Introduction: It has been suggested that palliative care integrated into standard cancer treatment from the early phase of the disease can improve the quality of life of patients with cancer. In this paper, we present the protocol for a multicentre randomised controlled trial to examine the effectiveness of a nurse-led, screening-triggered, early specialised palliative care intervention programme for patients with advanced lung cancer.
Methods and analysis: A total of 206 patients will be randomised (1:1) to the intervention group or the control group (usual care). The intervention, triggered with a brief self-administered screening tool, comprises comprehensive need assessments, counselling and service coordination by advanced-level nurses. The primary outcome is the Trial Outcome Index of the Functional Assessment of Cancer Therapy (FACT) at 12 weeks. The secondary outcomes include participants’ quality of life (FACT-Lung), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), illness perception (Prognosis and Treatment Perceptions Questionnaire), medical service use and survival. A mixed-method approach is expected to provide an insight about how this intervention works.
Ethics and dissemination: This study has been approved by the Institutional Review Board of the National Cancer Center Japan (approval number: 2016-235). The findings will be disseminated through peer-reviewed publications and conference presentations and will be reflected on to the national healthcare policy.
Trial registration number UMIN000025491.
INTRODUCTION: Current research on prostate cancer is heavily focused on early detection and new treatments. There is a lack of research on the overall morbidity prostate cancer survivors face and the amount of healthcare treatment they receive toward the end of their lives. Identifying these care needs will allow appropriate healthcare modeling, resource allocation and service re-design to ensure higher quality care toward the end of life. The aim of this study is to quantify and analyze the use of healthcare services by patients dying with but not necessarily of prostate cancer.
METHODS: All patients who died with a diagnosis of prostate cancer during a 2-year period at a single hospital were included. Data on outpatient attendances, elective and emergency admissions and palliative care involvement in the 12 months prior to death were collected.
RESULTS: A total of 77 patients were included and of these, 60 (78.0%) had 545 scheduled appointments with 473 (86.8%) attendances. More non-attendances occurred in the last 6 months of life; 56 vs 16, p < 0.001. Nurse led clinics doubled in the last 6 months of life, 117 vs 66. There were 173 admissions from 63 (81.8%) patients resulting in 1816 days inpatient stay. This averaged to 2.7 admissions per patient for 10.5 days per episode. 32 (41.6%) patients were seen by palliative care resulting in 192 visits in total. 78 (40.6%) were inpatient and 114 (59.4%) were community reviews.
CONCLUSIONS: In the last year of life, prostate cancer patients use a considerable amount of healthcare resources. Understanding this clinical and economical burden is important for healthcare remodeling to provide better quality care that is cost effective.
Background: With increasing cost of healthcare in our aging society, a consistent pain point is that of end-of-life care. It is particularly difficult to prognosticate in non-cancer patients, leading to more healthcare utilisation without improving quality of life. Additionally, older adults do not age homogenously. Hence, we seek to characterise healthcare utilisation in young-old and old-old at the end-of-life.
Methods: We conducted a single-site retrospective review of decedents under department of Advanced Internal Medicine (AIM) over a year. Young-old is defined as 65–79 years; old-old as 80 years and above. Data collected was demographic characteristics; clinical data including Charlson Comorbidity Index (CCI), FRAIL-NH and advance care planning (ACP); healthcare utilisation including days spent in hospital, hospital admissions, length of stay of terminal admission and clinic visits; and quality of end-of-life care including investigations and symptomatic control. Documentation was individually reviewed for quality of communication.
Results: One hundred eighty-nine older adult decedents. Old-old decedents were mostly females (63% vs. 42%, p = 0.004), higher CCI scores (7.7 vs 6.6, p = 0.007), similarly frail with lower polypharmacy (62.9% vs 71.9%, p = 0.01). ACP uptake was low in both, old-old 15.9% vs. young-old 17.5%. Poor prognosis was conveyed to family, though conversation did not result in moderating extent of care.
Old-old had less healthcare utilisation. Adjusting for sex, multimorbidity and frailty, old-old decedents had 7.3 ± 3.5 less hospital days in their final year. Further adjusting for cognition and residence, old-old had 0.5 ± 0.3 less hospital admissions. When accounted for home care services, old-old spent 2.7 ± 0.8 less hospital days in their last admission.
Conclusion: There was high healthcare utilisation in older adults, but especially young-old. Enhanced education and goal-setting are needed in the acute care setting. ACP needs to be reinforced in acute care with further research to evaluate if it reduces unnecessary utilisation at end-of-life.
Objectives: To set up a pragmatic Plan–Do–Study–Act cycle by analysing patient experiences and determinants of satisfaction with care in the last year of life.
Design: Cross-sectional postbereavement survey.
Setting: Regional health services research and development structure representing all health and social care providers involved in the last year of life in Cologne, a city with 1 million inhabitants in Germany.
Participants: 351 bereaved relatives of adult decedents, representative for age and gender, accidental and suspicious deaths excluded.
Results: For the majority (89%) of patients, home was the main place of care during their last year of life. Nevertheless, 91% of patients had at least one hospital admission and 42% died in hospital. Only 60% of informants reported that the decedent had been told that the disease was leading to death. Hospital physicians broke the news most often (58%), with their communication style often (30%) being rated as ‘not sensitive’. Informants indicated highly positive experiences with care provided by hospices (89% ‘good’) and specialist palliative home care teams (87% ‘good’). This proportion dropped to 41% for acute care hospitals, this rating being determined by the feeling of not being treated with respect and dignity (OR=23.80, 95% CI 7.503 to 75.498) and the impression that hospitals did not work well together with other services (OR=8.37, 95% CI 2.141 to 32.71).
Conclusions: Following those data, our regional priority for action now is improvement of care in acute hospitals, with two new projects starting, first, how to recognise and communicate a limited life span, and second, how to improve care during the dying phase. Results and further improvement projects will be discussed in a working group with the city of Cologne, and repeating this survey in 2 years will be able to measure regional achievements.
Trial registration number DRKS00011925.
Une « bonne mort », un deuil serein, cela existe, mais la recherche en parle bien peu. En fait, ce sont les trajectoires difficiles et les embuches sous-jacentes qui font surtout l’objet des études, avec raison d’ailleurs puisque l’objectif relève souvent de la volonté d’offrir aux personnes endeuillées un accompagnement qui réponde à leurs besoins.
OBJECTIVES: This study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes.
DESIGN: A clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention.
SETTING AND PARTICIPANTS: after assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients' general practitioners (GPs) participated in a before/after survey and in interviews and focus groups.
INTERVENTION: A multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes.
MEASURES: Measures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization.
RESULTS: GPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care.
CONCLUSIONS AND IMPLICATIONS: An integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.
Purpose: Little is known about the use of palliative and hospice care and their impact on healthcare utilization near the end of life (EOL) in early-onset pancreatic cancer (EOPC).
Methods: Patients with EOPC (= 50 years) were identified using the institutional tumor registry for years 2011–2018, and demographic, clinical, and rates of referral to palliative and hospice services were obtained retrospectively. Predictors of healthcare utilization, defined as use of = 1 emergency department (ED) visit or hospitalization within 30 days of death, place of death (non-hospital vs. hospital), and time from last chemotherapy administration prior to death, were assessed using descriptive, univariable, and multivariable analyses including chi-square and logistic regression models.
Results: A total of 112 patients with EOPC with a median age of 46 years (range, 29–50) were studied. Forty-four percent were female, 28% were Black, and 45% had metastatic disease. Fifty-seven percent received palliative care at a median of 7.8 weeks (range 0–265) following diagnosis. The median time between last chemotherapy and death was 7.9 weeks (range 0–102). Seventy-four percent used hospice services prior to death for a median of 15 days (range 0–241). Rate of healthcare utilization at the EOL was 74% in the overall population. Black race and late use of chemotherapy were independently associated with increase in ED visits/hospitalization and hospital place of death.
Conclusions: Although we observed early referrals to palliative care among patients with newly diagnosed EOPC, short duration of hospice enrollment and rates of healthcare utilization prior to death were substantial.
BACKGROUND/OBJECTIVES: Experts have suggested that patients represented by professional guardians receive higher intensity end-of-life treatment than other patients, but there is little corresponding empirical data.
DESIGN: Retrospective cohort study.
SETTING AND PARTICIPANTS: Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non-VA).
MEASUREMENTS: Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home-to-hospital transfers in the last 90 days of life, and in-hospital death.
RESULTS: ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89–1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end-of-life hospitalizations, and in-hospital death were more common among matched controls.
CONCLUSION: Rates of high-intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high-intensity treatment occurred more frequently than expected among patients without guardians.
PURPOSE: There is limited evidence on the intensity of end-of-life (EOL) care for women < 65 years old, who account for about 40% of breast cancer deaths in the United States. Using established indicators, we estimated the intensity of EOL care among these women.
METHODS: We used 2000-2014 claims data from a large US insurer to identify women with metastatic breast cancer who, in the last month of their lives, had more than one hospital admission, emergency department visit, or an intensive care unit (ICU) admission and/or used antineoplastic therapy in the last 14 days of life. Using multivariate logistic regression, we assessed whether intensity of EOL care differed by demographic characteristics, socioeconomic factors, or regions.
RESULTS: Adjusted estimates show an increase in EOL ICU admissions between 2000-2003 and 2010-2014 from 14% (95% CI, 10% to 17%) to 23% (95% CI, 20% to 26%) and a small increase in emergency department visits from 10% (95% CI, 7% to 13%) to 12% (95% CI, 9% to 15%), both statistically significant. There was no statistically significant change in the proportions of women experiencing more than one EOL hospitalization (14% in 2010-2014; 95% CI, 11% to 17%) and of those receiving EOL antineoplastic treatment (24% in 2010-2014; 95% CI, 21% to 27%). Living in predominantly mixed, Hispanic, Black, or Asian neighborhoods correlated with more intense care (odds ratio, 1.39; 95% CI, 1.10 to 1.77 for ICU).
CONCLUSION: Consistent with findings in the Medicare population, our results suggest an overall increase in the number of ICU admissions at the EOL over time. They also suggest that patients from non-White neighborhoods receive more intense acute care.
BACKGROUND: Myelophthisis (MPT) has been associated with a dreadful prognosis. Patients' access to palliative care (PC) and factors influencing its clinical outcomes are poorly described. Our aim was to analyze the impact of patient- and disease-specific characteristics on survival of patients with MPT and describe their use of PC in a resource-limited setting.
METHODS: Retrospective study including patients with solid tumor MPT, diagnosed between 1996 and 2018.
RESULTS: Seventy patients (median 58 years) were included. 58% were synchronously diagnosed with MPT at time of primary tumor diagnosis. Most common oncologic diagnoses were prostate (25.7%), gastrointestinal (20%), and breast (18.6%) neoplasms. Median overall survival (OS) was 1.9 months. Primaries other than prostate, breast, and lung (HR 1.37, 95% CI 1.15 - 1.8; p = 0.02) and transfusion requirements (HR 2.8, 95% CI 1.01 - 7.9; p = 0.04) were independently associated with decreased OS. Administration of multiple systemic therapeutic interventions (HR 0.15, 95% CI 0.06 - 0.39; p = 0.01) was the sole factor improving OS. Assessment by PC was pursued in 51.4% of patients. The median number of consults per patient was two, with no difference in assessment rate or consult number across different primaries (P = 0.96). Four cases of palliative sedation were reported, all performed by the primary care team.
CONCLUSION: MPT is highly heterogeneous and risk stratification to optimize the use of therapeutic interventions in unison with palliative interventions is needed to maximize efforts toward improving patient quality of life. There is an alarming need of PC services in the multidisciplinary management of patients within developing regions.
OBJECTIVES: Assess whether frequently-used claims-based end-o-life (EOL) measures are associated with higher ratings of care quality.
DESIGN: Retrospective cohort study.
SETTING/PARTICIPANTS: Deceased fee--for-service Medicare beneficiaries with cancer who underwent chemotherapy during July 2016 to January 2017 and died within 12 months and their caregiver respondents to an after-death survey (n = 2,559).
MEASUREMENTS: We examined claims-based measures of EOL care: chemotherapy 14 days or more before death; inpatient admissions, intensive care unit (ICU) use, and emergency department (ED) visits 30 days or more before death; hospice election and the timing of election before death. Primary outcomes are family ratings of “excellent” care in the last month of life and reports that hospice care began “at the right time.” Associations were assessed with logistic regression, adjusted by patient characteristics.
RESULTS: Family rated EOL care as excellent less often, if within 30 days before death the cancer patient had inpatient admissions (1 hospitalization = 41.5% vs 51.5% none, adjusted difference -10.1 percentage points), ICU use (38.6% for any ICU use vs 47.4% none; adjusted difference -8.8 percentage points), ED visits (41.0% 1 visit vs 51.6% no visits; adjusted difference -10.6 percentage points), or elected hospice within 7 days before death. Among hospice enrollees, family more often reported that hospice began at the right time if it started at least 7 days before death (hospice 1–2 days before death 60.2% vs hospice 7–13 days 74.9%; adjusted difference +14.7 percentage points).
CONCLUSIONS: Claims-based measures of EOL care for cancer patients that reflect avoidance of hospital-based care and earlier hospice enrollment are associated with higher ratings of care quality by bereaved family members.
Because of their longstanding relationships with patients, family physicians often are in the best position to identify signs of serious illness progression, provide support and guidance to patients and caregivers, and tailor care plans to individual needs and preferences at the end of life. Significant signs of illness progression include worsening of one or more conditions, decline in function, and increase in the number of emergency department visits or hospitalizations. Prognostication refers to estimation of the remaining life expectancy. Several tools are available to inform such estimates. Prognostication should include discussion of the expected illness progression to help patients and family members prepare, plan, and cope. Advance care planning, ideally started before or early in the course of illness, should include identification of patient surrogate decision-makers as well as a discussion of patient values, priorities, and care preferences. Planning should continue and evolve to inform care plans that match patient and family member priorities at each stage of illness. Family physicians should be familiar with resources available in their communities to support care plans, including palliative care subspecialists, home- and facility-based palliative care teams, and hospice physicians.
OBJECTIVES: The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria.
DESIGN: Retrospective cohort.
SETTING: Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database.
PATIENTS: Hospitalized children with nonneonatal ICU admissions from 2007 to 2018.
MEASUREMENTS: The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria.
RESULTS: The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups.
CONCLUSIONS: Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
Background: A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada.
Methods: We conducted a population-based retrospective-cohort study of Canadian adults aged =18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC).
Results: We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had =2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had =2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs.
Conclusions: High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.
Importance: The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.
Objective: To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.
Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.
Study Selection: Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.
Data Extraction and Synthesis: Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.
Main Outcomes and Measures: Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).
Results: Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).
Conclusions and Relevance: In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.
PURPOSE: Cancer patients in university hospitals often face a difficult decision regarding transfer to other care settings at the end-of-life. Arrangements for a satisfying transfer are important for reducing the psychosocial impact of the transition, but few studies have evaluated this aspect. This study aimed to identify factors related to the satisfying arrangement of transfers to other care settings from university hospitals.
METHODS: A total of 400 bereaved family members of cancer patients in Japan participated in this cross-sectional web-based questionnaire survey. Statistical methods including decision tree analysis were conducted to identify factors significantly associated with satisfying transfer arrangements.
RESULTS: More than 60% of cancer patients were satisfied with the transfer arrangements made by university hospitals. Decision tree analysis revealed that the factor most significantly associated with satisfaction with transfer arrangements was "satisfaction with contents of the explanation about transfer." The following significant factors were also extracted: "timing of being informed of transfer," "presence of primary care physician," and "presence of trustworthy staff." "Satisfaction with overall care from university hospital staff" and "involvement of palliative care team" were identified as factors contributing to a high degree of satisfaction with transfer arrangements.
CONCLUSION: In order to make satisfying transfer arrangements from university hospitals for cancer patients at the end-of-life, healthcare professionals should provide satisfactory explanations about the transfer process in order to meet the information needs of patients. To be effective, healthcare professionals should initiate transfer arrangements prior to cancer treatment, while simultaneously building trusting relationships with patients.
Background: Integration of palliative care services into the surgical treatment plan is important for holistic patient care. We sought to examine the association between patient race/ethnicity and county-level vulnerability relative to patterns of hospice utilization.
Patients and Methods: Medicare Standard Analytic Files were used to identify patients undergoing lung, esophageal, pancreatic, colon, or rectal cancer surgery between 2013 and 2017. Data were merged with the Centers for Disease Control and Prevention’s social vulnerability index (SVI). Logistic regression was utilized to identify factors associated with overall hospice utilization among deceased individuals.
Results: A total of 54,256 Medicare beneficiaries underwent lung (n = 16,645, 30.7%), esophageal (n = 1427, 2.6%), pancreatic (n = 6183, 11.4%), colon (n = 26,827, 49.4%), or rectal (n = 3174, 5.9%) cancer resection. Median patient age was 76 years (IQR 71–82 years), and 28,887 patients (53.2%) were male; the majority of individuals were White (91.1%, n = 49,443), while a smaller subset was Black or Latino (racial/ethnic minority: n = 4813, 8.9%). Overall, 35,416 (65.3%) patients utilized hospice services prior to death. Median SVI was 52.8 [interquartile range (IQR) 30.3–71.2]. White patients were more likely to utilize hospice care compared with minority patients (OR 1.24, 95% CI 1.17–1.31, p < 0.001). Unlike White patients, there was reduced odds of hospice utilization (OR 0.97, 95% CI 0.96–0.99) and early hospice initiation (OR 0.94, 95% CI 0.91–0.97) as SVI increased among minority patients.
Conclusions: Patients residing in counties with high social vulnerability were less likely to be enrolled in hospice care at the time of death, as well as be less likely to initiate hospice care early. The effects of increasing social vulnerability on hospice utilization were more profound among minority patients.
OBJECTIVE: Determine the role of palliative care on terminal code status and setting of death for those with heart failure.
BACKGROUND: Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis.
METHODS: Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate.
RESULTS: 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient's chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001).
CONCLUSION: Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.