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      Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

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          Abstract

          Background:

          Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups.

          Aim:

          To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care.

          Design:

          Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information.

          Setting/participants:

          Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019.

          Results:

          The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05–1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019.

          Conclusions:

          Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

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          Most cited references50

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          Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial.

          Camilla Zimmermann, Nadia Swami, Monika Krzyzanowska … (2014)
          Patients with advanced cancer have reduced quality of life, which tends to worsen towards the end of life. We assessed the effect of early palliative care in patients with advanced cancer on several aspects of quality of life. The study took place at the Princess Margaret Cancer Centre (Toronto, ON, Canada), between Dec 1, 2006, and Feb 28, 2011. 24 medical oncology clinics were cluster randomised (in a 1:1 ratio, using a computer-generated sequence, stratified by clinic size and tumour site [four lung, eight gastrointestinal, four genitourinary, six breast, two gynaecological]), to consultation and follow-up (at least monthly) by a palliative care team or to standard cancer care. Complete masking of interventions was not possible; however, patients provided written informed consent to participate in their own study group, without being informed of the existence of another group. Eligible patients had advanced cancer, European Cooperative Oncology Group performance status of 0-2, and a clinical prognosis of 6-24 months. Quality of life (Functional Assessment of Chronic Illness Therapy--Spiritual Well-Being [FACIT-Sp] scale and Quality of Life at the End of Life [QUAL-E] scale), symptom severity (Edmonton Symptom Assessment System [ESAS]), satisfaction with care (FAMCARE-P16), and problems with medical interactions (Cancer Rehabilitation Evaluation System Medical Interaction Subscale [CARES-MIS]) were measured at baseline and monthly for 4 months. The primary outcome was change score for FACIT-Sp at 3 months. Secondary endpoints included change score for FACIT-Sp at 4 months and change scores for other scales at 3 and 4 months. This trial is registered with ClinicalTrials.gov, number NCT01248624. 461 patients completed baseline measures (228 intervention, 233 control); 393 completed at least one follow-up assessment. At 3-months, there was a non-significant difference in change score for FACIT-Sp between intervention and control groups (3·56 points [95% CI -0·27 to 7·40], p=0·07), a significant difference in QUAL-E (2·25 [0·01 to 4·49], p=0·05) and FAMCARE-P16 (3·79 [1·74 to 5·85], p=0·0003), and no difference in ESAS (-1·70 [-5·26 to 1·87], p=0·33) or CARES-MIS (-0·66 [-2·25 to 0·94], p=0·40). At 4 months, there were significant differences in change scores for all outcomes except CARES-MIS. All differences favoured the intervention group. Although the difference in quality of life was non-significant at the primary endpoint, this trial shows promising findings that support early palliative care for patients with advanced cancer. Canadian Cancer Society, Ontario Ministry of Health and Long Term Care. Copyright © 2014 Elsevier Ltd. All rights reserved.
          Article 0 comments Cited 262 times – based on 0 reviews     Review now
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            Heterogeneity and changes in preferences for dying at home: a systematic review

            Bárbara Pereira Gomes, Natalia Calanzani, Marjolein Gysels … (2013)
            Background Home-based models of hospice and palliative care are promoted with the argument that most people prefer to die at home. We examined the heterogeneity in preferences for home death and explored, for the first time, changes of preference with illness progression. Methods We searched for studies on adult preferences for place of care at the end of life or place of death in MEDLINE (1966–2011), EMBASE (1980–2011), psycINFO (1967–2011), CINAHL (1982–2011), six palliative care journals (2006–11) and reference lists. Standard criteria were used to grade study quality and evidence strength. Scatter plots showed the percentage preferring home death amongst patients, lay caregivers and general public, by study quality, year, weighted by sample size. Results 210 studies reported preferences of just over 100,000 people from 33 countries, including 34,021 patients, 19,514 caregivers and 29,926 general public members. 68% of studies with quantitative data were of low quality; only 76 provided the question used to elicit preferences. There was moderate evidence that most people prefer a home death–this was found in 75% of studies, 9/14 of those of high quality. Amongst the latter and excluding outliers, home preference estimates ranged 31% to 87% for patients (9 studies), 25% to 64% for caregivers (5 studies), 49% to 70% for the public (4 studies). 20% of 1395 patients in 10 studies (2 of high quality) changed their preference, but statistical significance was untested. Conclusions Controlling for methodological weaknesses, we found evidence that most people prefer to die at home. Around four fifths of patients did not change preference as their illness progressed. This supports focusing on home-based care for patients with advanced illness yet urges policy-makers to secure hospice and palliative care elsewhere for those who think differently or change their mind. Research must be clear on how preferences are elicited. There is an urgent need for studies examining change of preferences towards death.
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              Illness trajectories and palliative care.

              Scott Murray, Marilyn Kendall, Kirsty Boyd … (2005)
              Article 0 comments Cited 158 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Palliat Med
                Journal ID (iso-abbrev): Palliat Med
                Journal ID (publisher-id): PMJ
                Journal ID (hwp): sppmj
                Title: Palliative Medicine
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Print): 0269-2163
                ISSN (Electronic): 1477-030X
                Publication date (Electronic): 14 July 2023
                Publication date (Print): September 2023
                Volume: 37
                Issue: 8
                Pages: 1241-1251
                Affiliations
                [1 ]Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
                [2 ]Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
                [3 ]Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
                Author notes
                [*]Michael Bonares, Division of Palliative Care, Sunnybrook Health Sciences Centre, Room H336, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. Email: michael.bonares@ 123456mail.utoronto.ca
                Author information
                https://orcid.org/0000-0003-4552-920X
                https://orcid.org/0000-0001-6769-130X
                https://orcid.org/0000-0002-1594-0260
                Article
                Publisher ID: 10.1177_02692163231183009
                DOI: 10.1177/02692163231183009
                PMC ID: 10503238
                PubMed ID: 37452565
                SO-VID: 00f7f2c8-b203-4c07-8e2c-c58d6d8db9ef
                Copyright © © The Author(s) 2023
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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                Subject: Original Articles
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                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: hospitalization,malignancy,mortality,stroke,dementia,heart failure,pulmonary disease,chronic obstructive,renal insufficiency,chronic,cohort studies,palliative care
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: hospitalization, malignancy, mortality, stroke, dementia, heart failure, pulmonary disease, chronic obstructive, renal insufficiency, chronic, cohort studies, palliative care

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