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Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett MI. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 2020; 18:368. [PMID: 33239021 PMCID: PMC7690105 DOI: 10.1186/s12916-020-01829-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature. METHODS We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death). RESULTS One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries. CONCLUSIONS Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Helen L Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium.,Vrije Universiteit Brussel, Brussels, Belgium
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Kang E, Lee J, Choo J, Min J, Yun YH. Randomized Controlled Trial of Advance Care Planning Video Decision Aid for the General Population. J Pain Symptom Manage 2020; 59:1239-1247. [PMID: 31866488 DOI: 10.1016/j.jpainsymman.2019.12.353] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Advance care planning (ACP) in a healthy general population could improve the quality of care when a health problem arises. OBJECTIVES The purpose of this study was to evaluate the efficacy of video decision support aid in increasing the intention to document ACP in the general healthy population. METHODS In this randomized controlled trial, we enrolled 250 members of the general population (aged 20 years and older and determined to be healthy), stratified by age and sex. The intervention was a video that provided information about ACP and end-of-life care options such as cardiopulmonary resuscitation (CPR) and palliative care. An attention-control arm was given a booklet about advance directives. Primary outcome was a change in intention to document ACP. Secondary outcomes included the intention to refuse CPR at terminal status, CPR and palliative care knowledge score, and the Hospital Anxiety and Depression Scale. RESULTS About 250 participants were randomly assigned, half to the video-assisted intervention group and half to the attention-control group. Within one week postintervention, the intention to document ACP was significantly higher in the video-assisted intervention arm (68.0% vs. 39.2%; P < 0.001), and changes in the intention to document ACP were significantly greater in the video group than in the brochure group (P = 0.008; Δ = 14.4%). Palliative care knowledge score was also significantly increased in the video group (P = 0.036). CONCLUSION A well-constructed video decision support intervention can increase the intention to document ACP in the general population that presumably had little opportunity to discuss ACP with physicians.
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Affiliation(s)
- EunKyo Kang
- Department of Family Medicine, Seoul National University Hospital, Jongno gu, Seoul, Korea; Institute for Public Health and Medical Service, Seoul National University Hospital, Jongno-gu, Seoul, Korea
| | - Jihye Lee
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - Jiyeon Choo
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - JeongHee Min
- Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea
| | - Young Ho Yun
- Department of Family Medicine, Seoul National University Hospital, Jongno gu, Seoul, Korea; Department of Biomedical Science, Seoul National University College of Medicine, Jongno gu, Seoul, Korea.
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Mathew C, Hsu AT, Prentice M, Lawlor P, Kyeremanteng K, Tanuseputro P, Welch V. Economic evaluations of palliative care models: A systematic review. Palliat Med 2020; 34:69-82. [PMID: 31854213 DOI: 10.1177/0269216319875906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Palliative care aims to improve quality of life by relieving physical, emotional, and spiritual suffering. Health system planning can be informed by evaluating cost and effectiveness of health care delivery, including palliative care. AIM The objectives of this article were to describe and critically appraise economic evaluations of palliative care models and to identify cost-effective models in improving patient-centered outcomes. DESIGN We conducted a systematic review and registered our protocol in PROSPERO (CRD42016053973). DATA SOURCES A systematic search of nine medical and economic databases was conducted and extended with reference scanning and gray literature. Methodological quality was assessed using the Drummond checklist. RESULTS We identified 12,632 articles and 5 were included. We included two modeling studies from the United States and England, and three economic evaluations from England, Australia, and Italy. Two studies compared home-based palliative care models to usual care, and one compared home-based palliative care to no care. Effectiveness outcomes included hospital readmission prevented, days at home, and palliative care symptom severity. All studies concluded that palliative care was cost-effective compared to usual care. The methodological quality was good overall, but three out of five studies were based on small sample sizes. CONCLUSION Applicability and generalizability of evidence is uncertain due to small sample sizes, short duration, and limited modeling of costs and effects. Further economic evaluations with larger sample sizes are needed, inclusive of the diversity and complexity of palliative care populations and using patient-centered outcomes.
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Affiliation(s)
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada.,Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michelle Prentice
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada
| | - Peter Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Vivian Welch
- Bruyère Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Jegier BJ, O'Mahony S, Johnson J, Flaska R, Perry A, Runge M, Sommerfeld T. Impact of a Centralized Inpatient Hospice Unit in an Academic Medical Center. Am J Hosp Palliat Care 2015; 33:755-9. [PMID: 26275783 DOI: 10.1177/1049909115599157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Rush University Medical Center (RUMC) and Horizon Hospice opened the first centralized inpatient hospice unit (CIPU) in a Chicago academic medical center in 2012. This study examined if there was a difference in cost or length of stay (LOS) in a CIPU compared to hospice care in scattered beds throughout RUMC. STUDY DESIGN AND METHODS This retrospective, cross-sectional study compared cost and LOS for patients admitted to the CIPU (n = 141) and those admitted to hospice scattered beds (SBM) throughout RUMC (n = 56). RESULTS The CIPU patients had a median LOS of 6.0 days versus 2.0 days for SBM patients. CONCLUSIONS The CIPU patients had longer hospice LOS but lower hospital costs. Academic medical centers may benefit from aggregating hospice beds.
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Affiliation(s)
- Briana J Jegier
- Health Services Administration, D'Youville College, Buffalo, NY, USA Health Systems Management, Rush University Medical Center, Chicago, IL, USA
| | - Sean O'Mahony
- Health Systems Management, Rush University Medical Center, Chicago, IL, USA Johnston R. Bowman Center, Rush University Medical Center, Chicago, IL, USA
| | - Julie Johnson
- Health Systems Management, Rush University Medical Center, Chicago, IL, USA Loyola University Medical Center, Maywood, IL, USA
| | | | - Anthony Perry
- Health Systems Management, Rush University Medical Center, Chicago, IL, USA Johnston R. Bowman Center, Rush University Medical Center, Chicago, IL, USA
| | | | - Teri Sommerfeld
- Health Systems Management, Rush University Medical Center, Chicago, IL, USA Johnston R. Bowman Center, Rush University Medical Center, Chicago, IL, USA
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El-Jawahri A, Mitchell SL, Paasche-Orlow MK, Temel JS, Jackson VA, Rutledge RR, Parikh M, Davis AD, Gillick MR, Barry MJ, Lopez L, Walker-Corkery ES, Chang Y, Finn K, Coley C, Volandes AE. A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients. J Gen Intern Med 2015; 30:1071-80. [PMID: 25691237 PMCID: PMC4510229 DOI: 10.1007/s11606-015-3200-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/17/2014] [Accepted: 01/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. OBJECTIVES We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. DESIGN This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. PARTICIPANTS One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. INTERVENTION Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). MAIN MEASURES The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). RESULTS Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). CONCLUSIONS Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers. TRIAL REGISTRATION Clinicaltrials.gov NCT01325519 Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.
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Affiliation(s)
- Areej El-Jawahri
- Hematology-Oncology Department, Massachusetts General Hospital, 55 Fruit Street, Cox 120, Boston, MA, 02114, USA,
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Pathak EB, Wieten S, Djulbegovic B. From hospice to hospital: short-term follow-up study of hospice patient outcomes in a US acute care hospital surveillance system. BMJ Open 2014; 4:e005196. [PMID: 25052170 PMCID: PMC4120426 DOI: 10.1136/bmjopen-2014-005196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES In the USA, there is little systematic evidence about the real-world trajectories of patient medical care after hospice enrolment. The objective of this study was to analyse predictors of the length of stay for hospice patients who were admitted to hospital in a retrospective analysis of the mandatorily reported hospital discharge data. SETTING All acute-care hospitals in Florida during 1 January 2010 to 30 June 2012. PARTICIPANTS All patients with source of admission coded as 'hospice' (n=2674). PRIMARY OUTCOME MEASURES The length of stay and discharge status: (1) died in hospital; (2) discharged back to hospice; (3) discharged to another healthcare facility; and (4) discharged home. RESULTS Patients were elderly (median age=81) with a high burden of disease. Almost half died (46%), while the majority of survivors were discharged to hospice (80% of survivors, 44% of total). A minority went to a healthcare facility (5.6%) or to home (5.2%). Only 9.2% received any procedure. Respiratory services were received by 29.4% and 16.8% were admitted to the intensive care unit. The median length of stay was 1 day for those who died. In an adjusted survival model, discharge to a healthcare facility resulted in a 74% longer hospital stay compared with discharge to hospice (event time ratio (ETR)=1.74, 95% CI 1.54 to 1.97 p<0.0001), with 61% longer hospital stays among patients discharged home (ETR=1.61, 95% CI 1.39 to 1.86 p<0.0001). Total financial charges for all patients exceeded $25 million; 10% of patients who appeared to exit hospice incurred 32% of the charges. CONCLUSIONS Our results raise significant questions about the ethics and pragmatics of end-of-life medical care, and the intentions and scope of hospices in the USA. Future studies should incorporate prospective linkage of subjective patient-centred data and objective healthcare encounter data.
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Affiliation(s)
- Elizabeth Barnett Pathak
- Division of Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Sarah Wieten
- Division of Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Department of Philosophy, University of South Florida, Tampa, Florida, USA
| | - Benjamin Djulbegovic
- Division of Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Affiliation(s)
- Mark T. Hughes
- General Internal Medicine and Berman Institute of Bioethics, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-0941;
| | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-0005;
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Kelly RJ, Smith TJ. Delivering maximum clinical benefit at an affordable price: engaging stakeholders in cancer care. Lancet Oncol 2014; 15:e112-8. [PMID: 24534294 DOI: 10.1016/s1470-2045(13)70578-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cancer costs continue to increase alarmingly despite much debate about how they can be reduced. The oncology community needs to take greater responsibility for our own practice patterns, especially when using expensive tests and treatments with marginal value: we cannot continue to accept novel therapeutics with very small benefits for exorbitant prices. Patients, payers, and pharmaceutical communities should be constructively engaged to communicate medically and economically possible goals, and eventually, to reduce use and costs. Diagnostic tests and treatments should have to show true value to be added to existing protocols. In this article, we discuss three key drivers of costs: end-of-life care patterns, medical imaging, and drugs. We propose health-care models that have the potential to decrease costs and discuss solutions to maintain clinical benefit at an affordable price.
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Affiliation(s)
- Ronan J Kelly
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Thomas J Smith
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Sexauer A, Cheng MJ, Knight L, Riley AW, King L, Smith TJ. Patterns of hospice use in patients dying from hematologic malignancies. J Palliat Med 2014; 17:195-9. [PMID: 24383458 DOI: 10.1089/jpm.2013.0250] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Hospice brings substantial clinical benefits to dying patients and families but is underutilized by patients dying of hematologic malignancies (HM); nationwide, only 2% of HM patients use hospice. There are 70,000 deaths among U.S. patients with hematologic malignancies yearly. OBJECTIVE We measured the use and length of stay (LOS) in hospice among patients with HMs at a large academic cancer center. DESIGN This was a single center retrospective review of adult patients (≥18 years) with lymphoma, leukemia, myelodysplastic syndrome, aplastic anemia, and multiple myeloma referred for hospice. MEASUREMENTS Information included demographics, transplant, hospice type, LOS, and use of "expanded access" services. RESULTS Fifty-nine patients were referred to hospice, and 53 utilized hospice services, 25% of 209 HM decedents. Thirty-five received home hospice and 18 used inpatient hospice. The median home hospice LOS was nine days (SD 13) and inpatient hospice six days (SD 10). Nine patients with "expanded access" hospice received only a few blood transfusions, and none received radiation. CONCLUSIONS HM patients are referred late or never for hospice services. Studies evaluating earlier integration of palliative and hospice care with usual HM care are warranted. We present a one-page negotiation form that we have found useful in negotiations among HM physicians, hospice medical directors, and payers.
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Affiliation(s)
- Amy Sexauer
- 1 Oncology Department, Johns Hopkins School of Medicine , Baltimore, Maryland
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Alsirafy SA, Abou-Alia AM, Ghanem HM. Palliative care consultation versus palliative care unit: which is associated with shorter terminal hospitalization length of stay among patients with cancer? Am J Hosp Palliat Care 2013; 32:275-9. [PMID: 24301082 DOI: 10.1177/1049909113514476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospital length of stay (LoS) may be used to assess end-of-life care aggressiveness and health care delivery efficiency. We describe the terminal hospitalization LoS of patients with cancer managed by a hospital-based palliative care (PC) program comprising a palliative care consultation (PCC) service and an inpatient palliative care unit (PCU). A total of 328 in-hospital cancer deaths were divided into 2 groups. The PCU group included patients admitted by the PC team directly to the PCU. The PCC group included patients admitted by other specialties and referred to the PCC team. The LoS of the PCU group was significantly shorter than that of the PCC group (9.9 [±9.4] vs 17.8 [±19.7] days, respectively; P < .001). Direct terminal hospitalization to PCU is not associated with longer LoS among cancer deaths managed by a hospital-based PC service.
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Affiliation(s)
- Samy A Alsirafy
- Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Ahmad M Abou-Alia
- Palliative Care Department, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Hafez M Ghanem
- Palliative Care Department, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
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Lin YH, Chen YC, Tseng YH, Lin MH, Hwang SJ, Chen TJ, Chou LF. Trend of urban-rural disparities in hospice utilization in Taiwan. PLoS One 2013; 8:e62492. [PMID: 23658633 PMCID: PMC3637250 DOI: 10.1371/journal.pone.0062492] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 03/22/2013] [Indexed: 11/18/2022] Open
Abstract
AIMS The palliative care has spread rapidly worldwide in the recent two decades. The development of hospice services in rural areas usually lags behind that in urban areas. The aim of our study was to investigate whether the urban-rural disparity widens in a country with a hospital-based hospice system. METHODS From the nationwide claims database within the National Health Insurance in Taiwan, admissions to hospices from 2000 to 2006 were identified. Hospices and patients in each year were analyzed according to geographic location and residence. RESULTS A total of 26,292 cancer patients had been admitted to hospices. The proportion of rural patients to all patients increased with time from 17.8% in 2000 to 25.7% in 2006. Although the numbers of beds and the utilizations in both urban and rural hospices expanded rapidly, the increasing trend in rural areas was more marked than that in urban areas. However, still two-thirds (898/1,357) of rural patients were admitted to urban hospices in 2006. CONCLUSIONS The gap of hospice utilizations between urban and rural areas in Taiwan did not widen with time. There was room for improvement in sufficient supply of rural hospices or efficient referral of rural patients.
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Affiliation(s)
- Yi-Hsuan Lin
- Department of Family Medicine, Kaohsiung Veterans General Hospital Pingtung Branch, Pingtung, Taiwan
| | - Yi-Chun Chen
- Department of Family Medicine, Taitung Veterans Hospital, Taitung, Taiwan
| | - Yen-Han Tseng
- Respiratory Therapy Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shinn-Jang Hwang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Fang Chou
- Department of Public Finance, National Chengchi University, Taipei, Taiwan
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