic value of the G8 geriatric screening tool.

RESULTS

Of the 8067 eligible patients with a new cancer diagnosis, linkage of data from the GS/GA study and data from the BCR was successful for 93.7%, resulting in a cohort of 7556 patients available for the current analysis. Further linkage with the IMA and TCT database resulted in a cohort of 7314 patients (96.8%). Based on G8 geriatric screening, 67.9% of the patients had a geriatric risk profile. Malnutrition and functional dependence were the most common GA-identified risk factors. An abnormal baseline G8 score (≤14/17) was associated with lower overall survival (adjusted HR [aHR] = 1.62 [1.50-1.75], p < 0.001).

DISCUSSION

Linking clinical and population-based databases for older patients with cancer has shown to be feasible. The GS/GA results at cancer diagnosis demonstrate the vulnerability of this population and the G8 score showed prognostic value for overall survival. The established cohort of almost 8000 patients with long-term follow-up will serve as a basis in the future for detailed analyses on long-term outcomes beyond survival.

Functional status in older patients with cancer and a frailty risk profile: A multicenter observational study

INTRODUCTION

Functional status (FS) and frailty are significant concerns for older adults, especially those with cancer. Data on FS (Activities of Daily Living [ADL]; Instrumental Activities of Daily Living [IADL]) and its evolution during cancer treatment in older patients and a frailty risk profile are scarce. Therefore, this study examines FS and its evolution in older patients with cancer and a frailty risk profile and investigates characteristics associated with functional decline.

MATERIAL AND METHODS

This secondary data-analysis, focusing on FS, uses data from a large prospective multicenter observational cohort study. Patients ≥70 years with a solid tumor and a frailty risk profile based on the G8 screening tool (score ≤ 14) were included. A geriatric assessment was performed including evaluation of FS based on ADL and IADL. At approximately three months of follow-up, FS was reassessed. Univariable and multivariable logistic regression analyses were used to identify predictive factors for functional decline in ADL and IADL.

RESULTS

Data on ADL and IADL were available at baseline and follow-up in 3388 patients. At baseline 1886 (55.7%) patients were dependent for ADL, whereas 2085 (61.5%) patients were dependent at follow-up. Functional decline was observed in 23.6% of patients. For IADL 2218 (65.5%) patients were dependent for IADL, whereas 2591 (76.5%) patients were dependent at follow-up. Functional decline in IADL was observed in 41.0% of patients. In multivariable analysis, disease stage III or IV, comorbidities, falls history in the past twelve months, and FS measured by IADL were predictive factors for functional decline in both ADL and IADL. Other predictive factors for functional decline in ADL were polypharmacy, Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) score 2-4, and cognitive impairment, and for functional decline in IADL were female sex, fatigue, and risk for depression.

DISCUSSION

Functional impairments are frequent in older persons with cancer and a frailty risk profile, and several characteristics are identified that are significantly associated with functional decline. Therefore, FS is an essential part of the geriatric assessment which should be standard of care for this patient population. Next step is to proceed with directed interventions with the aim to limit the risk of functional decline as much as possible.

General practitioner contacts, hospitalizations, and nursing home transfers in older patients up to three years after new cancer diagnosis: Results from a large data linkage cohort study

12041

Background: Long-term outcomes after cancer diagnosis in older persons are largely unexplored because of limited follow-up in clinical studies. By linking clinical data with population-based data, studying long-term outcomes in large cohorts becomes feasible. The current study aims to explore long-term outcomes in the care trajectory of older patients with cancer and to assess their association with baseline geriatric screening and assessment (GS/GA) results. Methods: A large cohort study of older patients with a new cancer diagnosis was set up by linking clinical, cancer registry and administrative health data based on a unique patient identifier. Clinical data were derived from a previously performed prospective multicentric Belgian study (2009-2015). Patients aged ≥ 70 years were screened with G8 followed by GA in case of an abnormal result (≤14/17). Tumor characteristics and vital status were derived from cancer registry data and long-term outcomes (general practitioner (GP) contacts, hospitalizations and nursing home transfers) from administrative health data. In patients that survived at least 3 months since inclusion, outcomes were assessed from the day after inclusion until 3 years after. Event rates were calculated using person-time at risk to allow for varying follow-up time. Patients were censored 3 months before death to exclude influence of end-of-life care. Results: After data linkage, 6,391 older patients with a new cancer diagnosis were available for this analysis. The median age was 77 (range: 70–100) and 59.8% was female. Diagnoses included solid (92.8%) and hematologic malignancies (7.2%). In the patients with a solid tumor, breast, colorectal and lung cancer were the most common and 20.1% of patients had stage IV. 64.3% of patients had an abnormal baseline G8 score. During the 3 year follow-up, 2,602 (40.7%) of the included patients died. In these 3 years, 5,985 (95.2%) patients had at least one contact with a GP and 4,634 (72.5%) had at least one new hospital admission (event rates in Table 1). Of the 3,724 patients living independently at inclusion and still alive after 3 years, 281 (7.5%) had been transferred to a nursing home and of those, 240 (85.4%) patients had an abnormal baseline G8 score. Conclusions: Older patients with an abnormal baseline G8 score have more GP contacts, hospital admissions and nursing home transfers in the 3 years following a new cancer diagnosis compared to patients with normal baseline G8 score. Baseline G8 could help identify patients at risk for higher long-term healthcare utilization.[Table: see text]

The added value of geriatric assessment in evaluating a patient's Health-Related Quality-of-Life: A study in ≥70-year-old early-stage invasive breast cancer patients

OBJECTIVE

The objective of this study was to assess the relationship between geriatric assessment (GA) and health-related Quality-of-Life (HRQOL) in older patients with breast cancer.

METHODS

Patients were assigned either to adjuvant chemotherapy (CTG) or to a control group (CG). Spearman rank coefficients (ρ) calculated correlations between HRQOL and GA at baseline, 3 months and 1 year. Multivariate regressions modelled the prognostic value of GA in evaluating of a patient's HRQOL and the accuracy of baseline GA in predicting HRQOL decline (change of ≥10 points).

RESULTS

The analysis included 57 patients in the CTG and 52 in the CG. Strong correlations (ρ ≥ 0.5) were reported between the EORTC QLQ-C30 Physical Functioning Scale and Activities of Daily Living (ADL), Instrumental ADL (iADL) and Leuven Oncogeriatric Frailty Score Scale (LOFS). Multivariate models demonstrated that poor iADL, ADL and LOFS (CG) and ADL and iADL (CTG) contributed to a statistically (all p < .05) worse HRQOL. The relative gain in predicting 3-month and 1-year HRQOL decline was 24.1% and 4.7% (CG) and 6.1% and 18.3% (CTG).

CONCLUSION

Our results show that the functional measures in the GA are strongly correlated with patient self-reported functioning. Poor baseline GA has a modest probability of predicting HRQOL deterioration.

Adherence to geriatric assessment (GA)-based recommendations in older patients (pts) with cancer

10010

Background: In the general older population, GA-guided treatment plans improve overall survival, quality of life and functional status. In geriatric oncology, studies mainly focused on screening and assessment but not on geriatric interventions and follow-up. The aim of this study was to investigate the adherence to recommendations and subsequent interventions based on GA results in older pts with cancer. Methods: A prospective Belgian multicenter (n = 22) cohort study included pts ≥70 years with a malignant tumor when an oncological treatment decision had to be made. Pts with an abnormal G8 (≤14/17) underwent GA and were included in this study. Recommendations for interventions were formulated based on GA results. At follow-up adherence to GA-based recommendations was documented. Results: From 11-2012 till 2-2015, G8 screening was performed in 8451 pts. 5838 pts with an abnormal G8 were included in the study. Geriatric recommendations were given in 79.2% of pts with a median of 2/pt (range 0-10), most frequently consultation of a dietician (73%) for malnutrition, a social worker (54.8%) for social and functional status problems and a geriatrician (42.1%) for general geriatric problems. Follow-up data were available for 4167 pts. In the group of pts where recommendations were given, at least one intervention was performed in 69% with a median of 1/pt (range 0-6), most frequently dietician (43.4%), social worker (26.1%) and geriatrician (22.6%). A total of 7569 actions were undertaken for a total of 5725 geriatric recommendations. Recommendations were most frequently adhered to for malnutrition, social status and functional status problems. The most frequent actions undertaken were nutritional support and supplements, extended home care and psychological support. Conclusions: This large scale Belgian study focusses on the adherence to GA based interventions in older pts with cancer and contributes to the optimization of care for these pts. We identified the domains for which geriatric interventions are most frequently recommended and adhered to and which health care professionals and referrals are essential in the multidisciplinary approach of older pts with cancer.