Use of Inpatient Palliative Care Services in Patients With Advanced Cancer Receiving Critical Care Therapies

Perioperative Complications and In-hospital Mortality After Cystectomy for Nonbladder Cancer Conditions Versus Radical Cystectomy for Bladder Cancer

OBJECTIVE

This study was designed to test for perioperative complications, mortality, and length of stay after cystectomy for nonbladder cancer (non-BCa) v radical cystectomy (RC) for bladder cancer (BCa).

METHODS

Patients were identified within the National Inpatient Sample (2000-2019). Multivariable logistic and Poisson regression models were fitted.

RESULTS

Of 26,721 cystectomy patients, 1314 (5%) harbored non-BCa diagnosis: 515 (39%) neurogenic bladder; 379 (29%) radiation cystitis; 238 (18%) interstitial cystitis; 181 (14%) bladder fistula. Relative to RC for BCa, cystectomy for neurogenic bladder, radiation cystitis and bladder fistula resulted in higher genitourinary (22-39 vs. 14%; multivariable odds ratios [MOR] 1.7-3.8), infectious (7-8 vs. 4%; MOR 1.5-2.3), and wound (9 vs. 5%; MOR 1.5-2.0) complications rates. Only cystectomy for neurogenic bladder resulted in higher pulmonary complications (15 vs. 11%; MOR 1.8). Additionally, cystectomy for neurogenic bladder and bladder fistula independently predicted 1.5-fold higher rate of critical care therapy (CCT) use, but only cystectomy for neurogenic bladder exhibited 2.4-fold higher in-hospital mortality rate. Finally, cystectomy for neurogenic bladder, radiation cystitis, and bladder fistula resulted in higher rates of hospital stay ≥ 75th percentile (33-47 vs. 27%; MOR 1.7-2.8).

CONCLUSIONS

Relative to RC for BCa, cystectomy for three of four non-BCa conditions resulted in higher rates of four of 12 in-hospital adverse outcomes. Additionally, cystectomy for two of four non-BCa conditions resulted in higher CCT use, but only cystectomy for neurogenic bladder predicted higher rate of in-hospital mortality.

Comparison of In-Hospital Outcomes at Robot-Assisted Versus Open Partial Nephrectomy

OBJECTIVE

The aim of this work is to quantify the magnitude of improvement in in-hospital outcomes between historical and contemporary robot-assisted partial nephrectomy (RPN) versus historical and contemporary open PN (OPN).

METHODS

Within the Nationwide Inpatient Sample (2010-2019), we identified patients who underwent RPN and OPN. Multivariable logistic regression models were fit.

RESULTS

Historical (2010-2014) versus contemporary (2015-2019) proportions were 39% (n = 5,897) versus 61% (n = 9168) for RPN and 59% (n = 7289) versus 41% (n = 5,120) for OPN. Relative to historical, contemporary RPN patients exhibited significantly better in-hospital outcomes in 6 of 12 categories that ranged from-76% for intraoperative complications to-24% for length of stay (LOS) ≥ 75th percentile. Relative to historical, contemporary OPN patients also exhibited significantly better in-hospital outcomes in 7 of 12 categories that ranged from-76% for intraoperative complications to-23% for LOS ≥ 75th percentile. When historical RPN was compared with historical OPN, RPN in-hospital outcomes were better in 10 of 12 comparisons that ranged from-75% for LOS ≥ 75th percentile to-28% for perioperative bleeding. Similarly, when contemporary RPN was compared with contemporary OPN, RPN outcomes were better in 8 of 12 comparisons that ranged from-75% for LOS ≥ 75th percentile to-27% for postoperative complications.

CONCLUSION

The magnitude of improvement in in-hospital outcomes was more pronounced for contemporary versus historical OPN (seven improved categories) than for contemporary versus historical RPN (six improved categories). However, contemporary RPN outperformed contemporary OPN patients in eight in-hospital outcome categories.

Critical care therapy and in-hospital mortality after radical nephroureterectomy for nonmetastatic upper urinary tract carcinoma

BACKGROUND

Use of critical care therapies (CCT), that include invasive mechanical ventilation (IMV), total parenteral nutrition (TPN) and other modalities are unknown after radical nephroureterectomy (RNU) for upper urinary tract carcinoma (UUTC). Their relationship with in-hospital mortality is also unknown.

METHODS

Within the National Inpatient Sample (2008-2019), we identified non-metastatic UUTC patients treated with RNU. Multivariable logistic regression models were used.

RESULTS

Of 8,995 patients, 375 (4.2%) received CCT and 82 (0.9%) experienced in-hospital mortality. Of CCT modalities, 215 (2.4%) received IMV and 139 (1.5%) TPN. Temporal CCT, IMV, and TPN trends very closely followed in-hospital mortality trends. Relative to historical UUTC patients (2008-2013), contemporary (2014-2019) patients exhibited lower CCT (Δ = 2.2%, P value < 0.0001), lower IMV (Δ = 1.4%, P < 0.0001), lower TPN (Δ = 2.2%, P < 0.0001), and lower in-hospital mortality (Δ = 0.4%, P = 0.03) rates. Of in-hospital mortalities, 52 out of 82 received CCT but 30 of 82 did not. Median age (> 72 years; odds ratio [OR] 1.4; P = 0.002) and Charlson comorbidity index ≥ 3 (OR 4.1; P < 0.001) and ≥ 1-2 (OR 1.7; P = 0.001) independently predicted overall higher CCT, IMV, TPN, and in-hospital mortality.

CONCLUSION

After RNU, CCT rates parallels in-hospital mortality rates. CCT represents a 5 to 6-fold multiple of in-hospital mortality rate. In RNU patients, CCT rates are higher in older and sicker individuals. Lower CCT rates that are paralleled by lower in-hospital mortality may be interpreted as an indicator of improved quality of care. Ideally all in-hospital mortalities should be predated by CCT exposure.

The Effect of Chronic Kidney Disease on Adverse In-Hospital Outcomes at Radical Prostatectomy

OBJECTIVE

Radical prostatectomy (RP) may be a treatment option for prostate cancer in patients with chronic kidney disease (CKD). However, the effect of CKD on adverse in-hospital outcomes after RP is not well known.

METHODS

Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample RP patients between 2005 and 2019. CKD severity was stratified as mild (stage I/II) versus moderate (stage III) versus severe (stage IV/V).

RESULTS

Of 191 050 RP patients, 4349 (2.3%) had CKD. Of those, 2301 (52.9%), 1416 (32.6%), and 632 (14.5%) were classified as mild, moderate, or severe CKD, respectively. The CKD rate increased from 0.3% to 5.6% (2005-2019, EAPC: + 15.3%, p < 0.001). CKD patients invariably exhibited higher rates of adverse in-hospital outcomes, except for in-hospital mortality. The absolute differences were largest for overall complications (+ 12.5%), length of stay > 2 days (+ 11.8%), and blood transfusions (+ 3.7%, all p < 0.001). CKD was an independent predictor in all comparisons except for in-hospital mortality (p < 0.05). The detrimental effect was most pronounced for dialysis for acute kidney failure (multivariable odds ratio [OR] 10.49), genitourinary complications (OR: 2.47), and critical care therapies (OR: 2.45, all p < 0.001). Finally, a dose-response relationship of CKD severity (mild vs. moderate vs. severe) and its effect on adverse in-hospital outcomes was observed in seven of 14 comparisons.

CONCLUSIONS

CKD patients invariably exhibited higher rates of adverse in-hospital outcomes after RP. The presence of CKD should be carefully considered when RP represents a management option.

The effect of chronic kidney disease on adverse in-hospital outcomes after radical cystectomy with ileal conduit urinary diversion

PURPOSE

Chronic kidney disease (CKD) is frequent in bladder cancer patients undergoing radical cystectomy (RC) with ileal conduit. However, the effect of CKD on adverse in-hospital outcomes after ileal conduit RC is not well known.

METHODS

Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample patients treated with ileal conduit RC between 2006 and 2019. CKD severity was stratified as mild (stage II) vs. moderate (stage III) vs. severe (stage IV/V).

RESULTS

Of 13,359 patients treated with RC with ileal conduit, 1973 (14.8%) had CKD. Of those, 956 (48.5%), 802 (40.6%), and 215 (10.9%) were classified as mild, moderate, or severe CKD, respectively. CKD rate increased from 4.1 to 21.9% (2006-2019, EAPC: +8.9%, p < 0.001). CKD RC patients exhibited higher rates of adverse in-hospital outcomes in 11 of 15 categories. The absolute differences were largest for overall complications (+ 13.2%), prolonged length of stay (+ 7.0%), blood transfusions (+ 6.0%, all p < 0.001). After detailed multivariable adjustment, CKD was an independent predictor of 11 of 15 adverse in-hospital outcomes' categories. The detrimental effect of CKD was most pronounced for dialysis (OR 7.09), overall complications (OR 1.84), and neurological complications (OR 1.61, all p < 0.001). Finally, a dose-response effect according to CKD severity on adverse in-hospital outcomes was observed in eight of 15 categories.

CONCLUSIONS

CKD RC patients invariably exhibited higher rates of adverse in-hospital outcomes after RC with ileal conduit. In consequence this patient group should receive particularly strong consideration for preoperative optimization.

Effect of Race/Ethnicity on In-hospital Outcomes After Radical Cystectomy

OBJECTIVE

Previously, African American race/ethnicity predisposed to higher rate of adverse in-hospital outcomes after radical cystectomy (RC). We tested whether this association applies to contemporary RC patients.

METHODS

Patients were identified within the National Inpatient Sample (NIS 2000-2019). Multivariable logistic and Poisson regression models were fitted.

RESULTS

Of 19,370 RC patients, 1,089 (5.6%) were African American, while 18,281 (94.4%) were Caucasian. Relative to Caucasians, African Americans were younger (median age 66 vs. 70 years; p < 0.001), more frequently female (33.8 vs. 18.5%; p < 0.001) and more frequently in the lowest income quartile (46.8 vs. 18.6%; p < 0.001). Relative to Caucasians, after RC, African Americans exhibited higher rates of postoperative complications (61.3 vs. 58.3%; multivariable odds ratio [MOR] 1.2; p = 0.009). Specifically, African Americans exhibited higher rates of blood transfusions (30.2 vs. 24.1%; MOR 1.3; p < 0.001), gastrointestinal (26.7 vs. 24.1%; MOR 1.2; p = 0.003), and infectious (6.2 vs. 4.2%; MOR 1.5; p = 0.001) complications, as well as deep vein thrombosis (3.1 vs. 1.7%; MOR 1.9; p < 0.001). Additionally, after RC, African Americans exhibited higher rates of critical care therapy use (CCT; 13.9 vs. 12.2%; MOR 1.3; p = 0.002) and in-hospital mortality (2.8 vs. 1.7%; MOR 1.8; p = 0.002). Finally, African Americans exhibited higher rates of length of stay ≥ 75th percentile (40.9 vs. 31.2%; MOR 1.6; p < 0.001).

CONCLUSIONS

In contemporary RC patients, African American race/ethnicity predisposes to less favorable in-hospital outcomes, including higher in-hospital mortality and longer hospital stay. Unfortunately, these race/ethnicity disadvantages have not been improved upon relative to the previous report.

Effects of Inpatient Hospice Care on Cost and Medication Use in Patients with Lung Cancer: A Population-Based Retrospective Study in South Korea

Background: Inpatient hospices (IHs) can alleviate distress and address economic burdens on patients with terminal cancer. However, there have been inconsistent findings regarding IHs in terms of cost savings and medication use. Objective: We aimed to examine cost savings associated with IHs, according to the timing of first hospitalization before death, and analyze their use of medication, among Korean patients with terminal lung cancer. Methods: Using the South Korean national health insurance claim database, we identified 31,139 patients with lung cancer who died between 2017 and 2020. Their daily hospitalization costs were analyzed using a generalized linear model stratified by time of first hospitalization before death. Medication use was examined using a negative binomial model. Results: IHs spent $134, and $21 less on patients during days 1-7, and 8-30 before death, but $18, $44, $36, and $54 more during days 31-60, 61-90, and 91-180, respectively, compared with non-IHs (all p < 0.05). However, total hospitalization costs in the year preceding death did not differ (relative risk: 0.990, 95% confidence interval [CI]: 0.972-1.007, p > 0.05). IHs used 2.103 times more opioid analgesics (95% CI: 1.980-2.233, p < 0.001). They also used more antiemetics, delirium medications, and antianxiety agents, as well as fewer antidepressive agents, systemic steroids, diuretics, total parenteral nutrition, and antibiotics (all p < 0.05). Conclusions: Patients with terminal lung cancer in IHs in Korea were more likely to receive symptom-oriented medications and experienced reduced hospitalization costs only during the 30 days preceding death.

Perioperative Complications and In-Hospital Mortality in Radical Nephroureterectomy Patients with Heart Valve Replacement

BACKGROUND

Perioperative complication rates and in-hospital mortality after radical nephroureterectomy (RNU) in patients with a history of heart valve replacement are unknown.

METHODS

Within the National Inpatient Sample (2000-2019), we identified non-metastatic upper urinary tract carcinoma patients treated with RNU according to the presence or absence of a history of heart valve replacement. Propensity score matching (1:10 ratio) and multivariable logistic regression as well as Poisson regression models were used.

RESULTS

Of 15,423 RNU patients, 151 (1.0%) harbored heart valve replacement. This proportion increased over the study span from 0.5% to 1.4% (p = 0.02). Heart valve replacement patients were older (median 78 vs. 72 years; p < 0.001), more frequently male (73 vs. 60%; p = 0.002), and more frequently harbored a Charlson Comorbidity Index (CCI) ≥3 (36 vs. 27%; p = 0.002). After 1:10 propensity score matching for age, sex, and CCI, the patients exhibited higher rates of perioperative bleeding (7.4 vs. 2.4%; odds ratio [OR] 3.2; p < 0.001), blood transfusions (24.0 vs. 17.0%; OR 1.6; p = 0.02), and cardiac complications (24.0 vs. 14.0%; OR 2.1; p < 0.001). Conversely, heart valve replacement patients did not exhibit higher rates of critical care therapy (OR 1.06; p = 0.8), higher rates of in-hospital mortality (OR 0.8; p = 0.8), and longer length of stay (OR 1.4; p = 0.052) than their RNU counterparts without a history of heart valve replacement.

CONCLUSION

RNU patients with a history of heart valve replacement are at significantly increased risk of perioperative bleeding, blood transfusions, and cardiac complications; however, despite these increased risks, they neither exhibited higher critical care therapy rates or higher in-hospital mortality rates, nor did they require significantly longer hospital stay.

Urinary Diversion Versus Adverse In-Hospital Outcomes After Radical Cystectomy

OBJECTIVE

This study aimed to compare adverse in-hospital outcomes in ileal conduit versus neobladder urinary diversion type after radical cystectomy (RC) in contemporary versus historical patients.

METHODS

Patients were identified within the National Inpatient Sample (NIS 2000-2019). Propensity score matching (PSM; 1:2 ratio) and multivariable logistic regression models (LRMs) were used.

RESULTS

Of 10,533 contemporary (2011-2019) patients, 943 (9.0%) underwent neobladder urinary diversion, while 9590 (91.0%) underwent ileal conduit urinary diversion. Furthermore, of 9742 historical (2010-2019) patients, 932 (9.6%) underwent neobladder urinary diversion and 8810 (90.4%) underwent ileal conduit urinary diversion. After 1:2 PSM, within the contemporary cohort, 943/943 (100%) neobladder versus 1886/9590 (19.6%) ileal conduit patients were included. Similarly, within the historical cohort, 932/932 (100%) neobladder versus 1864/8810 (21.1%) ileal conduit patients were included after PSM. In multivariable LRMs, relative to contemporary neobladder patients, contemporary ileal conduit patients exhibited higher rates of overall postoperative (49.0 vs. 43.6%; multivariable odds ratio [MOR] 1.2), wound (4.2 vs. 2.7%; MOR 1.6), and genitourinary (13.1% vs. 10.0%; MOR 1.3) complications as well as blood transfusions (19.0 vs. 15.6%; MOR 1.3). Conversely, in multivariable LRMs within the historical cohort, no differences were recorded between ileal conduit and neobladder patients.

CONCLUSIONS

Unlike historical comparisons between ileal conduit and neobladder patients, where no differences in adverse in-hospital outcomes were recorded, analyses relying on a contemporary patient cohort subject to PSM and multivariable adjustment revealed higher rates of adverse in-hospital outcomes in 4/13 examined categories. This observation should be considered at informed consent.

Palliative Care as a Component of High-Value and Cost-Saving Care During Hospitalization for Metastatic Cancer

PURPOSE

Randomized controlled trials have demonstrated that palliative care (PC) can improve quality of life and survival for outpatients with advanced cancer, but there are limited population-based data on the value of inpatient PC. We assessed PC as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer and identified hospitalization characteristics significantly associated with high costs.

METHODS

Hospitalizations of patients 18 years and older with a primary diagnosis of metastatic cancer from the National Inpatient Sample from 2010 to 2019 were analyzed. We used multivariable mixed-effects logistic regression to assess medical services, patient demographics, and hospital characteristics associated with higher charges billed to insurance and hospital costs. Generalized linear mixed-effects models were used to determine cost savings associated with provision of PC.

RESULTS

Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in US dollars (USD) to $56,098 USD, whereas the median hospital cost remained stable at $14,300 USD. Receipt of inpatient PC was associated with significantly lower charges (odds ratio [OR], 0.62 [95% CI, 0.61 to 0.64]; P < .001) and costs (OR, 0.59 [95% CI, 0.58 to 0.61]; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), young age (18-49 years, P < .001), and for-profit hospitals (P < .001). PC provision was associated with a $1,310 USD (-13.6%, P < .001) reduction in costs per hospitalization compared with no PC, independent of the receipt of invasive care and age.

CONCLUSION

Inpatient PC is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Integration of inpatient PC may de-escalate costs incurred through low-value inpatient interventions.

Trends and Disparities in Inpatient Palliative Care Use in Metastatic Renal Cell Carcinoma Patients Receiving Critical Care Therapy

PURPOSE

Temporal trends in and predictors of inpatient palliative care use in patients with metastatic renal cell carcinoma (mRCC) undergoing critical care therapy are unknown.

METHODS

Relying on the National Inpatient Sample (2008-2019), we identified mRCC patients undergoing critical care therapy, namely invasive mechanical ventilation, percutaneous endoscopic gastrostomy tube insertion, dialysis for acute kidney failure, total parenteral nutrition, or tracheostomy. Estimated annual percentage changes (EAPC) analyses and multivariable logistic regression models addressed inpatient palliative care use.

RESULTS

Of 3802 mRCC patients undergoing critical care therapy, 817 (21.5%) received inpatient palliative care. Overall, inpatient palliative care use increased from 4.9% to 31.5% between 2008 and 2019 (EAPC +9.2%). In subgroup analyses, the highest increase in inpatient palliative care use was observed in the Midwest (EAPC: +11.9%), in the South (EAPC +10.4%), and in teaching hospitals (EAPC +9.0%; all P ≤ .004). In logistic regression models, teaching hospital status (odds ratio [OR] 1.41) and contemporary year interval (OR 2.12; all P < .001) independently predicted higher inpatient palliative care rates. Conversely, hospital admission in the Northeast (OR 0.53) or in the South (OR 0.79; all P ≤ .03) was associated with lower inpatient palliative care rates than in the West.

CONCLUSION

In mRCC patients, inpatient palliative care rates have improved over time, with the highest increase in hospitals in the Midwest and in the South. Moreover, admission to teaching hospitals or in the West is associated with higher inpatient palliative care rates. In consequence, regional disparities, as well as differences according to teaching hospital status represent targets to achieve comprehensive inpatient palliative care coverage in mRCC patients receiving critical care therapy.

In-Hospital Outcomes after Robotic Vs Open Radical Nephroureterectomy

Objective: To test whether the contemporary robot-assisted nephroureterectomy (RNU) is associated with more favorable in-hospital outcomes than historical RNU, relative to the same endpoints in open NU (ONU). Methods: Within the National Inpatient Sample (2008-2019), we identified RNU and ONU patients. Multivariable logistic and Poisson regression models were fitted. Results: Of 8032 NU patients, historical (2008-2013) vs contemporary (2014-2019) proportions were 776 (41%) vs 1104 (59%) for RNU and 3719 (60%) vs 2433 (40%) for ONU. The rates of RNU have increased over time (2008-2019; Δ absolute: +18%; p < 0.001). Contemporary RNU patients exhibited significantly better in-hospital outcomes in 6 of 12 comparisons vs historical that ranged from -54% for genitourinary complications to -12% for median length of stay (LOS). Contemporary ONU patients also exhibited significantly better in-hospital outcomes in 11 of 12 comparisons vs historical that ranged from -67% for blood transfusions to -26% for gastrointestinal complications. When historical RNU was compared with historical ONU, RNU in-hospital outcomes were better in 7 of 12 comparisons that ranged from -61% for median LOS to -16% for postoperative complications. Conversely, when contemporary RNU was compared with contemporary ONU, RNU in-hospital outcomes were only better in 2 of 12 comparisons: -25% cardiac complications and -13% for median LOS. Conclusion: The magnitude of in-hospital outcomes categories improvement between historical vs contemporary was two-fold more pronounced in ONU (11 improved categories) than in RNU (6 improved categories). Few outcome benefits remained (two categories only) when contemporary RNU was compared with contemporary ONU.

Use of inpatient palliative care in metastatic testicular cancer patients undergoing critical care therapy: insights from the national inpatient sample

To test for rates of inpatient palliative care (IPC) in metastatic testicular cancer patients receiving critical care therapy (CCT). Within the Nationwide Inpatient Sample (NIS) database (2008-2019), we tabulated IPC rates in metastatic testicular cancer patients receiving CCT, namely invasive mechanical ventilation (IMV), percutaneous endoscopic gastrostomy tube (PEG), dialysis for acute kidney failure (AKF), total parenteral nutrition (TPN) or tracheostomy. Univariable and multivariable logistic regression models addressing IPC were fitted. Of 420 metastatic testicular cancer patients undergoing CCT, 70 (17%) received IPC. Between 2008 and 2019, the rates of IPC among metastatic testicular cancer patients undergoing CCT increased from 5 to 19%, with the highest rate of 30% in 2018 (EAPC: + 9.5%; 95% CI + 4.7 to + 15.2%; p = 0.005). IPC patients were older (35 vs. 31 years, p = 0.01), more frequently had do not resuscitate (DNR) status (34 vs. 4%, p < 0.001), more frequently exhibited brain metastases (29 vs. 17%, p = 0.03), were more frequently treated with IMV (76 vs. 53%, p < 0.001) and exhibited higher rate of inpatient mortality (74 vs. 29%, p < 0.001). In multivariable analyses, DNR status (OR 10.23, p < 0.001) and African American race/ethnicity (OR 4.69, p = 0.003) were identified as independent predictors of higher IPC use. We observed a significant increase in rates of IPC use in metastatic testicular cancer patients receiving CCT, rising from 5 to 19% between 2008 and 2019. However, this rates remain lower compared to metastatic lung cancer patients, indicating the need for further awareness among clinicians treating metastatic testicular cancer. The increase in IPC rates for metastatic testicular cancer patients receiving CCT indicates a need for ongoing education and awareness among healthcare providers. This could enhance the integration of IPC in the treatment of advanced cancer, potentially improving quality of life and care outcomes for survivors.

Critical Care Therapy After Cytoreductive Nephrectomy for Metastatic Kidney Cancer

OBJECTIVES

To examine critical care therapy rates after cytoreductive nephrectomy in metastatic kidney cancer patients.

DESIGN, SETTING, AND PATIENTS

Relying on the National Inpatient Sample (2000-2019), we addressed critical care therapy use (total parenteral nutrition, invasive mechanical ventilation, renal replacement therapy, percutaneous endoscopic gastrostomy tube insertion, and tracheostomy) and in-hospital mortality in surgically treated metastatic kidney cancer patients. Estimated annual percentage changes and multivariable logistic regression models were fitted.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 10,915 patients, 802 (7.3%) received critical care therapy and 249 (2.4%) died in-hospital. Over time, critical care therapy rates did not differ significantly (6.6% in 2000 to 5.7% in 2019; p = 0.07), while in-hospital mortality decreased from 2.3% to 1.9% (p = 0.004). Age 71 years old or older (odds ratio [OR], 1.43; p < 0.001) and higher comorbidity burden (Charlson Comorbidity Index [CCI] ≥ 3: OR, 2.92; p < 0.001 and CCI 1-2: OR, 1.45; p < 0.001) independently predicted higher critical care therapy rates. Conversely, partial nephrectomy (OR, 0.51; p = 0.003) and minimally invasive surgery (OR, 0.33; p < 0.001) predicted lower critical care therapy rates. Virtually the same associations were recorded for in-hospital mortality.

CONCLUSIONS

After cytoreductive nephrectomy, critical care therapy rate was 7.3% vs. in-hospital mortality was 2.4%. Of patients at highest risk of critical care therapy need were those with CCI greater than or equal to 3 and those 71 years old or older. Ideally, these patients should represent targets for thorough assessment of risk factors for complications before cytoreductive nephrectomy.

Perioperative Complications and In-Hospital Mortality in Paraplegic Radical Cystectomy Patients

OBJECTIVE

The aim of this study was to test for the association between paraplegia and perioperative complications as well as in-hospital mortality after radical cystectomy (RC) for non-metastatic bladder cancer.

METHODS

Perioperative complications and in-hospital mortality were tabulated in RC patients with or without paraplegia in the National Inpatient Sample (2000-2019).

RESULTS

Of 25,527 RC patients, 185 (0.7%) were paraplegic. Paraplegic RC patients were younger (≤70 years of age; 75 vs. 53%), more frequently female (28 vs. 19%), and more frequently harbored Charlson Comorbidity Index ≥3 (56 vs. 18%). Of paraplegic vs. non-paraplegic RC patients, 141 versus 15,112 (76 vs. 60%) experienced overall complications, 38 versus 2794 (21 vs. 11%) pulmonary complications, 36 versus 3525 (19 vs. 14%) genitourinary complications, 33 versus 3087 (18 vs. 12%) intraoperative complications, 21 versus 1035 (11 vs. 4%) infections, and 17 versus 1343 (9 vs. 5%) wound complications, while 62 versus 6267 (34 vs. 25%) received blood transfusions, 47 versus 3044 (25 vs. 12%) received critical care therapy (CCT), and intrahospital mortality was recorded in 13 versus 456 (7.0 vs. 1.8%) patients. In multivariable logistic regression models, paraplegic status independently predicted higher overall CCT use (odds ratio [OR] 2.1, p < 0.001) as well as fourfold higher in-hospital mortality (p < 0.001), higher infection rate (OR 2.5, p < 0.001), higher blood transfusion rate (OR 1.45, p = 0.009), and higher intraoperative (OR 1.56, p = 0.02), wound (OR 1.89, p = 0.01), and pulmonary (OR 1.72, p = 0.004) complication rates.

CONCLUSION

Paraplegic patients contemplating RC should be counseled about fourfold higher risk of in-hospital mortality and higher rates of other untoward effects.

Adverse In-Hospital Outcomes after Radical Prostatectomy in Leukemia History Patients

INTRODUCTION

Leukemia history affects some radical prostatectomy (RP) patients. Although its prevalence and effect as an adverse risk factor are well known in cardiac surgery, the number of RP patients with a leukemia history, as well as their rate of adverse in-hospital outcomes, are unknown.

METHODS

We identified RP patients (National Inpatient Sample 2000-2019), stratified according to the presence or absence of a leukemia history. Descriptive analyses, propensity score matching (PSM, ratio 1:10), and multivariable logistic regression models were used.

RESULTS

Of 259,939 RP patients, 416 (0.2%) had a leukemia history. Their proportion increased from 0.1 to 0.2% covering the study span (p < 0.01). Leukemia history patients were older (median age, 64 vs. 62 years, p < 0.001). After PSM for age, insurance status, ethnicity, pelvic lymph node dissection, and Charlson Comorbidity Index, leukemia history RP patients exhibited higher rates of acute kidney injury (<2.6 vs. 0.9%; Odds Ratio [OR] 2.0, p = 0.02), more frequently underwent dialysis (3.6 vs. 1.9%; OR 1.9, p = 0.03), and more frequently had a length of stay exceeding one week (4.8 vs. 2.5%; OR 2.0, p = 0.006).

CONCLUSIONS

Although leukemia history RP patients are rare, their numbers have increased. Renal complications and extended hospital stays are more frequent in those individuals.

Perioperative Complications and In-Hospital Mortality in Partial and Radical Nephrectomy Patients with Heart-Valve Replacement

BACKGROUND

In-hospital mortality and complication rates after partial and radical nephrectomy in patients with history of heart-valve replacement are unknown.

PATIENTS AND METHODS

Relying on the National Inpatient Sample (2000-2019), kidney cancer patients undergoing partial or radical nephrectomy were stratified according to presence or absence of heart-valve replacement. Multivariable logistic and Poisson regression models addressed adverse hospital outcomes.

RESULTS

Overall, 39,673 patients underwent partial nephrectomy versus 94,890 radical nephrectomy. Of those, 248 (0.6%) and 676 (0.7%) had a history of heart-valve replacement. Heart-valve replacement patients were older (median partial nephrectomy 69 versus 60 years; radical nephrectomy 71 versus 63 years), and more frequently exhibited Charlson comorbidity index ≥ 3 (partial nephrectomy 22 versus 12%; radical nephrectomy 32 versus 23%). In partial nephrectomy patients, history of heart-valve replacement increased the risk of cardiac complications [odds ratio (OR) 4.33; p < 0.001), blood transfusions (OR 2.00; p < 0.001), intraoperative complications (OR 1.53; p = 0.03), and longer hospital stay [rate ratio (RR) 1.25; p < 0.001], but not in-hospital mortality (p = 0.5). In radical nephrectomy patients, history of heart-valve replacement increased risk of postoperative bleeding (OR 4.13; p < 0.001), cardiac complications (OR 2.72; p < 0.001), intraoperative complications (OR 1.53; p < 0.001), blood transfusions (OR 1.27; p = 0.02), and longer hospital stay (RR 1.12; p < 0.001), but not in-hospital mortality (p = 0.5).

CONCLUSIONS

History of heart-valve replacement independently predicted four of twelve adverse outcomes in partial nephrectomy and five of twelve adverse outcomes in radical nephrectomy patients including intraoperative and cardiac complications, blood transfusions, and longer hospital stay. Conversely, no statistically significant differences were observed in in-hospital mortality.

Use of inpatient palliative care in metastatic urethral cancer

BACKGROUND

In metastatic urethral cancer, temporal trends, and patterns of inpatient palliative care (IPC) use are unknown.

METHODS

Relying on the National Inpatient Sample (2006-2019), metastatic urethral cancer patients were stratified according to IPC use. Estimated annual percentage changes (EAPC) analyses and multivariable logistic regression models (LRM) for the prediction of IPC use were fitted.

RESULTS

Of 1,106 metastatic urethral cancer patients, 199 (18%) received IPC. IPC use increased from 5.8 to 28.0% over time in the overall cohort (EAPC +9.8%; P < 0.001), from <12.5 to 35.1% (EAPC +11.2%; P < 0.001), and from <12.5 to 24.7% (EAPC +9.4%; P = 0.01) in respectively females and males. Lowest IPC rates were recorded in the Midwest (13.5%) vs. highest in the South (22.5%). IPC patients were more frequently female (44 vs. 37%), and more frequently exhibited bone metastases (45 vs. 34%). In multivariable LRM, female sex (multivariable odds ratio [OR] 1.46, 95% confidence interval [CI] 1.05-2.02; P = 0.02), and bone metastases (OR 1.46, 95%CI 1.02-2.10; P = 0.04) independently predicted higher IPC rates. Conversely, hospitalization in the Midwest (OR 0.53, 95%CI 0.31-0.91; P = 0.02), and in the Northeast (OR 0.48, 95%CI 0.28-0.82; P = 0.01) were both associated with lower IPC use than hospitalization in the West.

CONCLUSION

IPC use in metastatic urethral cancer increased from a marginal rate of 5.8% to as high as 28%. Ideally, differences according to sex, metastatic site, and region should be addressed to improve IPC use rates.

Perioperative complications and in-hospital mortality in radical cystectomy patients with heart-valve replacement

PURPOSE

To assess in-hospital mortality and complication rates after radical cystectomy (RC) in patients with history of heart-valve replacement.

MATERIALS AND METHODS

Using the National Inpatient Sample (2000-2019), non-metastatic bladder cancer patients undergoing RC were stratified according to history of heart-valve replacement. Regression models (RM) predicted hospital outcomes.

RESULTS

Of 25,535 RC patients, 250 (1.0%) harbored history of heart-valve replacement. Heart-valve replacement patients were older (median 74 vs. 70 years), more frequently male (87.2 vs. 80.6%), and more frequently had Charlson comorbidity index ≥3 (26.8 vs. 18.9%). In RC patients with history of heart-valve replacement vs. others, 62 vs. 2634 (24.8 vs. 10.4%) experienced cardiac complications, 28 vs. 3092 (11.2 vs. 12.2%) intraoperative complications, 11 vs. 1046 (4.4 vs. 4.1%) infections, <11 vs. 594 (<4.4 vs. 2.3%) perioperative bleeding, <11 vs. 699 (<4.4 vs. 2.8%) vascular complications, 74 vs. 6225 (29.6 vs. 24.7%) received blood transfusions, 37 vs. 3054 (14.8 vs. 12.1%) critical care therapy (CCT), and in-hospital mortality was recorded in <11 vs. 463 (<4.4 vs. 1.8%) patients. In multivariable RM, history of heart-valve replacement independently predicted cardiac complications (odds ratio 2.20, 95% confidence interval 1.62-2.99; p < 0.001). Conversely, no statically significant association was recorded between history of heart-valve replacement and length of stay, estimated hospital cost, intraoperative complications, perioperative bleeding, vascular complications, infections, blood transfusions, CCT use, and in-hospital mortality.

CONCLUSIONS

Radical cystectomy patients with history of heart-valve replacement exhibited a 2.2-fold higher risk of cardiac complications, but no other complications, including no significantly higher in-hospital mortality.

End-of-Life and Palliative Care Issues for Patients Living with Pulmonary Arterial Hypertension: Barriers and Opportunities

Pulmonary arterial hypertension (PAH) is a progressive, incurable disease that results in significant symptom burden, health care utilization, and eventually premature death. Despite the advancements made in treatment and management strategies, survival has remained poor. End-of-life care is a challenging issue in management of PAH, especially when patients are in younger age group. End-of-life care revolves around symptom palliation and reducing psychosocial disease burden for a dying patient and entails advanced care planning that are often challenging. Thus, support from palliative care specialist becomes extremely important in these patients. Early introduction to palliative care in patients with high symptom burden and psychosocial suffering is suggested. Despite of the benefits of an early intervention, palliative care remains underutilized in patients with PAH, and this significantly raises issues around end-of-life care in PAH. In this review, we will discuss the opportunities offered and the existing barriers in addressing high symptom burden and end-of-life care issues. We will focus on the current evidence, identify areas for future research, and provide a call-to-action for better guidance to PAH specialists in making timely, appropriate interventions that can help mitigate end-of-life care issues.

Temporal trends and barriers for inpatient palliative care referral in metastatic gynecologic cancer patients receiving specific critical care therapies

Objective

Existing evidence suggests that palliative care (PC) is highly underutilized in metastatic gynecologic cancer (mGCa). This study aims to explore temporal trends and predictors for inpatient PC referral in mGCa patients who received specific critical care therapies (CCT).

Methods

The National Inpatient Sample from 2003 to 2015 was used to identify mGCa patients receiving CCT. Basic characteristics were compared between patients with and without PC. Annual percentage change (APC) was estimated to reflect the temporal trend in the entire cohort and subgroups. Multivariable logistic regression was employed to explore potential predictors of inpatient PC referral.

Results

In total, 122,981 mGCa patients were identified, of whom 10,380 received CCT. Among these, 1,208 (11.64%) received inpatient PC. Overall, the rate of PC referral increased from 1.81% in 2003 to 26.30% in 2015 (APC: 29.08%). A higher increase in PC usage was found in white patients (APC: 30.81%), medium-sized hospitals (APC: 31.43%), the Midwest region (APC: 33.84%), and among patients with ovarian cancer (APC: 31.35%). Multivariable analysis suggested that medium bedsize, large bedsize, Midwest region, West region, uterine cancer and cervical cancer were related to increased PC use, while metastatic sites from lymph nodes and genital organs were related to lower PC referral.

Conclusion

Further studies are warranted to better illustrate the barriers for PC and finally improve the delivery of optimal end-of-life care for mGCa patients who receive inpatient CCT, especially for those diagnosed with ovarian cancer or admitted to small scale and Northeast hospitals.

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review

CONTEXT

Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations.

OBJECTIVES

To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes.

METHODS

We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention.

RESULTS

We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model.

CONCLUSION

Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.

Critical illness in patients with metastatic cancer: a population-based cohort study of epidemiology and outcomes

The appropriateness of intensive care unit (ICU) admission of patients with metastatic cancer remains debated. We aimed to examine the short-term outcomes and their temporal pattern in critically ill patients with metastatic disease. We used state-wide data to identify hospitalizations aged ≥18 years with metastatic cancer admitted to ICU in Texas during 2010-2014. Multivariable logistic regression modeling was used to examine the factors associated with short-term mortality and its temporal trends among all ICU admissions and those undergoing mechanical ventilation. Among 136,644 ICU admissions with metastatic cancer, 50.8% were aged ≥65 years, with one or more organ failures present in 53.3% and mechanical ventilation was used in 11.1%. The crude short-term mortality among all ICU admissions and those mechanically ventilated was 28.1% and 62.0%, respectively. Discharge to home occurred in 57.1% of all ICU admissions. On adjusted analyses, short-term mortality increased with rising number of organ failures (adjusted OR (aOR) 1.399, 95% CI 1.374 to 1.425), while being lower with chemotherapy (aOR 0.467, 95% CI 0.432 to 0.506) and radiation therapy (aOR 0.832, 95% CI 0.749 to 0.924), and decreased over time (aOR 0.934 per year, 95% CI 0.924 to 0.945). Predictors of short-term mortality were largely similar among those undergoing mechanical ventilation. Most ICU admissions with metastatic cancer survived hospitalization, although short-term mortality was very high among those undergoing mechanical ventilation. Short-term mortality decreased over time and was lower among those receiving chemotherapy and radiation therapy. These findings support consideration of critical care in patients with metastatic cancer, but underscore the need to address patient-centered goals of care ahead of ICU admission.

Portable Medical Orders and End of Life Measures in Acute Myeloid Leukemia and Myelodysplastic Syndromes

Patients with AML or MDS often receive high-intensity care near EOL, including admission to the hospital/ICU and life-sustaining treatments.

Completion of a portable medical order form >30 days before death was associated with lower intensity care near the end of life.

Patients with acute myeloid leukemia (AML) or a myelodysplastic syndrome (MDS) experience high rates of hospitalization, intensive care unit (ICU) admission, and in-hospital death at the end of life. Early goals-of-care (GOC) discussions may reduce the intensity of end-of-life (EOL) care. Portable Medical Order forms, known as Medical Orders for Life-Sustaining Treatment (MOLST) forms in New York state, assist patients in translating GOC discussions into specific medical orders that communicate their wishes during a medical emergency. To determine whether the timing of completion of a MOLST form is associated with EOL care in patients with AML or MDS, we conducted a retrospective study of 358 adult patients with AML or MDS treated at a single academic center and its affiliated sites, who died during a 5-year period. One-third of patients completed at least 1 MOLST form >30 days before death. Compared with patients who completed a MOLST form within 30 days of death or never, those who completed a MOLST form >30 days before death were less likely to receive transfusion (adjusted odds ratio [AOR], 0.39; P < .01), chemotherapy (AOR, 0.24; P < .01), or life-sustaining treatments (AOR, 0.21; P < .01) or to be admitted to the ICU (AOR, 0.21; P < .01) at EOL. They were also more likely to use hospice services (AOR, 2.72; P < .01). Earlier MOLST form completion was associated with lower intensity of care near EOL in patients with MDS or AML.

Inpatient palliative care utilization for patients with brain metastases

Introduction

Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients.

Methods

We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults.

Results

We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001).

Conclusions

In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

Inpatient Palliative Care Use Among Critically III Brain Metastasis Patients in the United States

OBJECTIVE

The objective of this study was to understand the trends and characteristics of palliative care delivery among critically ill brain metastasis patients using a nationally representative database.

MATERIALS AND METHODS

This study was a retrospective analysis of Nationwide Inpatient Sample data collected during 2005 to 2014. This study included critically ill patients, 18 years and above, diagnosed with brain metastasis, identified using International Classification of Diseases-Ninth Revision-Clinical Modification diagnosis and procedure codes. Multivariable logistic regression models were used for predicting factors associated with inpatient palliative care use.

RESULTS

Among 18,309 critically ill patients with brain metastasis, 3298 (18.0%) received inpatient palliative care. The rate of inpatient palliative care use among these patients increased from 3.2% to 28.5%, during 2005 to 2014 (P<0.001). Regression analysis showed that hospital teaching status (odds ratio [ORs], 1.45; 95% confidence interval [CI], 1.14-1.84), primaries located in head and neck (OR, 1.42; 95% CI, 1.21-2.05) or lung (OR, 1.32; 95% CI, 1.22-1.44), and primary diagnosis of pneumonia (OR, 1.42; 95% CI, 1.22-1.97) or septicemia (OR, 1.59; 95% CI, 1.30-1.97), were associated with higher palliative care use. Hispanic ethnicity (OR, 0.86; 95% CI, 0.67-0.96), and hospital location in Northeast (OR, 0.73; 95% CI, 0.54-0.96), Midwest (OR, 0.63; 95% CI, 0.45-0.87), or South (OR, 0.64; 95% CI, 0.48-0.86) were associated with lower palliative care use.

CONCLUSIONS

Inpatient palliative care use increased significantly among critically ill patients with brain metastases, though overall rate was low. There were geographical and racial disparities among these patients. Health care providers and policy makers should focus on decreasing these disparities. In addition, hospitals should focus on adopting more palliative care services.

Prevalence, trend and disparities of palliative care utilization among hospitalized metastatic breast cancer patients who received critical care therapies

BACKGROUND

Early integration of palliative care (PC) for patients with advanced cancer has been recommended to improve quality of care. This study aims to describe prevalence, temporal trend and predictors of PC use in metastatic breast cancer (mBCa) patients receiving critical care therapies (CCT; included invasive mechanic ventilation, percutaneous endoscopic gastrostomy tube, total parenteral nutrition, tracheostomy and dialysis).

METHODS

The National Inpatient Sample was queried for mBCa patients receiving CCT between 2005 and 2014. Annual percent changes (APC) were calculated for PC prevalence in the overall cohort and subgroups. Multivariable logistic analysis was used to explore predictors of PC use.

RESULTS

Of 5833 mBCa patients receiving CCT, 880 (15.09%) received PC. Rate of PC use increased significantly from 2.53% in 2005 to 25.96% in 2014 (APC: 35.75%; p < 0.0001). Higher increase in PC use was observed in South (from 0.65% to 27.11%; APC: 59.42%; p < 0.0001), medium bedsize hospitals (from 3.75% to 26.05%; APC: 38.16%; p = 0.0006) and urban teaching hospitals (from 4.13% to 29.86%; APC: 37.33%; p = 0.0005). Multivariable analysis revealed that year interval, urban teaching hospitals, and invasive mechanical ventilation were associated with increased PC use, while primary diagnosis of gastrointestinal disorders, fractures, metastatic sites from lymph nodes and tracheostomy were associated with lower PC use.

CONCLUSIONS

PC use in mBCa patients receiving CCT increases significantly over the period. However, it still remains low. Efforts to illustrate disparities in PC use are needed to improve quality of care for mBCa patients receiving CCT, especially for those hospitalized in rural and nonteaching hospitals.

End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

OBJECTIVE

To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs.

METHODS

A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21).

RESULTS

The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.

Palliative care utilization in hospitalized children with cancer

BACKGROUND

There is growing evidence that palliative care (PC) is associated with increased quality of life in children with cancer. Despite increasing recommendations in support of PC to improve pediatric oncology care, little is known about its patterns of use.

METHODS

We analyzed the 2005-2011 National Inpatient Sample, a representative, cross-sectional sample of US hospital admissions. Our study cohort comprised 10 960 hospitalizations of children with cancer and high in-hospital mortality risk. Survey-weighted regression models were constructed to determine associations of person- and hospital-level characteristics with PC involvement and healthcare costs.

RESULTS

Overall, 4.4% of hospitalizations included PC involvement. In regression models invoking stepwise variable selection, a shorter length of stay (PC vs no PC; mean: 23.9 vs 32.6 days), solid cancer (solid vs hematologic vs brain cancer; PC use: 7.4% vs 2.8% vs 5.5%), and older age (PC vs no PC; mean: 10.2 vs 8.9 years) were associated with PC use. PC utilization was also associated with lower overall and daily hospital costs.

CONCLUSIONS

One in 20 pediatric inpatients with cancer and high mortality risk receives PC, with differential utilization by socio-economic groups. These results have significant implications for public health resource allocation and the delivery of pediatric PC as high-value care. Future research should focus on the development of new tools to help physicians assess when PC is appropriate for their patients.

Temporal trends and social barriers for inpatient palliative care delivery in metastatic prostate cancer patients receiving critical care therapies

BACKGROUND

Use of inpatient palliative care (IPC) in advanced cancer patients represents a well-established guideline recommendation. A recent analysis demonstrated that genitourinary (GU) cancer patients benefited of IPC at the second lowest rate within the four examined primaries, namely lung, breast, colorectal, and GU. Based on this observation, we examined temporal trends and predictors of IPC use in metastatic prostate cancer patients receiving critical care therapies (CCT).

MATERIALS AND METHODS

We identified mPCa patients receiving CCT within the Nationwide Inpatient Sample database (2004-2015). IPC use rates were evaluated using univariable estimated annual percentage changes analyses. Multivariable logistic regression (MLR) models were used after adjustment for clustering at hospital level.

RESULTS

Of 4168 mPCa patients receiving CCT, 449 (11.3%) received IPC. IPC use increased from 1.2 to 22.3% (EAPC: +19.6%, p < 0.001). After stratification according to regions, race, and teaching status, the highest increase of IPC use was recorded in the South (from 0 to 25.4 %, EAPC: +27.6%), in Caucasians (from 1.5 to 24.4 %, EAPC: +19.8%; p < 0.001) and in teaching hospitals (from 0.9 to 26.2 %, EAPC: +19.6%; p < 0.001). In MLR models, teaching status (Odds ratio [OR]: 1.74, p < 0.001) and contemporary year interval (OR: 4.63, p < 0.001) were associated with higher IPC rates. Conversely, African American race (OR: 0.66, p < 0.001) and primary diagnosis of GU disorders (OR: 0.49, p < 0.001) and gastrointestinal (GI) disorders at admission (OR: 0.61, p = 0.02) were associated with lower IPC rates.

CONCLUSIONS

IPC use rate in mPCa patients receiving CCT sharply increased between 2004 and 2015. The highest increase of IPC use across time was recorded in the South, in Caucasian race, and in teaching hospitals. African-American race and nonteaching status were identified as independent predictors of lower IPC use and represent targets for efforts aimed at improving IPC delivery in mPCa patients receiving CCT.