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Sergeant M, Ly O, Kandasamy S, Anand SS, de Souza RJ. Managing greenhouse gas emissions in the terminal year of life in an overwhelmed health system: a paradigm shift for people and our planet. Lancet Planet Health 2024; 8:e327-e333. [PMID: 38729672 DOI: 10.1016/s2542-5196(24)00048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/14/2024] [Accepted: 03/22/2024] [Indexed: 05/12/2024]
Abstract
Health care contributes 4·4% of global net carbon emissions. Hospitals are resource-intensive settings, using a large amount of supplies in patient care and have high energy, ventilation, and heating needs. This Viewpoint investigates emissions related to health care in a patient's last year of life. End of life (EOL) is a period when health-care use and associated emissions production increases exponentially due primarily to hospital admissions, which are often at odds with patients' values and preferences. Potential solutions detailed within this Viewpoint are facilitating advanced care plans with patients to ensure their EOL wishes are clear, beginning palliative care interventions earlier when treating a life-limiting illness, deprescribing unnecessary medications because medications and their supply chains make up a significant portion of health-care emissions, and, enhancing access to low-intensity community care settings (eg, hospices) within the last year of life if home care is not available. Our analysis was done using Canadian data, but the findings can be applied to other high-income countries.
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Affiliation(s)
- Myles Sergeant
- Department of Family Medicine, Michael G DeGroote School of Medicine, Hamilton, ON, Canada
| | - Olivia Ly
- Department of Family Medicine, Michael G DeGroote School of Medicine, Hamilton, ON, Canada
| | - Sujane Kandasamy
- Department of Child and Youth Studies, Brock University, St Catherine's, ON, Canada
| | - Sonia S Anand
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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Li W, Qureshi D, Rhodes E, Imsirovic H, Isenberg SR, Tanuseputro P. Place of Death and Place of Care at the End of Life: Are They Correlated? A Retrospective Cohort Study of Ontario Decedents. J Palliat Med 2024; 27:224-230. [PMID: 37967408 DOI: 10.1089/jpm.2023.0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background: Dying in nonpalliative acute care is generally considered inappropriate and avoidable. Place of death, a commonly reported big-dot indicator of end-of-life care quality, is often used as a proxy for place of care despite no empirical evidence for their correlations. Thus, we examined the correlations between place of death and place of care in the last month of life. We also investigated anecdotal claims that individuals cared in acute care often get discharged to die at home, and vice versa. Methods: We conducted a retrospective cohort study of Ontario decedents (18+) who died between January 1, 2015 and December 31, 2017. We identified individuals who died in nonpalliative acute care, palliative care unit, subacute care, long-term care (LTC), and the community. We calculated the number of days decedents spent in each setting in their last month of life, and used descriptive analyses to investigate their correlations. Results: Decedent's place of death generally correlated with their place of care in the last month of life-individuals who died in a particular setting spent more time in that setting than individuals who died elsewhere. Furthermore, 75.0% of individuals who spent more than two weeks of their last month in acute care died in acute care. Among individuals who died in the community and in LTC, 65.4% and 75.0%, respectively, spent zero days in acute care. Interpretation: We showed that place of death can be a useful high-level performance indicator, by itself and as a proxy for place of care, to gauge end-of-life quality and service provision/implementation.
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Affiliation(s)
- Wenshan Li
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Emily Rhodes
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Haris Imsirovic
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Rice E, Scott MM, Webber C, Seow H, Sivapathasundaram B, Tanuseputro P. Characterizing the Palliative Care Physician Workforce: A Retrospective Cross-Sectional Study With Population-Based Data in Ontario, Canada. J Am Med Dir Assoc 2023; 24:1849-1854.e1. [PMID: 37460087 DOI: 10.1016/j.jamda.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Because of an increasing need to build capacity for end-of-life care, improving access to palliative care is a priority. Where a physician practices (eg, hospital, outpatient clinic, home) directly relates to the type of service and the stage of illness at which care is provided. In this study, we describe the physician palliative care specialist workforce and the settings of care within which they practice. DESIGN A retrospective cohort. SETTING AND PARTICIPANTS All physicians with palliative care billing codes who were practicing between April 1, 2018, and March 31, 2019, in Ontario, Canada. METHODS Descriptive statistics of physician billing location and frequency using linked population-based health administrative data. RESULTS We identified 8883 physicians who provided palliative care during the study period. Of those, 723 (8.1%) were classified as palliative care specialists (>10% of their billings encounters were palliative care). The majority (57.4%) of palliative care specialists worked in 1 setting more than 90% of their time, across home visits (27.1%), indirect care (22.4%), and office (7.9%). There were 61 palliative care specialists practicing in mixed locations who provided home visits, meaning 310 (42.9%) of the palliative care specialists delivered some home-based care. CONCLUSIONS AND IMPLICATIONS This research provides a comprehensive description of the current palliative care specialist physician workforce that can support efforts to build capacity for high-quality end-of-life care.
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Affiliation(s)
- Emily Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Hsien Seow
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; ICES, Hamilton, Ontario, Canada
| | | | - Peter Tanuseputro
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada.
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4
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Scott MM, Ramzy A, Isenberg SR, Webber C, Eddeen AB, Murmann M, Mahdavi R, Howard M, Kendall CE, Klinger C, Marshall D, Sinnarajah A, Ponka D, Buchman S, Bennett C, Tanuseputro P, Dahrouge S, May K, Heer C, Cooper D, Manuel D, Thavorn K, Hsu AT. Nurse practitioner and physician end-of-life home visits and end-of-life outcomes. BMJ Support Palliat Care 2023:spcare-2023-004392. [PMID: 37979954 DOI: 10.1136/spcare-2023-004392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death. METHODS We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit. RESULTS Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both. CONCLUSIONS Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life.
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Affiliation(s)
- Mary M Scott
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amy Ramzy
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Maya Murmann
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Roshanak Mahdavi
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Klinger
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Denise Marshall
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Lakeridge Health, Oshawa, Ontario, Canada
| | - David Ponka
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sandy Buchman
- Division of Palliative Care, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Simone Dahrouge
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kathryn May
- Emergency Department, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carrie Heer
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Cooper
- Nurse Practitioners' Association, Toronto, Ontario, Canada
| | - Douglas Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Gitau K, Huang A, Isenberg SR, Stall N, Ailon J, Bell CM, Quinn KL. Association of patient sex with use of palliative care in Ontario, Canada: a population-based study. CMAJ Open 2023; 11:E1025-E1032. [PMID: 37935486 PMCID: PMC10635704 DOI: 10.9778/cmajo.20220232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use. METHODS We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance. RESULTS There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician. INTERPRETATION After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.
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Affiliation(s)
- Kevin Gitau
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Anjie Huang
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Sarina R Isenberg
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Nathan Stall
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Jonathan Ailon
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Chaim M Bell
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Kieran L Quinn
- Departments of Medicine (Gitau, Stall, Ailon, Bell, Quinn) and Family and Community Medicine (Isenberg), University of Toronto; ICES (Huang, Stall, Bell, Quinn); Department of Medicine (Stall, Bell, Quinn), Sinai Health System; Temmy Latner Centre for Palliative Care (Quinn), Sinai Health System, Toronto, Ont.; Department of Medicine (Isenberg), University of Ottawa; Bruyère Research Institute (Isenberg, Ailon), Ottawa, Ont.; Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
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Bonares M, Stillos K, Huynh L, Selby D. Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study. Palliat Med 2023; 37:1241-1251. [PMID: 37452565 PMCID: PMC10503238 DOI: 10.1177/02692163231183009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups. AIM To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care. DESIGN Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information. SETTING/PARTICIPANTS Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019. RESULTS The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019. CONCLUSIONS Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.
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Affiliation(s)
- Michael Bonares
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kalli Stillos
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lise Huynh
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Debbie Selby
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Hegagi M, James P, Hsu A, Tanuseputro P. Home Care Use and Out-of-Hospital Death in Pancreatic Cancer Patients: A Retrospective Cohort Study. J Palliat Care 2023; 38:175-183. [PMID: 35179424 DOI: 10.1177/08258597221075088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: This study aimed to determine the factors associated with usage of home care, including palliative home care, in patients with pancreatic cancer in Ontario. In addition, this study attempted to investigate factors associated with early-onset palliative home care as well as the impact of home care services on survival and out-of-hospital death. Methods: The Ontario Cancer Registry (OCR) was used to identify and capture basic patient/cancer characteristics of index cases of pancreatic cancer diagnosed between April first, 2010 and March 31st, 2016. Patients that received home care were identified using the Home Care Database (HCD) and stratified into general, transition-to-palliative, and early-onset palliative home care. Logistic regressions were used to describe determinants of home care use and determinants of out-of-hospital death. Results: A total of 6888 pancreatic cancer patients met eligibility criteria for this study. A high proportion of patients (83.7%) received home care, including palliative home care (56.8%). In general, older patients (OR = 3.07) and those with more advanced malignancy (OR = 4.98) for stage 4 versus stage 1) had greater odds of receiving palliative home care. Patients receiving home care (P < .01) and those residing in rural regions (P < .01) had greater odds of out-of-hospital death. Conclusion: A large proportion of patients with pancreatic cancer are directed to home care and those that do are more likely to die outside of hospital. Age and stage at diagnosis are significant predictors of home care use. Differences exist in the healthcare experience of patients depending on if they receive home care services and the type of home care.
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Affiliation(s)
- Mehdi Hegagi
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul James
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluation Sciences, Cancer Research Program, Toronto, Ontario, Canada
| | - Amy Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Population Health and Primary Care, Ottawa, Ontario, Canada
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8
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Salahub C, Kiran T, Na Y, Sinha SK, Stall NM, Ivers NM, Costa AP, Jones A, Lapointe-Shaw L. Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E282-E290. [PMID: 36944429 PMCID: PMC10035667 DOI: 10.9778/cmajo.20220124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits. METHODS This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%). RESULTS A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home. INTERPRETATION A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.
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Affiliation(s)
- Christine Salahub
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Tara Kiran
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Yingbo Na
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Samir K Sinha
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Nathan M Stall
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Noah M Ivers
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Andrew P Costa
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Aaron Jones
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.
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9
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The specialist palliative care team as a local resource. Can Oncol Nurs J 2023; 33:122-130. [PMID: 36789226 PMCID: PMC9894364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background Specialist-level palliative care support is intended for patients with complex physical and psychosocial needs. In addition to direct clinical care, specialist teams can be utilized to support the delivery of community-based palliative care by providing 24/7 access to advice and support for primary care providers, patients, and their families. Aim This paper describes how a specialist palliative care team, based in a tertiary level hospital, can provide timely access to palliative care for patients in a surrounding sub-region that has historically lacked a robust network of community-based palliative care supports. Design A retrospective database analysis was conducted from January 1 - December 31, 2019, to describe the demographic and clinical characteristics of patients referred to the Palliative Care Consult Team who reside in the sub-region of Scarborough, Ontario. Data were reviewed to highlight the role the team plays in supporting end-of-life care for this community of patients, families, and providers. Patients referred to the Palliative Care Consult Team with a residential address within the sub-region of interest were the focus. Results In total, 343 patients living in the selected sub-region were seen by the Palliative Care Consult Team during a 12-month period, representing 18% of the team's annual clinical volume. The majority of these patients (94%) had a cancer diagnosis. Median Palliative Performance Scale score at time of initial consult was 40 for inpatients and 60 for ambulatory patients. More than half the patients (56%) were "full code" at the time of initial palliative care consultation. Median survival from initial consult to death was 18 days for inpatients and 68 days for ambulatory patients. More than half of the patients (54%) died in a palliative care unit, with a smaller percentage dying in the home setting (7%). Conclusions Our report highlights the utilization of a database as a quality improvement tool to illustrate our institution's palliative care mission and vision of engaging in the provision of palliative care expertise to community-based patients and healthcare colleagues.
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10
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Chagani J, Li D, Keating B, Chasen M. Experiences and Lessons Learned from Implementing the RELIEF Digital Symptom Self-Reporting App in a Palliative Home Care Setting. Curr Oncol 2022; 29:9401-9406. [PMID: 36547152 PMCID: PMC9777421 DOI: 10.3390/curroncol29120738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
The majority of Canadians agree they have the right to end-of-life care in their own homes. While a palliative approach to care in the home setting has been demonstrated to be beneficial for patients and the healthcare system, it has rarely been well-integrated through an eHealth approach. Thus, in 2018, we piloted the RELIEF app, a digital symptom self-reporting tool for patients with palliative care needs. This was followed by the initiation of an extension phase of RELIEF in the home care setting. In this commentary, we share the implementation perspectives and experiences of the researchers and healthcare workers involved in this home care phase. It was mainly expressed that there were challenges with nurses feeling involved, supporting the research program, and using the technology, while patients and family caregivers had challenges using the app and cooperating with staff. We describe our lessons learned from these experiences and future changes to be enacted. A detailed report of this trial will be made available in future publications.
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Affiliation(s)
- Jehanara Chagani
- Central West Local Health Integration Network, Brampton, ON L6W 4P3, Canada
| | - Donny Li
- Department of Palliative and Supportive Care, William Osler Health System, Brampton, ON L6R 3J7, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L7, Canada
- Department of Research, Humber River Hospital, Toronto, ON M3M 0B2, Canada
- Correspondence:
| | | | - Martin Chasen
- Department of Palliative and Supportive Care, William Osler Health System, Brampton, ON L6R 3J7, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON L8S 4L7, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5S 1A4, Canada
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11
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Lapointe-Shaw L, Kiran T, Costa AP, Na Y, Sinha SK, Nelson KE, Stall NM, Ivers NM, Jones A. Physician home visits in Ontario: a cross-sectional analysis of patient characteristics and postvisit use of health care services. CMAJ Open 2022; 10:E732-E745. [PMID: 35944922 PMCID: PMC9377547 DOI: 10.9778/cmajo.20210307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is unknown how much of current physician home visit volume is driven by low-complexity or low-continuity visits. Our objectives were to measure physician home visit volumes and costs in Ontario from 2005/06 to 2018/19, and to compare patient characteristics and postvisit use of health care services across home visit types. METHODS This was a retrospective cross-sectional study using health administrative data. We examined annual physician home visit volumes and costs from 2005/06 to 2018/19 in Ontario, and characteristics and postvisit use of health care services of residents who received at least 1 home visit from any physician in 2014/15 to 2018/19. We categorized home visits as palliative, provided to a patient who also received home care services or "other," and compared characteristics and outcomes between groups. RESULTS A total of 4 418 334 physician home visits were performed between 2005/06 and 2018/19. More than half (2 256 667 [51.1%]) were classified as "other" and accounted for 39.1% ($22 million) of total annual physician billing costs. From 2014/15 to 2018/19, of the 413 057 home visit patients, 240 933 (58.3%) were adults aged 65 or more, and 323 283 (78.3%) lived in large urban areas. Compared to the palliative care and home care groups, the "other" group was younger, had fewer comorbidities, and had lower rates of emergency department visits and hospital admissions in the 30 days after the visit. INTERPRETATION About half of physician home visits in 2014/15 to 2018/19 were to patients who were receiving neither palliative care nor home care, a group that was younger and healthier, and had low use of health care services after the visit. There is an opportunity to refine policy tools to target patients most likely to benefit from physician home visits.
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Affiliation(s)
- Lauren Lapointe-Shaw
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.
| | - Tara Kiran
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Andrew P Costa
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Yingbo Na
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Samir K Sinha
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Katherine E Nelson
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Nathan M Stall
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Noah M Ivers
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Aaron Jones
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
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12
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Tarberg AS, Thronaes M, Landstad BJ, Kvangarsnes M, Hole T. Physicians' perceptions of patient participation and the involvement of family caregivers in the palliative care pathway. Health Expect 2022; 25:1945-1953. [PMID: 35765248 PMCID: PMC9327811 DOI: 10.1111/hex.13551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/01/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Patient participation is essential for quality palliative care, and physicians play a crucial role in promoting participation. This study explores physicians' perceptions of patients and family caregivers' involvement in the different phases of the palliative pathway and employs a qualitative design with thematic analysis and a hermeneutic approach. Methods A purposive sampling included physicians who worked in different phases of the palliative pathway. In‐depth, semi‐structured interviews were conducted with 13 physicians in Norway between May and June 2020. Results Three main themes illustrate physicians' perceptions of patients' and family caregivers' involvement: (1) beneficence for the patient and the family caregivers in the early phase, (2) autonomy and shared decision‐making in the middle phase, and (3) family involvement in the terminal phase. Conclusion The physicians perceived bereavement conversations as essential, particularly if the pathway had been challenging. They also perceived patient participation and family caregivers' involvement as contextual. The results reveal that participation differs across the different phases of the palliative pathway. This type of knowledge should be included in the education of health‐care professionals. Future research should explore elements vital to successful patient participation and family involvement in the different phases of care. Patient or Public Contributions Family caregivers were involved in a previous study through individual interviews. The same interview guide used for the family caregivers was used when interviewing the physicians. The family caregivers' contribution led to nuanced questions in the interviews with the physicians, questions leaning on their stories told.
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Affiliation(s)
- Anett S Tarberg
- Medical Department, Møre og Romsdal Hospital Trust, Ålesund, Norway.,Department of Clinical and Molecular Medicine, European Palliative Care Centre (PRC), Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
| | - Morten Thronaes
- Department of Clinical and Molecular Medicine, European Palliative Care Centre (PRC), Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Cancer Clinic, St. Olav Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bodil J Landstad
- Department of Health Sciences, Mid Sweden University, Ostersund, Sweden.,Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,Unit of Research, Education and Development, Ostersund Hospital, Ostersund, Sweden
| | - Marit Kvangarsnes
- Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.,Department of Research and Innovation, Fagavdelinga, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Torstein Hole
- Department of Research and Innovation, Fagavdelinga, Møre og Romsdal Hospital Trust, Ålesund, Norway.,Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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13
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Webber C, Isenberg SR, Scott M, Hafid A, Hsu AT, Conen K, Jones A, Clarke A, Downar J, Kadu M, Tanuseputro P, Howard M. Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study. J Palliat Med 2022; 25:897-906. [PMID: 35007439 DOI: 10.1089/jpm.2021.0496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abe Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- ICES, Ottawa, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anna Clarke
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Zwicker J, Qureshi D, Talarico R, Webber C, Watt C, Kim W, Milani C, Ramanathan U, Mestre T, Tanuseputro P. Dying with Parkinson's Disease: Healthcare Utilization and Costs in the Last Year of Life. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2249-2259. [PMID: 36120791 DOI: 10.3233/jpd-223429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The end-of-life period is associated with disproportionately higher health care utilization and cost at the population level but there is little data in Parkinson's disease (PD). OBJECTIVE The goals of this study were to 1) compare health care use and associated cost in the last year of life between decedents with and without PD, and 2) identify factors associated with palliative care consultation and death in hospital. METHODS Using linked administrative datasets held at ICES, we conducted a retrospective, population-based cohort study of all Ontario, Canada decedents from 2015 to 2017. We examined demographic data, rate of utilization across healthcare sectors, and cost of health care services in the last year of life. RESULTS We identified 291,276 decedents of whom 12,440 (4.3%) had a diagnosis of PD. Compared to decedents without PD, decedents with PD were more likely to be admitted to long-term care (52% vs. 23%, p < 0.001) and received more home care (69.0 vs. 41.8 days, p < 0.001). Receipt of palliative homecare or physician palliative home consultation were associated with lower odds of dying in hospital (OR: 0.24, 95% CI: 0.19- 0.30, and OR: 0.38, 95% CI: 0.33- 0.43, respectively). Mean cost of care in the last year of life was greater for decedents with PD ($68,391 vs. $59,244, p < 0.001). CONCLUSION Compared to individuals without PD, individuals with PD have higher rates of long-term care, home care and higher health care costs in the last year of life. Palliative care is associated with a lower rate of hospital death.
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Affiliation(s)
- Jocelyn Zwicker
- The Ottawa Hospital, Division of Neurology, Ottawa, ON, Canada
- The University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Danial Qureshi
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Colleen Webber
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Christine Watt
- The Ottawa Hospital, Division of Palliative Care, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Elisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - WooJin Kim
- The Ottawa Hospital, Division of Neurology, Ottawa, ON, Canada
- The University of Ottawa, Ottawa, ON, Canada
| | | | - Usha Ramanathan
- Scarborough Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Tiago Mestre
- The Ottawa Hospital, Division of Neurology, Ottawa, ON, Canada
- The University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- University of Ottawa Mind and Brain Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- The Ottawa Hospital, Division of Palliative Care, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
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Quality of End-of-Life Cancer Care in Canada: A 12-Year Retrospective Analysis of Three Provinces' Administrative Health Care Data Evaluating Changes over Time. Curr Oncol 2021; 28:4673-4685. [PMID: 34898554 PMCID: PMC8628746 DOI: 10.3390/curroncol28060394] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
This retrospective cohort study of cancer decedents during 2004-2015 examined end-of-life cancer care quality indicators (QIs) in the provinces of British Columbia (BC), Ontario, and Nova Scotia (NS). These included: emergency department use, in-patient hospitalization, intensive care unit admissions, physician house calls, home care visits, and death experienced in hospital. Ontario saw the greatest 12-year decrease in in-hospital deaths from 52.8% to 41.1%. Hospitalization rates within 30 days of death decreased in Ontario, increased in NS, and remained the same in BC. Ontario's usage of aggressive end-of-life measures changed very little, while BC increased their utilization rates. Supportive care use increased in both NS and Ontario. Those who were male or living in a lower income/smaller community (in Ontario) were associated with a decreased likelihood of receiving supportive care. Despite the shift in focus to providing hospice and home care services, approximately 50% of oncology patients are still dying in hospital and 11.7% of patients overall are subject to aggressive care measures that may be out of line with their desire for comfort care. Supportive care use is increasing, but providers must ensure that Canadians are connected to palliative services, as its utilization improves a wide variety of outcomes.
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Bhargava R, Keating B, Isenberg SR, Subramaniam S, Wegier P, Chasen M. RELIEF: A Digital Health Tool for the Remote Self-Reporting of Symptoms in Patients with Cancer to Address Palliative Care Needs and Minimize Emergency Department Visits. Curr Oncol 2021; 28:4273-4280. [PMID: 34898539 PMCID: PMC8544531 DOI: 10.3390/curroncol28060363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
The lack of timely symptom reporting remains a barrier to effective symptom management and comfort for patients with cancer-related palliative care needs. Poor symptom management at home can lead to unwanted outcomes, such as emergency department visits and death in hospital. We developed and evaluated RELIEF, a remote symptom self-reporting app for community patients with palliative care needs. A pilot feasibility study was conducted at a large, community hospital in Ontario, Canada. Patients self-reported their symptoms each morning using validated clinical symptom measures and RELIEF would alert for worsening or severe symptoms. RELIEF alerts were monitored by palliative care nurses who would then contact patients to determine if appropriate clinical intervention could be initiated to avoid unnecessary emergency department visits. A total of 20 patients were recruited to use RELIEF for two months. Patients completed 80% of daily self-report assessments; 133 alerts were trigged, half of which required clinical intervention. No patient visited the emergency department for symptom management during the study. Clinical staff estimated five emergency department visits were avoided because of RELIEF-saving an estimated cost of over CAD 60,000. RELIEF is a feasible and acceptable method for the remote monitoring of patients with palliative care needs through regular symptom self-reporting.
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Affiliation(s)
- Ravi Bhargava
- Pharmaceutical & Healthcare Management and Innovation, Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
- Global Institute of Psychosocial, Palliative and End-of-Life Care, University of Toronto, Toronto, ON M5S 1A4, Canada
| | - Bonnie Keating
- Division of Supportive and Palliative Care, William Osler Health System, Brampton, ON L6R 3J7, Canada;
| | - Sarina R. Isenberg
- Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada;
- Department of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON M5S 1A4, Canada;
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5S 1A4, Canada
| | | | - Pete Wegier
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON M5S 1A4, Canada;
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5S 1A4, Canada
- Humber River Hospital, Toronto, ON M3M 0B2, Canada;
| | - Martin Chasen
- Global Institute of Psychosocial, Palliative and End-of-Life Care, University of Toronto, Toronto, ON M5S 1A4, Canada
- Division of Supportive and Palliative Care, William Osler Health System, Brampton, ON L6R 3J7, Canada;
- Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada;
- Department of Family & Community Medicine, University of Toronto, Toronto, ON M5S 1A4, Canada
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A4, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON L8S 4L7, Canada
- Correspondence:
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17
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What Variables Contribute to the Achievement of a Preferred Home Death for Cancer Patients in Receipt of Home-Based Palliative Care in Canada? Cancer Nurs 2021; 44:214-222. [PMID: 32649334 DOI: 10.1097/ncc.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Home is often deemed to be the preferred place of death for most patients. Knowing the factors related to the actualization of a preferred home death may yield evidence to enhance the organization and delivery of healthcare services. OBJECTIVE The objectives of this study were to measure the congruence between a preferred and actualized home death among cancer patients in receipt of home-based palliative care in Canada and explore predictors of actualizing a preferred home death. METHODS A longitudinal prospective cohort design was conducted. A total of 290 caregivers were interviewed biweekly over the course of patients' palliative care trajectory between July 2010 and August 2012. Cross-tabulations and multivariate analyses were used in the analysis. RESULTS Home was the most preferred place of death, and 68% of patients who had voiced a preference for home death had their wish fulfilled. Care context variables, such as living with others and the intensity of home-based nursing visits and hours of care provided by personal support workers (PSW), contributed to actualizing a preferred home death. The intensity of emergency department visits was associated with a lower likelihood of achieving a preferred home death. CONCLUSIONS Higher intensity of home-based nursing visits and hours of PSW care contribute to the actualization of a preferred home death. IMPLICATIONS FOR PRACTICE This study has implications for policy decision-makers and healthcare managers. Improving and expanding the provision of home-based PSW and nursing services in palliative home care programs may help patients to actualize a preferred home death.
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Hsu AT, Manuel DG, Spruin S, Bennett C, Taljaard M, Beach S, Sequeira Y, Talarico R, Chalifoux M, Kobewka D, Costa AP, Bronskill SE, Tanuseputro P. Predicting death in home care users: derivation and validation of the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT). CMAJ 2021; 193:E997-E1005. [PMID: 34226263 PMCID: PMC8248571 DOI: 10.1503/cmaj.200022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND: Prognostication tools that report personalized mortality risk and survival could improve discussions about end-of-life and advance care planning. We sought to develop and validate a mortality risk model for older adults with diverse care needs in home care using self-reportable information — the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT). METHODS: Using a derivation cohort that comprised adults living in Ontario, Canada, aged 50 years and older with at least 1 Resident Assessment Instrument for Home Care (RAI-HC) record between Jan. 1, 2007, and Dec. 31, 2012, we developed a mortality risk model. The primary outcome was mortality 6 months after a RAI-HC assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. We validated this algorithm for a second cohort of users of home care who were assessed between Jan. 1 and Dec. 31, 2013. We used Kaplan–Meier survival curves to estimate the observed risk of death at 6 months for assessment of calibration and median survival. We constructed 61 risk groups based on incremental increases in the estimated median survival of about 3 weeks among adults at high risk and 3 months among adults at lower risk. RESULTS: The derivation and validation cohorts included 435 009 and 139 388 adults, respectively. We identified a total of 122 823 deaths within 6 months of a RAI-HC assessment in the derivation cohort. The mean predicted 6-month mortality risk was 10.8% (95% confidence interval [CI] 10.7%–10.8%) and ranged from 1.54% (95% CI 1.53%–1.54%) in the lowest to 98.1% (95% CI 98.1%–98.2%) in the highest risk group. Estimated median survival spanned from 28 days (11 to 84 d at the 25th and 75th percentiles) in the highest risk group to over 8 years (1925 to 3420 d) in the lowest risk group. The algorithm had a c-statistic of 0.753 (95% CI 0.750–0.756) in our validation cohort. INTERPRETATION: The RESPECT mortality risk prediction tool that makes use of readily available information can improve the identification of palliative and end-of-life care needs in a diverse older adult population receiving home care.
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Affiliation(s)
- Amy T Hsu
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont.
| | - Douglas G Manuel
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Sarah Spruin
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Carol Bennett
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Monica Taljaard
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Sarah Beach
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Yulric Sequeira
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Robert Talarico
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Mathieu Chalifoux
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Daniel Kobewka
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Andrew P Costa
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Susan E Bronskill
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
| | - Peter Tanuseputro
- Bruyère Research Institute (Hsu, Manuel, Tanuseputro); Clinical Epidemiology Program (Hsu, Manuel, Bennett, Taljaard, Beach, Sequeira, Kobewka, Tanuseputro), Ottawa Hospital Research Institute; ICES uOttawa (Chalifoux, Manuel, Spruin, Talarico, Tanuseputro); School of Epidemiology and Public Health (Taljaard, Manuel), Division of Palliative Care (Tanuseputro) and Department of Medicine (Kobewka), University of Ottawa, Ottawa, Ont.; Department of Clinical Epidemiology and Biostatistics (Costa), McMaster University, Hamilton, Ont.; ICES Central (Bronskill); Women's College Research Institute (Bronskill), Women's College Hospital, Toronto, Ont
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Quinn KL, Stukel T, Huang A, Goldman R, Cram P, Detsky AS, Bell CM. Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study. Med Care 2021; 59:604-611. [PMID: 34100462 DOI: 10.1097/mlr.0000000000001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who receive palliative care are less likely to die in hospital. OBJECTIVE To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. RESEARCH DESIGN Population-based decedent cohort study using linked health administrative data in Ontario, Canada. SUBJECTS A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. EXPOSURE Physician annual rate of referral to palliative care (high, average, low). MEASURES Odds of death in hospital versus home, adjusted for patient characteristics. RESULTS There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. CONCLUSIONS AND RELEVANCE An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Thérèse Stukel
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Russell Goldman
- Interdepartmental Division of Palliative Care, Sinai Health System
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Allan S Detsky
- Department of Medicine, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
| | - Chaim M Bell
- Department of Medicine, University of Toronto
- ICES
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Medicine
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20
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What should be measured to assess the quality of community-based palliative care? Results from a collaborative expert workshop. Palliat Support Care 2021; 20:226-232. [PMID: 34154690 DOI: 10.1017/s1478951521000791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The need for palliative care (PC) will continue to increase in Canada with population aging. Many older adults prefer to "age in place" and receive care in their own homes. Currently, there is a lack of standardized quality indicators (QIs) for PC delivered in the community in Canada. METHODS A one-day workshop collected expert opinions on what should be measured to capture quality PC. Three brainstorming sessions were focused on addressing the following questions: (1) what is important to measure to support quality PC, regardless of setting? (2) Of the identified measures, are any of special importance to care provided in the home? (3) What are the challenges, barriers, and opportunities for creating these measures? The National Consensus Project (NCP) for Quality Palliative Care framework was used as a guide to group together important comments into key themes. RESULTS The experts identified four themes that are important for measuring quality, regardless of care setting, including access to care in the community by a multidisciplinary team, care for the individual with PC needs, support for the informal caregiver (e.g., family, friends), and symptom management for individuals with PC needs. Two additional themes were of special importance to measuring quality PC in the home, including spiritual care for individuals with PC needs and home as the preferred place of death. The challenges, barriers, and potential opportunities to these quality issues were also discussed. SIGNIFICANCE OF RESULTS PC experts, through this collaborative process, made a substantial contribution to the creation of a standardized set of QIs for community-based PC. Having a standardized set of QIs will enable health care professionals and decision makers to target areas for improvement, implement interventions to improve the quality of care, and ultimately, optimize the health and well-being of individuals with a serious illness.
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21
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Chu A, Barbera L, Sutradhar R, Oz UE, O'Leary E, Seow H. Association between end-of-life cancer care and immigrant status: a retrospective cohort study in Ontario, Canada. BMJ Open 2021; 11:e042978. [PMID: 34078633 PMCID: PMC8173292 DOI: 10.1136/bmjopen-2020-042978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To compare recent immigrants and long-term residents in Ontario, Canada, on established health service quality indicators of end-of-life cancer care. DESIGN Retrospective, population-based cohort study of cancer decedents between 2004 and 2015. SETTING Ontario, Canada. PARTICIPANTS We grouped 13 085 immigrants who arrived in Ontario in 1985 or later into eight major ethnic groups based on birth country, mother tongue and surname, and compared them to 229 471 long-term residents who were ≥18 years at the time of death. PRIMARY AND SECONDARY OUTCOME MEASURES Aggressive care, defined as a composite of ≥2 emergency department visits, ≥2 new hospitalisations or an intensive care unit admission within 30 days of death; and supportive care, defined as a physician house call within 2 weeks, or palliative nursing or personal support worker home visit within 6 months of death. Multivariable logistic regression was used to examine the association between immigration status and the odds of each main outcome. RESULTS Compared with long-term residents, immigrants overall and by ethnic group had higher rates of aggressive care (13.7% vs 17.5%, respectively; p<0.001). Among immigrants, Southeast Asians had the highest use while White-Eastern and Western Europeans had the lowest. Supportive care use was similar between long-term residents and immigrants (50.0% vs 50.5%, respectively; p=0.36), though lower among Southeast Asians (46.6%) and higher among White-Western Europeans (55.6%). After adjusting for sociodemographic characteristics and comorbidities, immigrants remained more likely than long-term residents to receive aggressive care (OR: 1.15, 95% CI 1.09 to 1.21), yet were less likely to receive supportive care (OR: 0.95, 95% CI 0.91 to 0.98). CONCLUSIONS Among cancer decedents in Ontario, immigrants are more likely to use aggressive healthcare services at the end of life than long-term residents, while supportive care varies by ethnicity. Contributors to variation in end-of-life care require further study.
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Affiliation(s)
- Anna Chu
- ICES, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Barbera
- ICES, Toronto, Ontario, Canada
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Rinku Sutradhar
- ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Hsien Seow
- ICES, Toronto, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Brown CRL, Webber C, Seow HY, Howard M, Hsu AT, Isenberg SR, Jiang M, Smith GA, Spruin S, Tanuseputro P. Impact of physician-based palliative care delivery models on health care utilization outcomes: A population-based retrospective cohort study. Palliat Med 2021; 35:1170-1180. [PMID: 33884934 DOI: 10.1177/02692163211009440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes. AIM To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death. DESIGN Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death. SETTING/PARTICIPANTS All adults aged 18-105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017. RESULTS Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%-59%), acute hospitalization (64%-69%) or ICU admission (7%-17%), as well as community death (36%-40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4-9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9-2.0). CONCLUSION The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.
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Affiliation(s)
- Catherine R L Brown
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Hsien-Yeang Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Mengzhu Jiang
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Glenys A Smith
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Sarah Spruin
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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23
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[Does primary care intervention have an impact in the place of death for patients in a palliative care program?]. Aten Primaria 2021; 53:102063. [PMID: 34044187 PMCID: PMC8167217 DOI: 10.1016/j.aprim.2021.102063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/07/2020] [Accepted: 01/07/2021] [Indexed: 11/27/2022] Open
Abstract
Objetivos Conocer si existe relación entre el lugar de fallecimiento y el proveedor de cuidados: equipo de atención primaria (EAP), equipo de soporte atención paliativa domiciliaria (ESAPD) o ambos. Identificar otras variables que pueden influir en el lugar de fallecimiento. Diseño Estudio descriptivo observacional retrospectivo. Emplazamiento Tres centros de salud, Dirección Asistencial Sureste, Comunidad de Madrid. Participantes Pacientes mayores de 18 años con episodio A.99.01 (paciente con necesidad de cuidados paliativos), según la codificación CIAP2, activo en su historia clínica informatizada (AP-Madrid) desde enero de 2016 hasta diciembre de 2018 (n = 499). No cumplieron criterios de inclusión 224 pacientes. Mediciones y resultados principales Se incluyeron 275 pacientes, la edad media fue de 78 años. El 80,4% (n = 221) tenían enfermedad oncológica. El 67,6% (n = 186) pertenecían al ámbito urbano. Existían diferencias significativas entre el lugar de fallecimiento y el equipo proveedor de cuidados: fallecieron en domicilio el 23,1% (n = 6) en seguimiento por EAP, el 14,5% (n = 10) en seguimiento por ESAPD y el 29,4% (n = 53) con seguimiento conjunto (p < 0,0001). Fallecieron en domicilio el 20,8% (n = 46) de pacientes oncológicos y el 42,6% (n = 23) no oncológicos (p < 0,0001). El 26,5% (n = 63) de los fallecidos en domicilio tenían cuidador principal y el 16,2% (n = 6) no lo tenían (p < 0,0001). Fallecieron en domicilio el 34,8% (n = 31) del ámbito rural y el 20,4% (n = 38) del ámbito urbano (p < 0,007). Conclusiones Los resultados avalan que el seguimiento conjunto aumenta el porcentaje de fallecimientos en domicilio.
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Funnell S, Walker J, Letendre A, Bearskin RLB, Manuel D, Scott M, Spruin S, Tanuseputro P. Places of death and places of care for Indigenous Peoples in Ontario: a retrospective cohort study. Canadian Journal of Public Health 2021; 112:685-696. [PMID: 34008135 DOI: 10.17269/s41997-021-00482-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Most people, including Indigenous people in Ontario, wish to die in their communities. How often Indigenous people in Ontario die in their preferred settings is unknown. This study aims to describe the places of care and death for Indigenous people in Ontario who received provincially funded home care services. METHODS We conducted a retrospective cohort study using linked health administrative databases housed at ICES. We used a population-based cohort of Indigenous and non-Indigenous people in Ontario who died between April 1, 2010 and March 31, 2015 to describe characteristics of people, places of death, and places of care. RESULTS Indigenous decedents were on average 8.8 years younger, had more chronic diseases, and lived in lower income neighbourhoods compared with their non-Indigenous counterparts. Indigenous decedents spent nearly 8 more days in acute care in the last year of life and more died in acute care (56.1% versus 46.1%). When controlling for covariates, Indigenous decedents received 1.9 fewer home care nursing hours and 5 fewer personal support worker hours and showed decreased odds (OR 0.72) of receiving a palliative physician visit in the last 90 days of life. Among Indigenous decedents, a palliative physician visit lowered odds of dying in acute care by 50% and total days in acute care by 18%. CONCLUSION Our study identified a gap in end-of-life care for Indigenous Peoples in Ontario receiving provincially funded home care. Without continued efforts to address challenges that perpetuate health inequalities, we expect many Indigenous people will continue to die in acute care away from their people, families, and culturally relevant supports.
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Affiliation(s)
- Sarah Funnell
- Department of Family Medicine, Queen's University, 220 Bagot Street, Kingston, ON, K7L 3G2, Canada.
| | | | - Angeline Letendre
- Canadian Indigenous Nurses Association (CINA), Ottawa, Ontario, Canada
| | | | - Douglas Manuel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Statistics Canada, Ottawa, Ontario, Canada.,C.T. Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada
| | | | | | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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25
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Howard M, Hafid A, Isenberg SR, Hsu AT, Scott M, Conen K, Webber C, Bronskill SE, Downar J, Tanuseputro P. Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study. CMAJ Open 2021; 9:E613-E622. [PMID: 34088732 PMCID: PMC8191591 DOI: 10.9778/cmajo.20210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories. METHODS We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory. RESULTS Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians. INTERPRETATION Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont.
| | - Abe Hafid
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Mary Scott
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Colleen Webber
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Susan E Bronskill
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - James Downar
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
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26
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Grant JK, Vincent L, Ebner B, Singh H, Maning J, Olorunfemi O, Olarte NI, Zablah G, Zaw K, Colombo R. In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support. Am J Cardiol 2021; 148:94-101. [PMID: 33684373 DOI: 10.1016/j.amjcard.2021.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 11/19/2022]
Abstract
Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.
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Affiliation(s)
- Jelani K Grant
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America.
| | - Louis Vincent
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Bertrand Ebner
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Harjit Singh
- University of Miami Leonard M. Miller School of Medicine, Miami/Florida/United States Of America
| | - Jennifer Maning
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Odunayo Olorunfemi
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Neal I Olarte
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Gerardo Zablah
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Khin Zaw
- Palliative Care and Hospice Division, University of Miami Leonard M. Miller School of Medicine/Jackson Memorial Hospital/Bruce W. Carter Miami Veterans Affair Medical Center, Miami/Florida/United States Of America
| | - Rosario Colombo
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
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27
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Quinn KL, Wegier P, Stukel TA, Huang A, Bell CM, Tanuseputro P. Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer. JAMA Netw Open 2021; 4:e210677. [PMID: 33662135 PMCID: PMC7933993 DOI: 10.1001/jamanetworkopen.2021.0677] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Palliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking. OBJECTIVE To examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada. EXPOSURES Cause of death (chronic organ failure, dementia, or cancer). MAIN OUTCOMES AND MEASURES Components of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death. RESULTS A total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, -18.3%) or dementia (3922 [27.9%]; absolute difference, -13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%). CONCLUSIONS AND RELEVANCE In this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings.
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Affiliation(s)
- Kieran L. Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and Ottawa, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Peter Wegier
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Therese A. Stukel
- ICES, Toronto and Ottawa, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto and Ottawa, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Toronto and Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, Ontario, Canada
- Temmy Latner Centre for Palliative Care, Toronto, Ontario, Canada
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Hospital Deaths Increased After Reforms Regardless of Dementia Status: An Interrupted Time-Series Analysis. J Am Med Dir Assoc 2021; 22:1507-1511. [PMID: 33453176 DOI: 10.1016/j.jamda.2020.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/09/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Dying in a hospital is highly stressful for older adults and families. Persons with dementia who are hospitalized are particularly vulnerable to negative outcomes. The objective of this study is to fill an evidence gap on whether the 2015 Dutch long-term care reforms were effective in increasing deaths at home while avoiding increases in hospital deaths for the total population aged ≥65 years and by dementia status. DESIGN We used annual cross-sectional, nationally representative data from 2012 to 2017. We performed an interrupted time-series analyses to evaluate changes in location of death after the implementation of the Dutch long-term reforms. SETTING AND PARTICIPANTS Dutch population aged ≥65 years (N = 727,519) who died between 2012 and 2017 using data from Statistics Netherlands. METHODS The primary outcome was death in a long-term care facility (LTCF), home, hospital, or elsewhere. RESULTS After adjusting for seasonality and sex, we found significantly increased adjusted relative risk ratios (aRRRs) for the total older adult population having a death at home [aRRR 1.17, 95% confidence interval (CI) 1.12.-1.23] and hospital (1.09, 1.04-1.15) compared to deaths in an LTCF after the reforms. For persons with dementia (N = 81,373), hospital deaths increased (2.03, 1.37-3.01) compared with long-term care deaths after the implementation of the long-term care reforms; however, there was no change in the aRRR for death at home. For people without dementia (N = 646,146), we found increased aRRR for death at home (1.21, 1.16-1.28) and death at hospital (1.12, 1.07-1.19) vs LTCF deaths following the reforms. CONCLUSIONS AND IMPLICATIONS Hospital and home deaths increased for the total population. Hospital deaths increased for persons with dementia after the long-term care reforms despite evidence of negative outcomes associated with end-of-life hospitalizations. The Netherlands may have overlooked the merits of home care and LTCFs, particularly for people with dementia.
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Davidoff AJ, Canavan ME, Prsic E, Saphire M, Wang SY, Presley CJ. End-of-life patterns of symptom management and cancer-directed care among Medicare beneficiaries with lung cancer: a claims-based analysis. Support Care Cancer 2021; 29:3921-3932. [PMID: 33389087 DOI: 10.1007/s00520-020-05964-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rather than early hospice enrollment, most Medicare beneficiaries receive "usual care" in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not. METHODS This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month. RESULTS Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time. CONCLUSION Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.
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Affiliation(s)
- Amy J Davidoff
- Department of Health Policy and Management, Yale School of Public Health, PO Box 208034, 60 College Street, New Haven, CT, 06520-8034, USA. .,Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA. .,Yale Cancer Center, New Haven, CT, USA.
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA
| | | | - Maureen Saphire
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Shi-Yi Wang
- Department of Health Policy and Management, Yale School of Public Health, PO Box 208034, 60 College Street, New Haven, CT, 06520-8034, USA.,Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Center, New Haven, CT, USA
| | - Carolyn J Presley
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA.,The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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Mondor L, Wodchis WP, Tanuseputro P. Persistent socioeconomic inequalities in location of death and receipt of palliative care: A population-based cohort study. Palliat Med 2020; 34:1393-1401. [PMID: 32772809 DOI: 10.1177/0269216320947964] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing equitable care to patients in need across the life course is a priority for many healthcare systems. AIM To estimate socioeconomic inequality trends in the proportions of decedents that died in the community and that received palliative care within 30 days of death (including home visits and specialist/generalist physician encounters). DESIGN Cohort study based on health administrative data. Socioeconomic position was measured by area-level material deprivation. Inequality gaps were quantified annually and longitudinally using the slope index of inequality (absolute gap) and relative index of inequality (relative gap). SETTING/PARTICIPANTS A total of 729,290 decedents aged ⩾18 years in Ontario, Canada from 2009 to 2016. RESULTS In 2016, the modelled absolute gap (corresponding 95% confidence interval) between the most- and least-deprived neighbourhoods in community deaths was 4.0% (2.9-5.1%), which was 8.6% (6.2-10.9%) of the overall mean (46.6%). Relative to 2009, these inequalities declined modestly. Inequalities in 2016 were evident for palliative home visits (6.8% (5.8-7.8%) absolute gap, 26.3% (22.5-30.0%) relative gap) and for physician encounters (6.8% (5.7-7.9%) absolute gap, 13.2% (11.0-15.3%) relative gap), and widened from 2009 for physician encounters only on the absolute scale. Inequalities varied considerably across disease trajectories (organ failure, terminal illness, frailty, and sudden death). CONCLUSION Key measures of end-of-life care are not achieved equally across socioeconomic groups. These data can be used to inform policy strategies to improve delivery of palliative and end-of-life services.
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Affiliation(s)
- Luke Mondor
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada
| | - Walter P Wodchis
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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Quinn KL, Shurrab M, Gitau K, Kavalieratos D, Isenberg SR, Stall NM, Stukel TA, Goldman R, Horn D, Cram P, Detsky AS, Bell CM. Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis. JAMA 2020; 324:1439-1450. [PMID: 33048152 PMCID: PMC8094426 DOI: 10.1001/jama.2020.14205] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Kieran L. Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ottawa and North, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Mohammed Shurrab
- ICES, Toronto, Ottawa and North, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine, Laurentian University, Sudbury, Ontario, Canada
| | - Kevin Gitau
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia
| | - Sarina R. Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan M. Stall
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Division of Geriatric Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Therese A. Stukel
- ICES, Toronto, Ottawa and North, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Russell Goldman
- Temmy Latner Centre for Palliative Care and Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daphne Horn
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ottawa and North, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Allan S. Detsky
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ottawa and North, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
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Webber C, Valiulis AO, Tanuseputro P, Schulz V, Apramian T, Schreier G, Hamilton K. An Active In-Home Physician Model of Palliative Care and Its Resulting Performance Indicators Related to Home Deaths, Unplanned Emergency Department Visits and Unplanned Hospital Admissions. J Palliat Care 2020; 36:46-49. [PMID: 32808567 DOI: 10.1177/0825859720951368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Limited research has characterized team-based models of home palliative care and the outcomes of patients supported by these care teams. CASE PRESENTATION A retrospective case series describing care and outcomes of patients managed by the London Home Palliative Care Team between May 1, 2017 and April 1, 2019. CASE MANAGEMENT The London Home Palliative Care (LHPC) Team care model is based upon 3 pillars: 1) physician visit availability 2) active patient-centered care with strong physician in-home presence and 3) optimal administrative organization. CASE OUTCOMES In the 18 month study period, 354 patients received care from the London Home Palliative Care Team. Most significantly, 88.4% (n = 313) died in the community or at a designated palliative care unit after prearranged direct transfer; no comparable provincial data is available. 21.2% (n = 75) patients visited an emergency department and 24.6% (n = 87) were admitted to hospital at least once in their final 30 days of life. 280 (79.1%) died in the community. These values are better than comparable provincial estimates of 62.7%, 61.7%, and 24.0%, respectively. CONCLUSION The London Home Palliative Care (LHPC) Team model appears to favorably impact community death rate, ER visits and unplanned hospital admissions, as compared to accepted provincial data. Studies to determine if this model is reproducible could support palliative care teams achieving similar results.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,152971Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Aurelia Ona Valiulis
- Department of Family Medicine, Schulich School of Medicine and Dentistry, 6221Western University, London, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,152971Bruyère Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Ontario, Canada
| | - Valerie Schulz
- Department of Anesthesia & Perioperative Medicine, Continuing Professional Development, Schulich School of Medicine and Dentistry, 6221Western University, London, Ontario, Canada
| | - Tavis Apramian
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gil Schreier
- Department of Family Medicine, Schulich School of Medicine and Dentistry, 6221Western University, London, Ontario, Canada
| | - Kirk Hamilton
- Department of Family Medicine, Schulich School of Medicine and Dentistry, 6221Western University, London, Ontario, Canada
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Quinn KL, Stukel T, Stall NM, Huang A, Isenberg S, Tanuseputro P, Goldman R, Cram P, Kavalieratos D, Detsky AS, Bell CM. Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study. BMJ 2020; 370:m2257. [PMID: 32631907 PMCID: PMC7336238 DOI: 10.1136/bmj.m2257] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. DESIGN Population based matched cohort study. SETTING Ontario, Canada between 2010 and 2015. PARTICIPANTS 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. MAIN OUTCOME MEASURES Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). RESULTS In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. CONCLUSIONS These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Therese Stukel
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Nathan M Stall
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Anjie Huang
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
| | - Sarina Isenberg
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
| | - Peter Tanuseputro
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
- Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | | | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
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Jones A, Bronskill SE, Seow H, Feeny D, Lapointe-Shaw L, Mowbray F, Costa AP. Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments. J Am Geriatr Soc 2020; 68:2074-2081. [PMID: 32579727 DOI: 10.1111/jgs.16639] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking. OBJECTIVE We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments. DESIGN Population-based retrospective cohort study. SETTING The setting was Ontario, Canada, from October 2014 to September 2016. PARTICIPANTS Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care. MEASUREMENTS We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment. RESULTS There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits. CONCLUSION Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Fabrice Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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36
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Hagarty AM, Bush SH, Talarico R, Lapenskie J, Tanuseputro P. Severe pain at the end of life: a population-level observational study. BMC Palliat Care 2020; 19:60. [PMID: 32354364 PMCID: PMC7193354 DOI: 10.1186/s12904-020-00569-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a prevalent symptom at the end of life and negatively impacts quality of life. Despite this, little population level data exist that describe pain frequency and associated factors at the end of life. The purpose of this study was to explore the prevalence of clinically significant pain at the end of life and identify predictors of increased pain. METHODS Retrospective population-level cohort study of all decedents in Ontario, Canada, from April 1, 2011 to March 31, 2015 who received a home care assessment in the last 30 days of life (n = 20,349). Severe daily pain in the last 30 days of life using linked Ontario health administrative databases. Severe pain is defined using a validated pain scale combining pain frequency and intensity: daily pain of severe intensity. RESULTS Severe daily pain was reported in 17.2% of 20,349 decedents. Increased risk of severe daily pain was observed in decedents who were female, younger and functionally impaired. Those who were cognitively impaired had a lower risk of reporting pain. Disease trajectory impacted pain; those who died of a terminal illness (i.e. cancer) were more likely to experience pain than those with frailty (odds ratio 1.66). CONCLUSION Pain is a common fear of those contemplating end of life, but severe pain is reported in less than 1 in 5 of our population in the last month of life. Certain subpopulations may be more likely to report severe pain at the end of life and may benefit from earlier palliative care referral and intervention.
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Affiliation(s)
- A Meaghen Hagarty
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Robert Talarico
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada.,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada. .,Bruyère Research Institute, Ottawa, Ontario, Canada. .,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada. .,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada.
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Wu MP, Huang SJ, Tsao LI. The Life Experiences Among Primary Family Caregivers of Home-Based Palliative Care. Am J Hosp Palliat Care 2020; 37:816-822. [PMID: 32116010 DOI: 10.1177/1049909120907601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND An increasing number of patients with terminal illnesses prefer to die in their own homes due to aging, high medical payments, a limited number of hospitalization days, and the ability to receive care from family members. However, few studies have been conducted on the subjective perception and value of caregivers for home-based palliative care (HBPC). OBJECTIVE To identify common themes and topics of primary family caregivers' lived experiences with HBPC when taking care of terminally ill family members. METHODS We conducted audio-recorded transcripts of one-on-one in-depth interviews of primary family caregivers of HBPC. Through a purposive sampling method, the participants were all interviewed; these interviews were transcribed verbatim and analyzed using a grounded theory approach. RESULTS A total of 22 primary family caregivers participated in the study. "Wholeheartedly accompanying one's family to the end of life at home" was the core category. Six main themes describing caregivers' experiences emerged from the interviews: (1) learning the basic skills of end-of-life home care, (2) arranging the sharing and rotation of care, (3) preparing for upcoming deaths and funerals, (4) negotiating the cultural and ethical issues of end-of-life home care, (5) ensuring a comfortable life with basic life support, and (6) maintaining care characterized by concern, perseverance, and patience. CONCLUSIONS Primary family caregivers of HBPC need support and must learn home care skills by means of the holistic approach. It is crucial to establish assessment tools for caregivers' preparedness for HBPC, including biopsychosocial and cultural considerations.
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Affiliation(s)
- Meng-Ping Wu
- Department of Nursing and Center of R/D in Community Based Palliative Care, Taipei, Taiwan.,Community Nursing Section, Department of Nursing, Taipei City Hospital, Taipei, Taiwan.,School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Sheng-Jean Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lee-Ing Tsao
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Quinn KL, Hsu AT, Smith G, Stall N, Detsky AS, Kavalieratos D, Lee DS, Bell CM, Tanuseputro P. Association Between Palliative Care and Death at Home in Adults With Heart Failure. J Am Heart Assoc 2020; 9:e013844. [PMID: 32070207 PMCID: PMC7335572 DOI: 10.1161/jaha.119.013844] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population-based cohort study using linked health administrative data in Ontario, Canada of 74 986 community-dwelling adults with heart failure who died between 2010 and 2015. Seventy-five percent of community-dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI, 2.03-2.20]; P<0.01). Delivery of home-based palliative care had a higher association with death at home (adjusted odds ratio 11.88 [95% CI, 9.34-15.11]; P<0.01), as did delivery during transitions of care between inpatient and outpatient care settings (adjusted odds ratio 8.12 [95% CI, 6.41-10.27]; P<0.01). Palliative care was most commonly initiated late in the course of a person's disease (≤30 days before death, 45.2% of subjects) and led by nonspecialist palliative care physicians 61% of the time. Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end-of-life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end-of-life care in people dying with chronic noncancer illness.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | - Amy T Hsu
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada.,School of Epidemiology, Public Health and Preventive Medicine University of Ottawa Ontario Canada.,Bruyère Research Institute Ottawa Ontario Canada
| | - Glenys Smith
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Nathan Stall
- Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Women's College Research Institute Women's College Hospital Toronto Ontario Canada.,Division of Geriatric Medicine University of Toronto Ontario Canada
| | - Allan S Detsky
- Department of Medicine University of Toronto Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | | | - Douglas S Lee
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada
| | - Chaim M Bell
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | - Peter Tanuseputro
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada.,School of Epidemiology, Public Health and Preventive Medicine University of Ottawa Ontario Canada.,Bruyère Research Institute Ottawa Ontario Canada.,Department of Medicine University of Ottawa Ontario Canada
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Fleisher JE, Klostermann EC, Hess SP, Lee J, Myrick E, Chodosh J. Interdisciplinary palliative care for people with advanced Parkinson's disease: a view from the home. ANNALS OF PALLIATIVE MEDICINE 2020; 9:S80-S89. [PMID: 31735037 PMCID: PMC7341729 DOI: 10.21037/apm.2019.09.12] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Advanced Parkinson's disease (PD) is a multidimensional neurodegenerative condition with motor and non-motor symptoms contributing to increasing disability and decreasing quality of life. As the disease progresses, patients may become homebound and estranged from neurological care, with dire consequences. We describe the increasing epidemiologic burden of and individual risks faced by patients with palliative-stage PD and their caregivers. METHODS With the aim of mitigating these risks, we designed and iterated two models of interdisciplinary home visits to maintain continuity of care and illuminate the unmet needs and barriers to care faced by this population. We describe both models in detail, with data on feasibility and patient-centered outcomes achieved in the initial model, and baseline characteristics of participants in the ongoing expanded model. Finally, we illustrate the scope and common themes of such palliative care-informed home visits with two cases. RESULTS The pilot model involved over 380 visits with 109 individual patients. Among those patients, PD severity worsened by nearly 12 points annually on the Unified Parkinson's Disease Rating Scale (UPDRS), without a corresponding decline in quality of life. In an ongoing study of the second iteration of the model, 52 patient-caregiver dyads have completed their initial visit, with 44% bearing a diagnosis of dementia and the majority requiring an assistive device or being bedbound. Two cases highlight the critical importance of thorough medication reconciliation and home safety assessment in the comprehensive evaluation and management of such patients. CONCLUSIONS As our population ages, therapies increase, and the number of individuals living with advanced PD and related disorders grows, so too does the imperative to recognize and address the palliative care needs of such patients and families. For many, home may be a viable, and perhaps optimal, site for this care.
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Affiliation(s)
- Jori E Fleisher
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA.
| | - Ellen C Klostermann
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - Serena P Hess
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - Jeanette Lee
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - Erica Myrick
- Department of Neurological Sciences, Rush University Medical Center, Chicago, USA
| | - Joshua Chodosh
- Department of Medicine, New York University School of Medicine, New York, USA; Medicine Service, VA New York Harbor Healthcare System, New York, USA
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Lai XB, Chen LQ, Chen SH, Xia HO. An examination of home-based end-of-life care for cancer patients: a qualitative study. BMC Palliat Care 2019; 18:115. [PMID: 31843006 PMCID: PMC6915891 DOI: 10.1186/s12904-019-0501-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background Only a small number of patients have utilized the home-based end-of-life care service in Shanghai that has been offered since 2012. This study explores how home-based end-of-life care is delivered in community health service centers in Shanghai and examines the difficulties in the delivery of the care. Methods This was a qualitative study in which data were collected from interviews and analyzed using qualitative content analysis. Nineteen health care providers with experience in delivering home-based end-of-life care in 12 community health service centers were recruited. The interviews were conducted between August 2018 and February 2019. Results Four themes emerged from the interviews: (i) Patients under home-based end-of-life care: Patients receiving the care were cancer patients with less than 1 year of life expectancy. The criteria for patients were broad. (ii) Service structure: The service was delivered regularly by the physicians and nurses using the approaches of home visits and/or telephone follow-ups. (iii) Service process: The service consisted of multiple components, including monitoring the patient’s condition, managing the patient’s symptoms, giving daily care instructions, performing nursing procedures, and giving psychological support. However, most of the care focused on monitoring the patients and managing their physical discomfort. (iv) Difficulties in delivering care: Being unable to provide the service and feeling powerless when facing psycho-spiritual problems were the two major difficulties. Three factors contributed to the suspension of the service: The gap between the service and the needs of the patients, a lack of patients, and low work motivation. The demand that the truth be concealed from the families and their attitude of avoiding talking about death were the key factors of the failure of psycho-spiritual care. Conclusions Several issues should be addressed before the service can be further developed, including fully understanding the needs and preferences of local patients and their families, securing more financial support and a better supply of drugs, delivering better training for staff, and ensuring greater rewards for individuals and institutions providing the service.
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Affiliation(s)
- Xiao Bin Lai
- School of Nursing, Fudan University, 305 Fenglin Road, Shanghai, 200032, China.
| | - Li Qun Chen
- School of Nursing, Fudan University, 305 Fenglin Road, Shanghai, 200032, China
| | - Shu Hui Chen
- School of Nursing, Fudan University, 305 Fenglin Road, Shanghai, 200032, China
| | - Hai Ou Xia
- School of Nursing, Fudan University, 305 Fenglin Road, Shanghai, 200032, China
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Zwicker J, Qureshi D, Talarico R, Bourque P, Scott M, Chin-Yee N, Tanuseputro P. Dying of amyotrophic lateral sclerosis. Neurology 2019; 93:e2083-e2093. [DOI: 10.1212/wnl.0000000000008582] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
ObjectiveTo describe health care service utilization and cost for decedents with and without amyotrophic lateral sclerosis (ALS) in the last year of life.MethodsUsing linked health administrative data, we conducted a retrospective, population-based cohort study of Ontario, Canada, decedents from 2013 to 2015. We examined demographic data, rate of utilization, and cost of health care services in the last year of life.ResultsWe identified 283,096 decedents in Ontario, of whom 1,212 (0.42%) had ALS. Decedents with ALS spent 3 times as many days in an intensive care unit (ICU) (mean 6.3 vs 2.1, p < 0.001), and twice as many days using complex continuing care (mean 12.7 vs 6.0, p < 0.001) and home care (mean 99.1 vs 41.3, p < 0.001). A greater percentage of decedents with ALS received palliative home care (44% vs 20%, p < 0.001) and palliative physician home visits (40% vs 18%, p < 0.001) than decedents without ALS. Among decedents with ALS, a palliative physician home visit in the last year of life was associated with reduced adjusted odds of dying in hospital (odds ratio 0.65, 95% confidence interval 0.48–0.89) and fewer days spent in the ICU. Mean cost of care in the last year of life was greater for those with ALS ($68,311.98 vs $55,773.48, p < 0.001).ConclusionsIn this large population-based cohort of decedents, individuals with ALS spent more days in the ICU, received more community-based services, and incurred higher costs of care in the last year of life. A palliative care physician home visit was associated with improved end of life outcomes; however, the majority of patients with ALS did not access such services.
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de Mestral C, Hsu AT, Talarico R, Lee DS, Hussain MA, Salata K, Al-Omran M, Tanuseputro P. End-of-life care following leg amputation in patients with peripheral artery disease or diabetes. Br J Surg 2019; 107:64-72. [DOI: 10.1002/bjs.11367] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/10/2019] [Accepted: 08/22/2019] [Indexed: 02/02/2023]
Abstract
Abstract
Background
The aim was to characterize end-of-life care in patients who have had a leg amputated for peripheral artery disease (PAD) or diabetes.
Methods
This was a population-based retrospective cohort study of patients with PAD or diabetes who died in Ontario, Canada, between 2011 and 2017. Those who had a leg amputation within 3 years of death were compared with a control cohort of deceased patients with PAD or diabetes, but without leg amputation. The patients were identified from linked health records within the single-payer healthcare system. Place and cause of death, as well as health services and costs within 90 days of death, were compared between the amputee and control cohorts. Among amputees, multivariable regression models were used to characterize the association between receipt of home palliative care and in-hospital death, as well as time spent in hospital at the end of life.
Results
Compared with 213 300 controls, 3113 amputees were less likely to die at home (15·5 versus 24·9 per cent; P < 0·001) and spent a greater number of their last 90 days of life in hospital (median 19 versus 8 days; P < 0·001). Amputees also had higher end-of-life healthcare costs across all sectors. However, receipt of palliative care was less frequent among amputees than controls (inpatient: 13·4 versus 16·8 per cent, P < 0·001; home: 14·5 versus 23·8 per cent, P < 0·001). Among amputees, receipt of home palliative care was associated with a lower likelihood of in-hospital death (odds ratio 0·49, 95 per cent c.i. 0·40 to 0·60) and fewer days in hospital (rate ratio 0·84, 0·76 to 0·93).
Conclusion
Palliative care is underused after amputation in patients with PAD or diabetes, and could contribute to reducing in-hospital death and time spent in hospital at the end of life.
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Affiliation(s)
- C de Mestral
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
| | - A T Hsu
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | | | - D S Lee
- ICES, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - M A Hussain
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - K Salata
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - M Al-Omran
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - P Tanuseputro
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
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Ferrè F, Vinci B, Murante AM. Performance of care for end‐of‐life cancer patients in Tuscany: The interplay between place of care, aggressive treatments, opioids, and place of death. A retrospective cohort study. Int J Health Plann Manage 2019; 34:1251-1264. [DOI: 10.1002/hpm.2789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Francesca Ferrè
- Scuola Superiore Sant'Anna Institute of Management and Department EMbeDS Pisa Italy
| | - Bruna Vinci
- Scuola Superiore Sant'Anna Institute of Management and Department EMbeDS Pisa Italy
| | - Anna Maria Murante
- Scuola Superiore Sant'Anna Institute of Management and Department EMbeDS Pisa Italy
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Chiang JK, Lee YC, Kao YH. Association between palliative care and end-of-Life care for patients with hematological malignancies: A population-based study. Medicine (Baltimore) 2019; 98:e17395. [PMID: 31577748 PMCID: PMC6783235 DOI: 10.1097/md.0000000000017395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To date, few studies have examined the end-of-life (EOL) care for patients with hematological malignancies (HMs). We evaluated the effects of palliative care on the quality of EOL care and health care costs for adult patients with HMs in the final month of life.We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for patient medical records, health care costs, and insurance system exit dates (our proxy for death) between 2000 and 2011.A total of 724 adult patients who died of HMs were investigated. Of these patients, 43 (5.9%) had received only inpatient palliative care (i-Pal group), and 19 (2.6%) received home palliative care (h-Pal group). The mean health care costs during the final month of life were not significantly different between the non-Pal and Pal groups (p=0.315) and between the non-Pal, i-Pal, and h-Pal groups (p=0.293) either. By the multivariate regression model, the i-Pal group had lower risks of chemotherapy, ICU admission, and receipt of CPR, but higher risks of at least two hospitalizations and dying in hospital after adjustments. The h-Pal group had the similar trends as the i-Pal group but lower risk of dying in hospital after adjustments.Patients with HMs who had received palliative care could benefit from less aggressive EOL cancer care in the final month of life. However, 8.6% patients with HMs received palliative care. The related factors of more hospitalizations and dying in hospital warrant further investigation.
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Affiliation(s)
- Jui-Kun Chiang
- Department of Family Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi
| | | | - Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
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Abstract
PURPOSE OF REVIEW Care near the end of life is expensive and frequently not aligned with the expressed preferences of decedents, creating an opportunity to improve value, or increase quality while lowering cost. This review examines publications from 2017 and 2018 on interventions and policies associated with high-value end-of-life care. Innovations in video and web-based advance care planning are promising to improve preference-congruent care at low cost. RECENT FINDINGS The patterns of care within hospice and in particular increased investment in patient care in hospice are shown to improve value. A meta-analysis demonstrated the role of inpatient palliative care consultations in decreasing hospitalization costs, as did several studies on inpatient palliative care units. Internationally, a range of home-based palliative care programs, implemented at the population level, demonstrated cost savings and reduced intensive care near the end of life. Finally, public policies that funded medical and long-term care and address broader inequalities were demonstrated to decrease low-value care near the end of life. SUMMARY This review demonstrates the efficacy of a range of approaches to improve value of care at the end of life, both within the health system and across public policy sectors.
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Webber C, Hsu AT, Tanuseputro P, Fitzgibbon E, Li C. Acute Care Utilization and Place of Death among Patients Discharged from an Inpatient Palliative Care Unit. J Palliat Med 2019; 23:54-59. [PMID: 31305204 DOI: 10.1089/jpm.2019.0162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Discharging patients from inpatient palliative care units to the community is aligned with patients' desires to be cared for and die at home. However, there is little research examining patient outcomes after discharge. Objective: To describe the outcomes of patients discharged from an inpatient palliative care unit. Design: A single-institution retrospective cohort study using medical record data linked to regional acute care hospital and home care data. Setting/Participants: Patients (n = 75) discharged to the community over a one-year period from a 31-bed inpatient palliative care unit in an academic continuing care facility. Measurements: Survival, postdischarge hospitalizations and emergency department visits, and place of death. Results: Patients discharged to the community had poor prognosis. Over one-third had a discharge Palliative Performance Score <50. The median survival after discharge was 96 days, and 36% of decedent patients died in an acute care hospital. Thirteen percent of patients were hospitalized, and 23% visited an emergency department within 30 days of discharge, often for reasons that could have been managed in the community. Certain groups of patients were at greater risk of acute care use and in-hospital deaths, including younger patients, patients with nonmalignant diseases, and patients discharged home or retirement home, compared to long-term care settings. Conclusions: Patients discharged from an inpatient palliative care setting are at risk of postdischarge hospitalizations, emergency department visits, and in-hospital deaths, despite having community supports in place. Variations in outcomes can point to groups of patients who may require greater intensity of supports postdischarge.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward Fitzgibbon
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Cecilia Li
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Wales J, Kalia S, Moineddin R, Husain A. The Impact of Socioeconomic Status on Place of Death Among Patients Receiving Home Palliative Care in Toronto, Canada: A Retrospective Cohort Study. J Palliat Care 2019; 35:167-173. [PMID: 31204570 DOI: 10.1177/0825859719855020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Socioeconomic disparities in home death have been noted in the literature. Home-based palliative care increases access to home death and has been suggested as a means to decrease these disparities. AIM Our study examines the association between socioeconomic status and other demographic factors on place of death in a population receiving home palliative care in Toronto, Canada. DESIGN This is a retrospective chart review of patients who died between August 2013 and August 2015 when admitted to a home-based palliative care service. Multivariate multinomial regression examined the relationship between the place of death (home, palliative care unit [PCU], or acute care) with age, gender, primary diagnosis, and income quintile. Bivariate logistic regression was fitted to calculate the odds ratio (OR) and probability of preference for home death. SETTING/PARTICIPANTS Patients receiving home-based palliative care services from the Latner Centre for Palliative Care in Toronto, Canada. RESULTS A total of 2066 patients were included in multivariate analysis. Patients in the lowest income quintile had increased odds of dying in acute care (OR = 2.41, P < .001) or dying in PCU (OR = 1.64, P = .008) than patients in highest income quintile. Patients in the next lowest income quintiles 2 and 3 were also more likely to die in acute care. The rate of preference for home death was significantly lower in the lowest income quintile (OR = 0.47, P = .0047). CONCLUSIONS Patients in lower income quintiles are less likely to die at home, despite receiving home-based palliative care, although they may also be less likely to prefer home death.
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Affiliation(s)
- Joshua Wales
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sumeet Kalia
- University of Toronto Practice Based Research Network, North York General Hospital, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amna Husain
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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Evans JM, Mackinnon M, Pereira J, Earle CC, Gagnon B, Arthurs E, Gradin S, Buchman S, Wright FC. Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project. Psychooncology 2019; 28:1261-1268. [PMID: 30946500 DOI: 10.1002/pon.5076] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys. RESULTS A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46 days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54 days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified. CONCLUSIONS A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.
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Affiliation(s)
- Jenna M Evans
- Integrated Care Unit, Cancer Care Ontario, Toronto.,DeGroote School of Business, McMaster University, Hamilton
| | | | - Jose Pereira
- Academic Family Medicine Division, College of Family Physicians of Canada, Mississauga.,School of Medicine, Faculty of Health Sciences, Queen's University, Kingston.,Division of Palliative Care, Department of Family Medicine, University of Ottawa, Ottawa.,Division of Palliative Care, Faculty of Health Sciences, McMaster University, Hamilton.,Pallium Canada, Ottawa
| | - Craig C Earle
- Institute for Clinical and Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto
| | - Bruno Gagnon
- Department of Family Medicine and Emergency Medicine, Cancer Research Centre, Laval University, Quebec City
| | - Erin Arthurs
- Integrated Care Unit, Cancer Care Ontario, Toronto
| | | | - Sandy Buchman
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto.,Division of Palliative Care, Department of Family & Community Medicine, University of Toronto, Toronto
| | - Frances C Wright
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto.,Department of Surgery, Faculty of Medicine, University of Toronto, Toronto
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