Association between survival time with metastatic breast cancer and aggressive end-of-life care.
Ontology highlight
ABSTRACT:
SUBMITTER: Accordino MK
PROVIDER: S-EPMC5695862 | biostudies-literature | 2017 Nov
REPOSITORIES: biostudies-literature
Publications
Association between survival time with metastatic breast cancer and aggressive end-of-life care.
Accordino Melissa K MK Wright Jason D JD Vasan Sowmya S Neugut Alfred I AI Gross Tal T Hillyer Grace C GC Hershman Dawn L DL
Breast cancer research and treatment 20170727 2
<h4>Purpose</h4>For women with stage IV breast cancer (BC), the association between survival time (ST) and use of aggressive end-of-life (EOL) care is unknown.<h4>Methods</h4>We used the SEER-Medicare database to identify women with stage IV BC diagnosed 2002-2011 who died by 12/31/2012. Aggressive EOL care was defined as receipt in the last month of life: >1 ED visit, >1 hospitalization, ICU admission, life-extending procedures, hospice admission within 3 days of death, IV chemotherapy within 1 ...[more]
Similar Datasets
Project description:Aggressive medical care at the end of life can be harmful to patients and families, but its prevalence in use among younger cancer patients is unknown. The goal of the study was to report on the use of aggressive care and hospice services for patients younger than age 65 years. Using the HealthCore Integrated Research Database, we analyzed patients who died between 2007 and 2014 with metastatic lung (n = 12 764), colorectal (n = 5207), breast (n = 5855), pancreatic (n = 3397), or prostate (n = 1508) cancer. Based on published quality measures, we assessed uses of chemotherapy, intensive care, emergency room visits, and hospice care at the end of life. We examined additional items including radiotherapy, invasive procedures, hospitalization, and in-hospital deaths. Multivariable modified Poisson regression models were used to adjust for age, sex, geographic region, rural/urban location, year of death, and regional education and income measures. Across the five cancers, 10.1% to 14.1% of patients received chemotherapy within the last 14 days of life, 15.9% to 20.6% received intensive care in last 30 days, and 1.5% to 2.5% went to the emergency room two or more times in last 30 days. Hospice enrollment at least three days before death was 54.4% to 59.6%. However, 55.3% to 59.3% of patients had a hospital admission in the last 30 days, and one-third died (30.3%-35.4%) in the hospital. There was low use of cancer-directed treatment at the end of life for younger cancer patients, and hospice use was higher than 50%. However, there was a relatively high utilization of hospital-based care. These results demonstrate an opportunity for continued improvements in the provision of high-value, patient-centered care at the end of life.
| S-EPMC6440271 | biostudies-literature
Project description:Patients with advanced-stage cancer are receiving increasingly aggressive medical care near death, despite growing concerns that this reflects poor-quality care.To assess the association of aggressive end-of-life care with bereaved family members' perceptions of the quality of end-of-life care and patients' goal attainment.Interviews with 1146 family members of Medicare patients with advanced-stage lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) who died by the end of 2011 (median, 144.5 days after death; interquartile range, 85.0-551.0 days).Claims-based quality measures of aggressive end-of-life care (ie, intensive care unit [ICU] admission or repeated hospitalizations or emergency department visits during the last month of life; chemotherapy ?2 weeks of death; no hospice or ?3 days of hospice services; and deaths occurring in the hospital).Family member-reported quality rating of "excellent" for end-of-life care. Secondary outcomes included patients' goal attainment (ie, end-of-life care congruent with patients' wishes and location of death occurred in preferred place).Of 1146 patients with cancer (median age, 76.0 years [interquartile range, 65.0-87.0 years]; 55.8% male), bereaved family members reported excellent end-of-life care for 51.3%. Family members reported excellent end-of-life care more often for patients who received hospice care for longer than 3 days (58.8% [352/599]) than those who did not receive hospice care or received 3 or fewer days (43.1% [236/547]) (adjusted difference, 16.5 percentage points [95% CI, 10.7 to 22.4 percentage points]). In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45.0% [68/151]) than those who were not admitted to an ICU within 30 days of death (52.3% [520/995]) (adjusted difference, -9.4 percentage points [95% CI, -18.2 to -0.6 percentage points]). Similarly, family members of patients who died in the hospital reported excellent end-of-life care less often (42.2% [194/460]) than those who did not die in the hospital (57.4% [394/686]) (adjusted difference, -17.0 percentage points [95% CI, -22.9 to -11.1 percentage points]). Family members of patients who did not receive hospice care or received 3 or fewer days were less likely to report that patients died in their preferred location (40.0% [152/380]) than those who received hospice care for longer than 3 days (72.8% [287/394]) (adjusted difference, -34.4 percentage points [95% CI, -41.7 to -27.0 percentage points]).Among family members of older patients with fee-for service Medicare who died of lung or colorectal cancer, earlier hospice enrollment, avoidance of ICU admissions within 30 days of death, and death occurring outside the hospital were associated with perceptions of better end-of-life care. These findings are supportive of advance care planning consistent with the preferences of patients.
| S-EPMC4919118 | biostudies-literature
Project description:ImportancePeople who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.ObjectiveTo examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.Design, setting, and participantsThis population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.ExposuresAll decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.Main outcomes and measuresLocation of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.ResultsAmong 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.Conclusions and relevanceAmong decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.
| S-EPMC5710367 | biostudies-literature
Project description:ContextThe comfort of patients with cancer near the end of life (EOL) is often undermined by unnecessary and burdensome treatments. There is a need for more research examining racial disparities in EOL care, especially in regions with a history of racial discrimination.ObjectivesTo examine whether black adults received more burdensome EOL care than white adults in a population-based data set of cancer decedents in Louisiana, a state with a history of slavery and long-standing racial disparities.MethodsThis was a retrospective analysis of EOL care from the Research Action for Health Network (REACHnet), a regional Patient-Centered Outcomes Research Institute-funded database. The sample consisted of 875 white and 415 black patients with metastatic cancer who died in Louisiana from 2011 to 2017. We used logistic regression to examine whether race was associated with five indicators of burdensome care in the last 30 days of life: chemotherapy use, inpatient hospitalization, intensive care unit admission, emergency department (ED) admission, and mechanical ventilation.ResultsMost patients (85.0%) received at least one indicator of burdensome care: hospitalization (76.5%), intensive care unit admission (44.1%), chemotherapy (29.1%), mechanical ventilation (23.0%), and ED admission (18.3%). Odds ratios (ORs) indicated that black individuals were more likely than white individuals to be hospitalized (OR = 1.66; 95% CI = 1.21-2.28; P = 0.002) or admitted to the ED (OR = 1.57; 95% CI = 1.16-2.13; P = 0.004) during their last month of life.ConclusionFindings have implications for informing health care decision making near the EOL for patients, families, and clinicians, especially in regions with a history of racial discrimination and disparities.
| S-EPMC8100959 | biostudies-literature
Project description:OBJECTIVES:As ICUs are increasingly a site of end-of-life care, many have adopted end-of-life care resources. We sought to determine the association of such resources with outcomes of ICU patients. DESIGN:Retrospective cohort study. SETTING:Pennsylvania ICUs. PATIENTS:Medicare fee-for-service beneficiaries. INTERVENTIONS:Availability of any of one hospital-based resource (palliative care consultants) or four ICU-based resources (protocol for withdrawal of life-sustaining therapy, triggers for automated palliative care consultation, protocol for family meetings, and palliative care clinicians embedded in ICU rounds). MEASUREMENTS AND MAIN RESULTS:In mixed-effects regression analyses, admission to a hospital with end-of-life resources was not associated with mortality, length of stay, or treatment intensity (mechanical ventilation, hemodialysis, tracheostomy, gastrostomy, artificial nutrition, or cardiopulmonary resuscitation); however, it was associated with a higher likelihood of discharge to hospice (odds ratio, 1.58; 95% CI, 1.11-2.24), an effect that was driven by ICU-based resources (odds ratio, 1.37; 95% CI, 1.04-1.81) rather than hospital-based resources (odds ratio, 1.19; 95% CI, 0.83-1.71). Instrumental variable analysis using differential distance (defined as the additional travel distance beyond the hospital closest to a patient's home needed to reach a hospital with end-of-life resources) demonstrated that among those for whom differential distance would influence receipt of end-of-life resources, admission to a hospital with such resources was not associated with any outcome. CONCLUSIONS:ICU-based end-of-life care resources do not appear to change mortality but are associated with increased hospice utilization. Given that this finding was not confirmed by the instrumental variable analysis, future studies should attempt to verify this finding, and identify specific resources or processes of care that impact the care of ICU patients at the end of life.
| S-EPMC6791744 | biostudies-literature
Project description:BackgroundAdvance care planning (ACP) is a process that supports adults in understanding and sharing their personal values, life goals, and preferences regarding future medical care. We examined the current status of ACP and end-of-life (EOL) communication between oncologists and patients with metastatic breast cancer.Materials and methodsWe conducted a survey among 41 institutions that specialize in oncology by using an online tool in October 2019. Participants (118 physicians) from 38 institutions completed a 39-item questionnaire that measured facility type and function; physicians' background and clinical approach, education about EOL communication, and understanding about ACP; and the current situation of ACP and EOL discussions.ResultsNinety-eight responses concerning physicians' engagement in ACP with patients were obtained. Seventy-one (72%) answered that they had engaged in ACP. Among these, 23 (33%) physicians used a structured format to facilitate the conversation in their institutions, and only 6 (8%) settled triggers or sentinel events for the initiation of ACP. In the multivariable analysis, only the opportunity to learn communication skills was associated with physicians' engagement with ACP (odds ratio: 2.8, 95% confidence interval: 1.1-7.0). The frequency and timing of communication about ACP and EOL care with patients substantially varied among the oncologists. Communication about patients' life expectancy was less frequent compared with other topics.ConclusionThe opportunity to improve EOL communication skills promoted physicians' engagement with ACP among patients with metastatic/advanced breast cancer. However, there were still substantial variabilities in the method, frequency, and timing of ACP and EOL communication among the oncologists.Implications for practiceThis study found that the opportunity to improve end-of-life (EOL) communication skills promoted physicians' engagement in advance care planning (ACP) among patients with metastatic/advanced breast cancer. All oncologists who treat said patients are encouraged to participate in effective education programs concerning EOL communication skills. In clinical practice, there are substantial variabilities in the method, frequency, and timing of ACP and EOL communication among oncologists. As recommended in several clinical guidelines, the authors suggest a system that identifies patients who require conversations about their care goals, a structured format to facilitate the conversations, and continuous measurement for improving EOL care and treatment.
| S-EPMC8018302 | biostudies-literature
Project description:BackgroundPatients with blood cancers experience high-intensity medical care near the end of life (EOL) and low rates of hospice use; attributes of goals of care (GOC) discussions may partly explain these outcomes.MethodsBy using a retrospective cohort of patients with blood cancer who received care at Dana-Farber Cancer Institute and died in 2014, the authors assessed the potential relationship between timing, location, and the involvement of hematologic oncologists in the first GOC discussion with intensity of care near the EOL and timely hospice use.ResultsAmong 383 patients, 39.2% had leukemia/myelodysplastic syndromes, 37.1% had lymphoma, and 23.7% had myeloma. Overall, 65.3% of patients had a documented GOC discussion. Of the first discussions, 33.2% occurred >30 days before death, 34.8% occurred in the outpatient setting, and 46.4% included a hematologic oncologist. In multivariable analyses, having the first discussion >30 days before death (odds ratio [OR], 0.37; 95% CI, 0.17-0.81), in the outpatient setting (OR, 0.21; 95% CI, 0.09-0.50), and having a hematologic oncologist present (OR, 0.40; 95% CI, 0.21-0.77) were associated with lower odds of intensive care unit admission ?30 days before death. The presence of a hematologic oncologist at the first discussion (OR, 3.07; 95% CI, 1.58-5.96) also was associated with earlier hospice use (>3 days before death).ConclusionsIn this large cohort of blood cancer decedents, most initial GOC discussions occurred close to death and in the inpatient setting. When discussions were timely, outpatient, or involved hematologic oncologists, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.
| S-EPMC6980246 | biostudies-literature
Project description:INTRODUCTION:Very few data are available regarding the use of chemotherapy in patients with metastatic breast cancer (MBC) near the end-of-life, i.e., the final month. The aim of this study was to provide a descriptive analysis of its use in two different European geographic areas (Sweden and Greece). MATERIALS AND METHODS:We retrospectively collected data regarding clinicopathologic characteristics, survival, and use of chemotherapy during the final 30 days of life using two sources: for the Swedish cohort, patients who were diagnosed with MBC in 2010-2015 were identified from the Stockholm-Gotland population-based Breast Cancer Registry and treatment data were collected using hospital charts. For the Greek cohort, patients with MBC were identified from hospital charts at two hospitals in Athens and Crete. RESULTS:In the Swedish cohort, 1571 patients were identified; median overall survival was 16.96 months (95% CI 15.4-18.4). 23.2% of patients were treated with chemotherapy during the final month of life, with higher rates among patients???60 years (p?<?0.001). Per OS monotherapy such as capecitabine or vinorelbine was most commonly used. In contrast, median OS in the Greek cohort (n?=?966) was 49.8 months (95% CI 45.6-54.1) and 46.5% of patients received chemotherapy at the end-of-life, most commonly intravenous drug combinations. In multivariable analysis, age and albumin levels were statistically significantly associated with chemotherapy use in the Swedish cohort. CONCLUSION:Chemotherapy use near the end-of-life was common, which might negatively impact patient quality of life.
| S-EPMC7220858 | biostudies-literature
Project description:Rationale: The care of critically ill patients often involves complex discussions surrounding prognosis, goals, and end-of-life decision-making. Yet, physician and hospital practice patterns, rather than patient goals, remain a major determinant of the intensity of end-of-life care. For critically ill patients, palliative care may help promote treatments that are concordant with patients' goals, while minimizing the use of invasive and costly intensive care unit resources that may not be consistent with those goals.Objectives: To determine whether inpatient palliative care, delivered by specialist consultants or a primary medical team, is associated with reduced hospital length of stay and costs for older adults with septic shock at the end of life.Methods: This was a retrospective cohort using the National Inpatient Sample from 2013 to 2014, examining patients aged ≥65 years with septic shock who died during their hospitalization. The exposure of interest was inpatient palliative care encounter, including either generalist- or specialist-delivered palliative care. Outcomes were hospital length of stay, total cost for the hospitalization, and daily hospital cost. Patient and hospital-level confounders were used to derive inverse probability of treatment weights and estimate the association between palliative care and outcomes in a generalized linear model.Results: We studied 45,868 patients who died with a diagnosis of septic shock; 15,370 of these patients had a palliative care encounter. After inverse probability of treatment weighting, there were no appreciable differences between the population characteristics. Palliative care was associated with a shorter adjusted mean hospital length of stay (12.0 vs. 13.1 d; difference, -1.1 d; 95% confidence interval [CI], -1.4 to -0.9; P < 0.001), lower total hospital costs (69,700 vs. 76,800 U.S. dollars [USD]; difference, -7,100 USD; 95% CI, -8.5 to -5.2 thousand USD; P < 0.001), and lower daily hospital cost (5,900 vs. 6,200 USD; difference, -310 USD per day; 95% CI, -420 to -200 USD; P < 0.001) when compared with no palliative care.Conclusions: In a nationally representative sample of adults who died during a hospitalization with septic shock, receipt of palliative care was associated with shorter length of stay and lower total and daily hospital costs. This finding was robust to adjustment for patient- and hospital-level confounders, though unmeasured confounders still could be affecting these findings.
| S-EPMC7531025 | biostudies-literature
Project description:ObjectiveTo compare recent immigrants and long-term residents in Ontario, Canada, on established health service quality indicators of end-of-life cancer care.DesignRetrospective, population-based cohort study of cancer decedents between 2004 and 2015.SettingOntario, Canada.ParticipantsWe 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 measuresAggressive 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.ResultsCompared 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).ConclusionsAmong 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.
| S-EPMC8173292 | biostudies-literature