Importance: Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare.
Objective: To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life.
Design, Setting, and Participants: This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual’s last month of life. Analysis was conducted in July 2020.
Exposures: MA enrollment at the time of death or before hospice enrollment.
Main Outcomes and Measures: Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score–weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month.
Results: Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001).
Conclusions and Relevance: In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.
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.
Objectives: We evaluated healthcare cost differences at the end of life (EOL) between language regions in Switzerland, accounting for a comprehensive set of variables, including treatment intensity.
Methods: We evaluated 9716 elderly who died in 2014 and were insured at Helsana Group, with data on final cause of death provided by the Swiss Federal Statistical Office. EOL healthcare costs and utilization, = 1 ICU admission and 10 life-sustaining interventions (cardiac catheterization, cardiac assistance device implantation, pulmonary artery wedge monitoring, cardiopulmonary resuscitation, gastrostomy, blood transfusion, dialysis, mechanical ventilation, intravenous antibiotics, cancer chemotherapies) reimbursed by compulsory insurance were examined.
Results: Taking into consideration numerous variables, relative cost differences decreased from 1.27 (95% CI 1.19–1.34) to 1.06 (CI 1.02–1.11) between the French- and German-speaking regions, and from 1.12 (CI 1.03–1.22) to 1.08 (CI 1.02–1.14) between the Italian- and German-speaking regions, but standardized costs still differed. Contrary to individual factors, density of home-care nurses, treatment intensity, and length of inpatient stay explain a substantial part of these differences.
Conclusions: Both supply factors and health-service provision at the EOL vary between Swiss language regions and explain a substantial proportion of cost differences.
OBJECTIVE: To determine factors associated with the utilization of palliative care (PC) in patients with metastatic gynecologic cancer who died while hospitalized.
METHODS: Data were abstracted from the National Inpatient Sample database for patients with cervical, uterine, and ovarian cancers from 2005 to 2011. Chi-squared and logistic regression models were used for statistical analyses.
RESULTS: Of 4559 women (median age: 65 years; range: 19-102), 1066 (23.4%) utilized PC. Patients were 24.9% low socioeconomic status (SES), 23.9% low-middle, 23.7% middle-high, and 25.1% high SES. Medicare, Medicaid, and private insurance coverage were listed at 46.2%, 37.5%, 11.3% of patients; 36.2%, 21.1%, 18.1%, 24.6% were treated in the South, West, Midwest, and Northeast. Over the 7 year study period, the use of PC increased from 12% to 45%. Older age (odds ratio [OR]: 1.36; 95% CI: 1.11-1.68; P = .003), high SES (OR: 1.41; 95% CI: 1.12-1.78; P = .003), more recent treatment (OR: 9.22; 95% CI: 6.8-12.51; P < .0001), private insurance (OR: 1.81; 95% CI: 1.46-2.25; P < .001), and treatment at large-volume hospitals (OR: 1.36; 95% CI: 1.04-1.77; P = .02), Western (OR: 2.00; 95% CI: 1.61-2.49; P < .001) and Midwestern hospitals (OR: 1.35; 95% CI: 1.08-1.68; P = .001) were associated with higher utilization of PC.
CONCLUSIONS: The use of inpatient PC for patients with gynecologic cancer increased over time. The lower utilization of PC for terminal illness was associated with younger age, lower SES, government-issued insurance coverage, and treatment in Southern and smaller volume hospitals, and warrants further attention.
Hospice is central to end-of-life care. Yet to receive hospice services, Medicare beneficiaries need to forgo treatments related to their terminal conditions. Thus, patients with cancer cannot receive radiotherapy or chemotherapy, such as single-fraction radiotherapy for painful bone metastasis, for palliative purposes. To alleviate this constraint, some hospices have developed open-access programs that allow patients to receive care for their terminal conditions. These hospices, however, encounter an increase in costs without an accompanying increase in reimbursement. In 2016, the Centers for Medicare & Medicaid Services initiated the Medicare Care Choices Model (MCCM), which allows participating hospices to provide care for beneficiaries’ terminal conditions and receive a higher payment rate. Despite this, very few hospices participate in the MCCM. To date, little is known about trends in hospices providing palliative radiotherapy and chemotherapy. This topic is particularly important now, as hospices may be reluctant to provide new, expensive immunotherapies.
Objective: To describe trends in hospice social work visits in the last week of life before and after the introduction of the service intensity add-on (SIA) payment reform in 2016.
Background: SIA was introduced to compensate hospices for the intensity of caring for individuals at the end of life; it is an hourly rate paid for registered nurse and social worker visits occurring during the last week of a beneficiary's life. Little is known about how hospices responded to this payment incentive.
Design: This is a pre-post descriptive study.
Setting/Subjects: Subjects were 2015–2016 hospices caring for Medicare beneficiaries.
Results: We find a modest increase in social work visits in the last week of life from 2015 (pre-SIA) to 2016 (post-SIA). This modest increase masks significant variation based on organizational characteristics, such as size, facility type, and participation in payment demonstrations.
Discussion: Our findings underscore the importance of examining both the overall impact of this type of policy and the change in distribution to identify whether change is being realized uniformly or is associated with certain types of organizations. A number of potential barriers exist to responding to policy incentives that may not be evenly felt across the hospice community.
PURPOSE: Although rates of hospice use have increased over time, insurance plan- and racial/ethnic-based disparities in rates have been reported in the USA. We hypothesized that increased rates of hospice use would reduce or eliminate insurance plan-based disparities and that racial/ethnic disparities would be eliminated in managed care (MC) insurance plans.
METHODS: We studied the use of hospice care in the final 30 days of life among 40,184 elderly Texas Medicare beneficiaries who died from primary breast, colorectal, lung, pancreas, or prostate cancer between January 1, 2007 and December 31, 2013, using statewide Medicare claims linked to cancer registry data. Rates of hospice use were computed by race/ethnicity and insurance plan (MC or fee-for-service (FFS)). We used logistic regression to account for the impact of confounding factors.
RESULTS: Rates of hospice use increased significantly over time, from 68.9% in 2007 to 76.1% in 2013. By 2013, differences in hospice use rates between MC and FFS plans had been reduced from 10% to < 5%. However, after accounting for insurance plan and confounding factors, racial/ethnic minority beneficiaries' hospice use was significantly lower than non-Hispanic white beneficiaries' (p < 0.0001). This disparity was observed among both FFS and MC beneficiaries.
CONCLUSIONS: Hospice use in the final 30 days of life has increased among elderly cancer patients in Texas, virtually eliminating the difference between FFS and MC insurance plans. Despite these positive trends, racial/ethnic-based disparities persist. These disparities are not explained by confounding factors. Future research should address social and behavioral influences on end-of-life decisions.
BACKGROUND: In Denmark, a tax-based universal healthcare setting, drug reimbursement for terminal illness (DRTI) should be equally accessible for all terminally ill patients. Examining DRTI status by regions provides new knowledge on inequality in palliative care provision and associated factors. This study aims to investigate geographical variation in DRTI among terminally ill cancer patients.
METHODS: We linked socioeconomic and medical data from 135 819 Danish cancer decedents in the period 2007-15 to regional healthcare characteristics. We analyzed associations between region of residence and DRTI. Prevalence ratios (PR) for DRTI were estimated using generalized linear models adjusted for patient factors (age, gender, comorbidity and socioeconomic profile) and multilevel models adjusted for both patient factors and regional healthcare capacity (patients per general practitioner, numbers of hospital and hospice beds).
RESULTS: DRTI allocation differed substantially across Danish regions. Healthcare capacity was associated with DRTI with a higher probability of DRTI among patients living in regions with high compared with low hospice bed supply (PR 1.13, 95% CI 1.10-1.17). Also, the fully adjusted PR of DRTI was 0.94 (95% CI 0.91-0.96) when comparing high with low number of hospital beds. When controlled for both patient and regional healthcare characteristics, the PR for DRTI was 1.17 (95% CI 1.14-1.21) for patients living in the Central Denmark Region compared with the Capital Region.
CONCLUSION: DRTI status varied across regions in Denmark. The variation was associated with the distribution of healthcare resources. These findings highlight difficulties in ensuring equal access to palliative care even in a universal healthcare system.
PURPOSE: To examine quality indicators of end-of-life (EOL) care among privately insured people with cancer in Brazil.
METHODS: We evaluated medical records linked to health insurance databank to study consecutive patients who died of cancer. We collected information about demographics, cancer type, and quality indicators of EOL care including emergency department (ED) visits, intensive care unit (ICU) admissions, chemotherapy use, medical imaging utilization, blood transfusions, home care support, days of inpatient care, and hospital deaths.
RESULTS: We included 865 patients in the study. In the last 30 days of life, 62% visited the ED, 33% were admitted to the ICU, 24% received blood transfusions, and 51% underwent medical imaging. Only 1% had home care support in the last 60 days of life, and 29% used chemotherapy in the last 14 days of life. Patients had an average of 8 days of inpatient care and 52% died in the hospital. Patients with advanced cancer who used chemotherapy were more likely to visit the ED (78% vs 59%; P < .001), undergo medical imaging (67% vs 51%; P < .001), and die in the hospital (73% vs 50%; P = .03) than patients who did not use chemotherapy. In the multivariate analysis, chemotherapy use near death and advanced cancer were associated with ED visits and ICU admissions, respectively (odds ratio >1).
CONCLUSION: Our study suggests that privately insured people with cancer receive poor quality EOL care in Brazil. Further research is needed to assess the impact of improvements in palliative care provision in this population.
CONTEXT: Chronic pain (CP) is a major concern in cancer survivors. Often underreported by patients, it is both under-assessed and undertreated by care providers.
OBJECTIVES: To assess CP prevalence and related treatment in cancer survivors five years after diagnosis; to identify factors associated with prescribing opioids among survivors with CP, focusing on access to palliative care (PC).
METHODS: In 2015-2016, we interviewed 4,174 French patients diagnosed with cancer five years previously. Combining patient and clinical reported outcomes together with medico-administrative data, we studied factors associated with Step II and Step III opioid prescription in cancer survivors with CP. We performed multinomial logistic regression adjusting for various covariates, including self-reported health status variables and inpatient PC.
RESULTS: Five years after cancer diagnosis, 63.5% of the respondents reported current chronic pain (CP) (i.e., pain = 3 months). Of these, 64.6% and 14.4% were prescribed at least one Step II or Step III opioid, respectively. Only 1.9% had had inpatient PC since diagnosis. After adjustment for age, gender, clinical and self-reported variables, we found that the latter were more likely to receive Step III opioids (adjusted Relative Risk ratio: 5.33; 95% CI: 1.15, 24.58).
CONCLUSIONS: This study showed a high prevalence of CP five years after cancer diagnosis. Step III opioids were underprescribed but positively associated with inpatient PC. PC access in France remains limited, especially among cancer survivors. Integrating PC in oncology is essential to provide the best cancer-related symptoms management.
At the end of life, patients with cancer can continue to require intensive intervention to alleviate symptoms. When enrolled in hospice, however, they may find expensive treatment modalities, even those administered with palliative intent, inaccessible. This is because current reimbursement artificially divides the continuum of disease management into arbitrary phases of care: Medicare parts A, B and D for curative therapy and the Medicare Hospice Benefit for hospice care. The mechanism of reimbursement can disproportionately dictate availability and access to certain types of care. This is problematic because some treatment modalities (eg, diuretics for heart failure) can span both phases, and many palliative therapies have been empirically shown to improve quality of life and lengthen life. We use palliative radiotherapy as an example to illustrate some of the unintended consequences of this approach.
OBJECTIVE: To determine factors influence place of death (POD) for end-stage cancer patients and investigate how the healthcare utilization mediates on the effect of socioeconomic status (SES) on POD.
DESIGN: A population-based, retrospective study from July 2015 to June 2017.
SETTING: Yichang, China.
PARTICIPANTS: 894 end-stage cancer patients.
MAIN OUTCOME MEASURE: POD.
RESULTS: Patients of hospital death experience more inpatient hospitalization services (IHS) and emergency department visits. Patients enrolled in the New Rural Cooperative Medical Scheme (OR = 7.60, P < 0.001) and Urban Employee Basic Medical Insurance (OR = 28.0, P < 0.001) have higher rates of hospital death than those in the Urban Resident-based Basic Medical Insurance. Living with spouse (OR = 1.72, P = 0.019) and receiving higher education (OR = 1.92, P = 0.004), increase the likelihood of hospital death by 72% and 92%, respectively. The probability of hospital death will increase by 14% and decrease by 4% per IHS and outpatient services occur, respectively. Outpatient services (Z = -2.28, P < 0.001), and IHS (Z = 2.17, P < 0.001) mediate 1.81% and 1.89%, respectively, of the effect of health insurance on POD. The overall effect of the mediators is non-statistically significant (Z = 0.09, P = 0.825).
CONCLUSION: POD is mainly driven by SES. The relationship between health insurance and POD is partly mediated by outpatient services and IHS, respectively. The results corroborated that hospital and home services should be coherently bridged. Furthermore, benefit packages for end-stage cancer patients could be redesigned.
Context: Internationally, a variety of reimbursement systems exists for palliative care (PC). In Germany, PC units (PCUs) may choose between per-diem rates and diagnosis-related groups (DRGs). Both systems are controversially discussed.
Objectives: To explore the experiences and views of German PCU clinicians and experts for PCU financing regarding per-diem rates and DRGs as reimbursement systems with a focus on (1) cost coverage, (2) strengths and weaknesses of both financing systems, and (3) options for further development of funding PCUs.
Design: Qualitative semistructured interviews with PCU clinicians and experts for PCU financing, analyzed by thematic analysis using the Framework approach.
Setting/Subjects/Measurements: Ten clinicians and 13 experts for financing were interviewed June-October 2015 on both reimbursement systems for PCU.
Results: Interviewees had divergent experiences with both reimbursement systems regarding cost coverage. A described strength of per-diem rates was the perceived possibility of individual care without direct financial pressure. The nationwide variation of per-diem rates and the lack of quality standards were named as weaknesses. DRGs were criticized for incentives perceived as perverse and inadequate representation of PC-specific procedures. However, the quality standards for PCUs required within the German DRG system were described as important strength. Suggestions for improvement of the funding system pointed toward a combination of per-diem rates with a grading according to disease severity/complexity of care.
Conclusions: Expert opinions suggest that neither current DRGs nor per-diem rates are ideal for funding of PCUs. Suggested improvements regarding adequate funding of PCUs resemble and supplement international developments.
Background: In 2004, Aetna, a national health insurer, launched the Aetna Compassionate Care Program (ACCP) targeting members diagnosed with an advanced illness with a view to increase access to palliative care and hospice services.
Objective: The objective of this study is to evaluate the impact of ACCP on health care utilization and hospice enrollment among enrolled members.
Methods: This was a retrospective cohort study comparing participants in ACCP to a matched control group using a propensity score method. The study group consisted of Aetna Medicare Advantage members who participated in the ACCP between January 2014 and June 2015. Potential control group members were those who were not identified by the predictive model nor were referred to the ACCP program through other means. The primary outcomes of interest were hospice use measured as percent of members electing hospice and median number of days in hospice; health care utilization and medical costs measured as rates and medical costs associated with acute inpatient admissions, emergency room, primary care, and specialty visits in the 30 and 90 days before death.
Results: Participants in the ACCP program were 36% more likely to enroll in hospice (79% vs. 58%, p < 0.0001) and had reduced acute inpatient medical costs ($4169 vs. $5863, p < 0.0001) driven primarily by fewer inpatient admissions (860 vs. 1017, p < 0.0001) in the last 90 days of life.
Conclusions: Advanced illness case management programs such as ACCP can improve access to hospice and improve patient outcomes while reducing unnecessary admissions in the last 90 days of life.
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: 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 in 12 southeastern cancer centers between 2012-2015. 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 3 days of death). Relative risks (RR) and 95% confidence intervals 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, 4,142 (33%) did not utilize hospice. "No hospice" was associated with non-white (RR 1.24, 95% CI 1.17, 1.32) and non-navigated 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=1,458) 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).
CONCLUSION: Hospice utilization differed by patient and hospital characteristics. Patients who were non-white, and non-navigated; 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.
OBJECTIVES: Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage.
DESIGN: Observational cohort study using seven waves of post-death interview data (2002-2014).
PARTICIPANTS: Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death.
MEASUREMENTS AND MAIN RESULTS: Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744-15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.
CONCLUSIONS: Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.
Objective This study aimed to define the end-of-life (EOL) healthcare utilisation and its cost and determinants for cancer patients and to proactively inform related strategies in mainland China.
Design A population-based retrospective study.
Setting and participants Data from 894 cancer patients were collected in urban Yichang, China from 01 July 2015 to 30 June 2017.
Outcome measures Emergency department (ED) visits, outpatient and inpatient hospitalisation services, intensive care unit (ICU) admission and total costs were used as the main outcomes.
Results In this study, 66.8% of the 894 patients were male, and the average age was 60.4 years. Among these patients, 37.6% died at home, and patients had an average of 4.86 outpatient services, 2.23 inpatient hospitalisation services and 1.44 ED visits. Additionally, 5.9% of these patients visited the ICU at least once. During the EOL periods, the costs in the last 6 months, 3 months, 1 month and 1 week were US$18 234, US$13 043, US$6349 and US$2085, respectively. The cost increased dramatically as death approached. The estimation results of generalised linear regression models showed that aggressive care substantially affected expenditure. Patients with Urban Employee Basic Medical Insurance spent more than those with Urban Resident-based Basic Medical Insurance or the New Rural Cooperative Medical Scheme. The place of death and the survival time are also risk factors for increased EOL cost.
Conclusion The findings suggested that the EOL cost for cancer patients is associated with aggressive care, insurance type and survival time. Timing palliative care is urgently needed to address ineffective and irrational healthcare utilisation and to reduce costs.
Ethics and dissemination This study was approved by the Ethics Committee of the Tongji Medical College, Huazhong University of Science and Technology (IORG No.: IORG0003571). All the data used in this study were de-identified.
Background In Denmark, patients who are terminally ill have the right to drug reimbursement due to terminal illness (DRTI). DRTI, a proxy marker of planned end-of-life care, is intended to be equally accessible regardless of socioeconomic position. This study examined social and socioeconomic differences in DRTI among Danish patients who are terminally ill.
Methods This cross-sectional study based on individual-level nationwide data included all patients dying from cancer, dementia, ischaemic heart disease, chronic obstructive pulmonary disease, chronic liver disease, congestive heart failure, diabetes or stroke in 2006–2015 (n=307 188). We analysed associations between social and socioeconomic position (education, income, cohabiting status, migrant status and employment) and DRTI. Prevalence ratios (PR) and 95% CIs were estimated using log-linear models adjusted for age, gender, comorbidity, cause of death and residence.
Results Overall, 27.9% of patients received DRTI (n=85 616). A substantial difference in likelihood of receiving DRTI was observed among patients with a social and socioeconomic profile associated with the highest versus lowest probability of DRTI (adjusted PR 1.44, 95% CI 1.18 to 1.75). The probability of DRTI was higher among patients with high income compared with low income (adjusted PR 1.22, 95% CI 1.17 to 1.26). Also, living with a partner and being immigrant or descendant of such were associated with higher probability of DRTI compared with living alone and of Danish origin, whereas employment was associated with lower probability of DRTI compared with retirement.
Conclusion Social and socioeconomic position was associated with the likelihood of receiving DRTI, which indicates that planned end-of-life care is not equally accessible in Denmark.
Comment indemniser un deuil pathologique qui trouve sa source directe et exclusive dans la mort d'un proche consécutive à une faute médicale ? Est-on en présence d'un préjudice d'affection ou d'un dommage corporel dans sa dimension psychique qui pourrait avoir des conséquences patrimoniales ou extrapatrimoniales ? C'est sur cette épineuse et douloureuse question que le tribunal administratif d'Amiens s'est prononcé par deux jugements, l'un du 27 avril 2017 et l'autre du 29 décembre 2017. Si le tribunal s'est prononcé en faveur de l'indemnisation de ce deuil, suivant ainsi les conclusions du rapporteur public Anne Khater, sa justification juridique ébranle le cadre traditionnel de la jurisprudence administrative comme le met en lumière le commentaire de Madame Alice Minet-Leleu. (R.A.).
Origine : BDSP. Notice produite par EHESP R0xDqjAp. Diffusion soumise à autorisation
Background: The American Society of Clinical Oncology's recommendation for "dedicated palliative care services, early in the disease course, concurrent with active treatment" for cancer patients is a challenge for cancer centers to accommodate. Despite demonstrated benefits of concurrent care, disparities among socioeconomic and ethnic groups in access to supportive care services have been described. The aim of this project was to evaluate: (a) how insurance coverage and ethnicity impact patient symptom burden and, (b) how those factors influence palliative access for patients at a South Texas NCI-designated cancer center. Methods: During a 5-month prospective period, 604 patients from five ambulatory oncology clinics completed the 10 question Edmonton Symptom Assessment Scale (ESAS) surveys during their clinic visit. Patient demographics, ESAS scores, palliative referral decisions, and time to palliative encounters were collected. We compared symptom burden and time to consult based on ethnicity and insurance status (insured = Group A; under-insured and safety net = Group B). Results: The mean ESAS score for all patients at the initial visit was 19.9 (SD = 18.1). Safety net patients were significantly more likely to be Hispanic, younger in age, and have an underlying GI malignancy in comparison to insured patients; however, the symptom severity was similar between groups with over 40% of individuals reporting at least one severe symptom. Twenty-one referrals were made to palliative care. On average, Group B had 33.3 days longer wait times until their first potential visit (p < 0.01) when compared to Group A. Time to actual visit was on average 57.6 days longer for patients in Group B compared to patients in Group A (p = 0.01), averaging at 73.8 days for safety net patients.
Conclusions: This project highlights the high symptom burden of oncology patients and disparities in access to services based on insurance coverage. This investigation revealed a 4-fold increase in the time to the first scheduled palliative care visit based on whether patients were insured vs. under-insured. While this study is limited by a small sample size, data suggest that under-insured oncology patients may have significant barriers to palliative care services, which may influence their cancer care quality.