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

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Objective</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Design</jats:title> <jats:p>Population based matched cohort study.</jats:p> </jats:sec> <jats:sec> <jats:title>Setting</jats:title> <jats:p>Ontario, Canada between 2010 and 2015.</jats:p> </jats:sec> <jats:sec> <jats:title>Participants</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Main outcome measures</jats:title> <jats:p>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).</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p> 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) <jats:italic>v</jats:italic> 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) <jats:italic>v</jats:italic> 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) <jats:italic>v</jats:italic> 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%) <jats:italic>v</jats:italic> 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) <jats:italic>v</jats:italic> 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) <jats:italic>v</jats:italic> 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%) <jats:italic>v</jats:italic> 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. </jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>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.</jats:p> </jats:sec>

Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer

“…We defined terminal noncancer illness as HF, chronic obstructive pulmonary disease (COPD), end-stage kidney disease (ESKD), cirrhosis, stroke, and dementia because these diseases represent the most common terminal noncancer conditions. 1,[4][5][6]16,[21][22][23] After the identification of differences in the outcome of timing of palliative care initiation according to illness type, we conducted a prespecified, exploratory, hypothesis-generating analysis using the timing of palliative care relative to death as the exposure to measure the potential association of timing with location of death. The timing of palliative care was categorized according to commonly used periods in the published literature: 30 days or less, 31 to 90 days, and 91 days or more before death.…”

“…Palliative care improves quality of life, reduces symptom burden and unwanted health care use, and helps patients die in their preferred location. 1 , 2 , 3 , 4 , 5 , 6 Palliative care is the active holistic care of people and their families experiencing suffering because of serious illness, especially near the end of life. It focuses on the prevention, early identification, assessment, and management of physical issues, including pain and other distressing symptoms, psychological distress, spiritual distress, and social needs.…”

Complementary frailty and mortality prediction models on older patients as a tool for assessing palliative care needs

“…It is recommended that it be incorporated early in the disease trajectory, even in conjunction with potentially curative treatments [1]. PC can improve quality of life [2], mood [3], symptom control [4], reduce emergency department visits and hospitalisation [5], and even increase the one-year survival [6] PC services have traditionally been mainly accessed by cancer patients but there is growing consensus about the importance of promoting access for patients with non-malignant disease at earlier stages [7,8,9]. In the same line, Raudonis et al [10] suggest in their study that frail older adults could benefit from involvement in PC programs.…”

“…It is recommended that it be incorporated early in the disease trajectory, even in conjunction with potentially curative treatments [1]. PC can improve quality of life [2], mood [3], symptom control [4], reduce emergency department visits and hospitalisation [5], and even increase the one-year survival [6]…”

Palliative care in illnesses other than cancer

“…In a linked paper, Quinn and colleagues (doi:10.1136/bmj.m2257) report a population based matched cohort study from Canada that suggests potential benefits of palliative care in some non-cancer illnesses 2. Few high quality randomised controlled trials have been conducted in palliative care,345 but this new study adds to a growing evidence base of observational research in this field 6.…”