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Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study.

ABSTRACT: OBJECTIVE:To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. DESIGN:Population based matched cohort study. SETTING:Ontario, Canada between 2010 and 2015. PARTICIPANTS:113?540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. MAIN OUTCOME MEASURES:Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). RESULTS:In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13?384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. CONCLUSIONS:These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.

SUBMITTER: Quinn KL

PROVIDER: S-EPMC7336238 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study.

Quinn Kieran L KL Stukel Therese T Stall Nathan M NM Huang Anjie A Isenberg Sarina S Tanuseputro Peter P Goldman Russell R Cram Peter P Kavalieratos Dio D Detsky Allan S AS Bell Chaim M CM

BMJ (Clinical research ed.) 20200706

<h4>Objective</h4>To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level.<h4>Design</h4>Population based matched cohort study.<h4>Setting</h4>Ontario, Canada between 2010 and 2015.<h4>Participants</h4>113 540 adults dying from cancer and non-cancer illness who were given newly i ...[more]

PMID: 32631907

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Project description:ImportancePalliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking.ObjectiveTo examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer.Design, setting, and participantsThis population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada.ExposuresCause of death (chronic organ failure, dementia, or cancer).Main outcomes and measuresComponents of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death.ResultsA total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, -18.3%) or dementia (3922 [27.9%]; absolute difference, -13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%).Conclusions and relevanceIn this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings.

Project description:Importance:Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations. Objective:To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness. Data Sources:Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017. Study Selection:Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. Data Extraction and Synthesis:Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis. Main Outcomes and Measures:Total direct hospital costs. Results:This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer. Conclusions and Relevance:The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.

Project description:ObjectivesTo evaluate the impact of palliative home care support on the quality of care and costs in the last 14 days of life.DesignMatched cohort study using linked administrative databases.SettingAll people who died in Belgium in 2012 (n=107 847).Participants8837 people who received palliative home care support in the last 720 to 15 days of life matched 1:1 by propensity score to 8837 people who received usual care.InterventionReceiving the allowance for palliative home patients, multidisciplinary palliative home care team visit or palliative nurse or physiotherapist visit at home.Main outcome measuresHome death, number of family physician contacts, number of primary caregiver contacts, hospital death, hospital admission, intensive care unit (ICU) admission, emergency department (ED) admission, diagnostic testing, blood transfusion and surgery. Total inpatient and outpatient costs. All outcomes were measured in the last 14 days of life.ResultsIn the unmatched cohort, 11 149 (13.5%) people received palliative home care support in the last 720 to 15 days of life. After matching, those using palliative home care support had, compared with those who did not, more family physician contacts (mean 3.1 [SD=6.5] vs 0.8 [SD=1.2]), more chance of home death (56.2%vs13.8%; relative risk [RR]=4.08, 95% CI 3.86 to 4.31), lower risk of hospital admission (27.4%vs60.8%; RR=0.45, 95% CI 0.43 to 0.46), ICU admission (18.3%vs40.4%; RR=0.45, 95% CI 0.43 to 0.48) or ED admission (15.2%vs28.1%; RR=0.54, 95% CI 0.51 to 0.57). Mean total costs of care were lower for those using palliative home care support (€3081 [95% CI €3025 to €3136] vs €4698 [95% CI €4610 to €4787]; incremental cost: -€1617 [p<0.001]).ConclusionsPalliative home care support use positively impacts quality of care and reduces total costs of care at the end of life in Belgium. Policy makers and healthcare practitioners should increasingly focus on communicating the existing options for palliative home care support to patients and their caregivers.

Project description:Timely outreach to individuals in an advanced stage of illness offers opportunities to exercise decision control over health care. Predictive models built using Electronic health record (EHR) data are being explored as a way to anticipate such need with enough lead time for patient engagement. Prior studies have focused on hospitalized patients, who typically have more data available for predicting care needs. It is unclear if prediction driven outreach is feasible in the primary care setting. In this study, we apply predictive modeling to the primary care population of a large, regional health system and systematically examine the impact of technical choices, such as requiring a minimum number of health care encounters (data density requirements) and aggregating diagnosis codes using Clinical Classifications Software (CCS) groupings to reduce dimensionality, on model performance in terms of discrimination and positive predictive value. We assembled a cohort of 349,667 primary care patients between 65 and 90?years of age who sought care from Sutter Health between July 1, 2011 and June 30, 2014, of whom 2.1% died during the study period. EHR data comprising demographics, encounters, orders, and diagnoses for each patient from a 12?month observation window prior to the point when a prediction is made were extracted. L1 regularized logistic regression and gradient boosted tree models were fit to training data and tuned by cross validation. Model performance in predicting one year mortality was assessed using held-out test patients. Our experiments systematically varied three factors: model type, diagnosis coding, and data density requirements. We found substantial, consistent benefit from using gradient boosting vs logistic regression (mean AUROC over all other technical choices of 84.8% vs 80.7% respectively). There was no benefit from aggregation of ICD codes into CCS code groups (mean AUROC over all other technical choices of 82.9% vs 82.6% respectively). Likewise increasing data density requirements did not affect discrimination (mean AUROC over other technical choices ranged from 82.5% to 83%). We also examine model performance as a function of lead time, which is the interval between death and when a prediction was made. In subgroup analysis by lead time, mean AUROC over all other choices ranged from 87.9% for patients who died within 0 to 3?months to 83.6% for those who died 9 to 12?months after prediction time.

Project description:ObjectiveTo compare perinatal outcomes in births of women with versus without a history of bariatric surgery.DesignPopulation based matched cohort study.SettingSwedish national health service.Participants1,742,702 singleton births identified in the Swedish medical birth register between 1992 and 2009. For each birth to a mother with a history of bariatric surgery (n=2562), up to five control births were matched by maternal age, parity, early pregnancy body mass index, early pregnancy smoking status, educational level, and year of delivery. Secondary control cohorts, including women eligible for bariatric surgery (body mass index ? 35 or ? 40), were matched for the same factors except body mass index. History of maternal bariatric surgery was ascertained through the Swedish national patient register from 1980 to 2009.Main outcome measuresPreterm birth (<37 weeks), small for gestational age birth, large for gestational age birth, stillbirth (? 28 weeks), and neonatal death (0-27 days).ResultsPost-surgery births were more often preterm than in matched controls (9.7% (243/2511) v 6.1% (750/12,379); odds ratio 1.7, 95% confidence interval 1.4 to 2.0; P<0.001). Body mass index seemed to be an effect modifier (P=0.01), and the increased risk of preterm birth was only observed in women with a body mass index <35. A history of bariatric surgery was associated with increased risks of both spontaneous (5.2% (130/2511) v 3.6% (441/12,379); odds ratio 1.5, 1.2 to 1.9; P<0.001) and medically indicated preterm birth (4.5% (113/2511) v 2.5% (309/12,379); odds ratio 1.8, 1.4 to 2.3; P<0.001). A history of bariatric surgery was also associated with an increased risk of a small for gestational age birth (5.2% (131/2507) v 3.0% (369/12,338); odds ratio 2.0, 1.5 to 2.5; P<0.001) and lower risk of a large for gestational age birth (4.2% (105/2507) v 7.3% (895/12,338); odds ratio 0.6, 0.4 to 0.7; P<0.001). No differences were detected for stillbirth or neonatal death. The increased risks for preterm and small for gestational age birth, as well as the decreased risk for large for gestational age birth, remained when post-surgery births were compared with births of women eligible for bariatric surgery.ConclusionWomen with a history of bariatric surgery were at increased risk of preterm and small for gestational age births and should be regarded as a risk group during pregnancy.

Project description:Background Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life-prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures. Methods and Results Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64-0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67-0.87). Conclusions Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.

Dataset Information

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study.

Publications

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study.

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