Influence of Peer Physicians on Intensity of End-of-Life Care for Cancer Decedents.
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ABSTRACT:
SUBMITTER: Keating NL
PROVIDER: S-EPMC6522329 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
Publications
Influence of Peer Physicians on Intensity of End-of-Life Care for Cancer Decedents.
Keating Nancy L NL O'Malley Alistair James AJ Onnela Jukka-Pekka JP Gray Stacy W SW Landon Bruce E BE
Medical care 20190601 6
<h4>Background</h4>The intensity of end-of-life care varies substantially both within and between areas. Differing practice patterns of individual physicians are likely influenced by their peers.<h4>Objective</h4>To assess whether intensity of end-of-life care previously provided by a physician's peers influences patterns of care at the end-of-life for that physician's patients.<h4>Research design</h4>Observational study.<h4>Subjects</h4>A total of 185,947 fee-for-service Medicare enrollees with ...[more]
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Project description:Background/objectiveThe Centers for Medicare & Medicaid Services (CMS) reimburses clinicians for advance care planning (ACP) discussions with Medicare patients. The objective of the study was to examine the association of CMS-billed ACP visits with end-of-life (EOL) healthcare utilization.DesignPatient-level analyses of claims for the random 20% Medicare fee-for-service (FFS) sample of decedents in 2017. To account for multiple comparisons, Bonferroni adjusted P value <.008 was considered statistically significant.SettingNationally representative sample of Medicare FFS beneficiaries.ParticipantsA total of 237,989 Medicare FFS beneficiaries who died in 2017 and included those with and without a billed ACP visit during 2016-17.InterventionThe key exposure variable was receipt of first billed ACP (none, >1 month before death).MeasurementsSix measures of EOL healthcare utilization or intensity (inpatient admission, emergency department [ED] visit, intensive care unit [ICU] stay, and expenditures within 30 days of death, in-hospital death, and first hospice within 3 days of death). Analyses was adjusted for age, race, sex, Charlson Comorbidity Index, expenditure by Dartmouth hospital referral region (high, medium, or low), and dual eligibility.ResultsOverall, 6.3% (14,986) of the sample had at least one billed ACP visit. After multivariable adjustment, patients with an ACP visit experienced significantly less intensive EOL care on four of six measures: hospitalization (odds ratio [OR] = .77; 95% confidence interval [CI] = .74-.79), ED visit (OR = .77; 95% CI = .75-.80), or ICU stay (OR = .78; 95% CI = .74-.81) within a month of death; and they were less likely to die in the hospital (OR = .79; 95% CI = .76-.82). There were no differences in the rate of late hospice enrollment (OR = .97; 95% CI = .92-1.01; P = .119) or mean expenditures ($242.50; 95% CI = -$103.63 to $588.61; P = .169).ConclusionBilled ACP visits were relatively uncommon among Medicare FFS decedents, but their occurrence was associated with less intensive EOL utilization. Further research on the variables affecting hospice use and expenditures in the EOL period is recommended to understand the relative role of ACP.
| S-EPMC8559724 | biostudies-literature
Project description:Rationale: Admissions to ICUs are common during terminal hospitalizations, but little is known about how ICU care affects the end-of-life experience for patients dying in hospitals and their families.Objectives: We measured the association between ICU care during terminal hospitalization and family ratings of end-of-life care for patients who died in 106 Veterans Affairs hospitals from 2010 to 2016.Methods: Patients were divided into four categories: no-ICU care, ICU-only care, mixed care (died outside ICU), and mixed care (died in ICU). Multivariable linear probability models were adjusted for patient and hospital characteristics. Patients receiving mixed care were also analyzed based on percentage of time in ICU.Measurements and Main Results: Of 57,550 decedents, 28,062 (48.8%) had a survey completed by a family member or close contact. In adjusted models, ICU-only care was associated with more frequent optimal ratings than no-ICU care, including overall excellent care (56.6% vs. 48.1%; P < 0.001), care consistent with preferences (78.7% vs. 72.4%; P < 0.001), and having pain controlled (51.3% vs. 46.7%; P < 0.001). Among patients with mixed care, increasing ICU time was associated with higher ratings on these same measures (all P < 0.001 for comparisons of those spending >75% time in ICU vs. ≤25% time).Conclusions: Among hospital decedents, ICU care was associated with higher family ratings of quality of end-of-life care than ward care. Reducing ICU use among hospital decedents may not improve end-of-life quality, and efforts to understand how ICU care improves end-of-life quality could help provide better care outside ICUs.
| S-EPMC7124720 | biostudies-literature
Project description:BackgroundVariation persists in the quality of end-of-life-care (EOLC) for people with cancer. This study aims to describe the characteristics of, and examine factors associated with, indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer.MethodA population-based retrospective cohort study of people aged ≥ 20 years who died with a cancer-related cause of death during 2014-2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, consisting of > 1 ED presentation or > 1 hospital admission or ≥ 1 ICU admission within 30 days of death, or died in acute care.ResultsOf the 80,005 cancer-related deaths, 86.9% were hospitalised in the 12 months prior to death. Fifteen percent had > 1 ED presentation, 9.9% had > 1 hospital admission, 8.6% spent ≥ 14 days in hospital, 3.6% had ≥ 1 intensive care unit admission, and 1.2% received mechanical ventilation on ≥ 1 occasion in the last 30 days of life. Seventeen percent died in acute care. The potentially burdensome care composite measure identified 20.0% had 1 indicator, and 10.9% had ≥ 2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥ 55 years), females, people with 1 or ≥ 2 Charlson comorbidities, people with neurological cancers, and people who died in 2018-2019 were less likely to experience potentially burdensome care. Compared to people with head and neck cancer, people with all cancer types (except breast and neurological) were more likely to experience ≥ 2 indicators of potentially burdensome care versus none.ConclusionThis study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.
| S-EPMC10835903 | biostudies-literature
Project description:BackgroundCarers' end-of-life caregiving greatly benefits society but little is known about the monetary value of this care.AimWithin an end-of-life cancer setting: (1) to assess the feasibility and content validity of a post-bereavement measure of hours of care; and (2) to obtain a monetary value of this informal care and identify variation in this value among sub-groups.Design and settingA census based cross-sectional survey of all cancer deaths from a 2-week period in England collected detailed data on caregiving activity (10 caregiving tasks and the time spent on each). We descriptively analyse the information carers provided in 'other' tasks to inform content validity. We assigned a monetary value of caregiving via the proxy good method and examined variation in the value via regression analysis.ResultsThe majority of carers (89.9%) were able to complete the detailed questions about hours and tasks. Only 153 carers reported engaging in 'other' tasks. The monetary value of caregiving at end-of-life was £948.86 per week with social and emotional support and symptom management tasks representing the largest proportion of this monetary valuation. Time of recall did not substantially relate to variation in the monetary value, whereas there was a stronger association for the relationship between the carer and recipient, carer gender and recipient daily living restrictions.ConclusionThe monetary valuation we produce for carers' work is substantial, for example the weekly UK Carers' Allowance only amounts to 7% of our estimated value of £948.86 per week. Our research provides further information on subgroup variation, and a valid carer time instrument and method to inform economic evaluation and policy.
| S-EPMC8022080 | biostudies-literature
Project description:ImportanceThe idea that physicians as patients choose less-aggressive care at the end of life for themselves is an often-cited rationale to advocate for less technology-laden end-of-life care.ObjectiveTo assess end-of-life care received by physicians compared with nonphysicians in a system with universal health care.Design, setting, and participantsIn this population-level decedent cohort study of data from April 1, 2004, through March 31, 2015 (fiscal years 2004-2014), in Ontario, Canada, 2507 physicians were matched approximately 1:3 to 7513 nonphysicians (ie, individuals who never were registered as a physician with the College of Physicians and Surgeons of Ontario) according to age, sex, income quintile, and location of residence.Main outcomes and measuresThe primary outcome was location of death. Other outcomes included measures of health care use in the last 6 months of life. Differences were assessed using Poisson regression with robust error variances, adjusting for the Charlson Comorbidity Index.ResultsIn total, 2516 physicians and 954 836 nonphysicians died between April 1, 2004, and March 31, 2015, in Ontario; 2247 physicians (89.3%) and 474 182 nonphysicians (49.7%) were men. The median (interquartile range) age at death was 82 (74-87) years for the physicians and 80 (68-87) years for the nonphysicians. After matching, data for 2507 physicians and 7513 nonphysicians were analyzed. For physicians, the risk of death at home was no different from that for nonphysicians (42.8% vs 39.0%; adjusted relative risk [aRR], 1.04; 95% CI, 0.99-1.09), but the risk of death in an intensive care unit was increased (11.9% vs 10.0%; aRR, 1.22; 95% CI, 1.08-1.39). In the prior 6 months, physicians had a decreased risk of an emergency department visit (73.0% vs 78.4%; aRR, 0.96; 95% CI, 0.94-0.98) but increased risks of an intensive care unit admission (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05-1.24) and of receipt of palliative care services (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13-1.23). Among a subgroup of 457 physicians and 1347 nonphysicians with cancer, the risk of death at home or intensive care unit was increased (37.6% vs 28.6%; aRR, 1.30; 95% CI, 1.13-1.50), as was the risk of receiving chemotherapy in the last 6 months of life.Conclusions and relevanceThere was no difference overall for physicians compared with nonphysicians in terms of the likelihood of dying at home; physicians were more likely to die in an intensive care unit and to receive chemotherapy, but also to receive palliative care services. These findings suggest that physicians do not consistently opt for less-aggressive care but instead receive end-of-life care that includes both intensive and palliative care. These findings inform a more nuanced perspective of what physicians may perceive to be optimal care at the end of life.
| S-EPMC6659139 | biostudies-literature
Project description:BackgroundMany studies have measured the intensity of end of life care. However, no summary of the measures used in the field is currently available.ObjectivesTo summarise features, characteristics of use and reported validity of measures used for evaluating intensity of end of life care.MethodsThis was a systematic review according to PRISMA guidelines. We performed a comprehensive literature search in Ovid Medline, Embase, The Cochrane Library of Systematic Reviews and reference lists published between 1990-2014. Two reviewers independently screened titles, abstracts, full texts and extracted data. Studies were eligible if they used a measure of end of life care intensity, defined as all quantifiable measures describing the type and intensity of medical care administered during the last year of life.ResultsA total of 58 of 1590 potentially eligible studies met our inclusion criteria and were included. The most commonly reported measures were hospitalizations (n = 44), intensive care unit admissions (n = 39) and chemotherapy use (n = 27). Studies measured intensity of care in different timeframes ranging from 48 hours to 12 months. The majority of studies were conducted in cancer patients (n = 31). Only 4 studies included information on validation of the measures used. None evaluated construct validity, while 3 studies considered criterion and 1 study reported both content and criterion validity.ConclusionsThis review provides a synthesis to aid in choosing intensity of end of life care measures based on their previous use but simultaneously highlights the crucial need for more validation studies and consensus in the field.
| S-EPMC4396980 | biostudies-literature
Project description:To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.United States, 1989-1999.Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.
| S-EPMC1824769 | biostudies-other
Project description:Background: Patients with limited English proficiency (LEP) experience lower quality end-of-life (EOL) care. This inequity may have been exacerbated during the COVID-19 pandemic. Objective: Compare health care utilization, EOL, and palliative care outcomes between COVID-19 decedents with and without LEP during the pandemic's first wave in Massachusetts. Methods: Retrospective cohort study of adult inpatients who died from COVID-19 between February 18, 2020 and May 18, 2020 at two academic and four community hospitals within a greater Boston health care system. We performed multivariable regression adjusting for patient sociodemographic variables and hospital characteristics. Primary outcome was place of death (intensive care unit [ICU] vs. non-ICU). Secondary outcomes included hospital and ICU length of stay and time to initial palliative care consultation. Results: Among 337 patients, 89 (26.4%) had LEP and 248 (73.6%) were English proficient. Patients with LEP were less often white (24 [27.0%] vs. 193 [77.8%]; p < 0.001); were more often Hispanic or Latinx (40 [45.0%] vs. 13 [5.2%]; p < 0.001); and less often had a medical order for life-sustaining treatment (MOLST) on admission (15 [16.9%] vs. 120 [48.4%]; p < 0.001) versus patients with English proficiency. In the multivariable analyses, LEP was not independently associated with ICU death, ICU length of stay, or time to palliative care consultation, but was independently associated with increased hospital length of stay (mean difference 4.12 days; 95% CI, 1.72-6.53; p < 0.001). Conclusions: Inpatient COVID-19 decedents with LEP were not at increased risk of an ICU death, but were associated with an increased hospital length of stay versus inpatient COVID-19 decedents with English proficiency.
| S-EPMC9836680 | biostudies-literature
Project description:BACKGROUND:We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers' end-of-life (EOL) quality metrics among minority and white decedents to explore center-attributable sources of EOL disparities. METHODS:We conducted a retrospective cohort study of Medicare beneficiaries with poor-prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients' EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk-adjusted metrics of EOL quality (hospice admission ?3 days before death; chemotherapy last 14 days of life; ?2 emergency department (ED) visits; intensive care unit (ICU) admission; or life-sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. RESULTS:Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life-sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within-center correlation for minority and white metrics (0.61-0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life-sustaining treatments (P < .01). CONCLUSION:EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority-serving centers had worse performance on many metrics.
| S-EPMC7050066 | biostudies-literature
Project description:Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.To explore the relationship between hospitals' cancer- and non-cancer-specific EOL treatment intensity.We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions for either cancer or congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) between 2001 and 2007, linked to vital statistics through 2008. We calculated Bayes's shrunken case-mix standardized (observed-to-expected) ratios of intensive care and life-sustaining treatment use among two EOL cohorts: those prospectively identified at high probability of dying on admission and those retrospectively identified as terminal admissions (decedents). We then summed these to create a hospital-specific prospective and retrospective overall EOL treatment intensity index for cancer vs. CHF/COPD.The sample included 207,523 admissions with 15% or greater predicted probability of dying on admission among 172,041 unique adults and 120,372 terminal admissions at 166 hospitals; these two cohorts overlapped by 52,986 admissions. There was substantial variation between hospitals in their standardized EOL treatment intensity ratios among cancer and CHF/COPD admissions. Within hospitals, cancer- and CHF/COPD-specific standardized EOL treatment intensity ratios were highly correlated for intensive care unit (ICU) admission (prospective ? = 0.81; retrospective ? = 0.78), ICU lengths of stay (? = 0.76; 0.64), mechanical ventilation (? = 0.73; 0.73), and hemodialysis (? = 0.60; 0.71) and less highly correlated for tracheostomy (? = 0.43; 0.53) and gastrostomy (? = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ? = 0.75; retrospective ? = 0.75) and had equal group means (P-value = 0.631; 0.699).Despite substantial difference between hospitals in EOL treatment intensity, within-hospital homogeneity in EOL treatment intensity for cancer- and non-cancer populations suggests the existence of condition-insensitive institutional norms of EOL treatment.
| S-EPMC4329285 | biostudies-other