Comparison of Prospective and Retrospective Indicators of the Quality of End-of-Life Cancer Care

Abstract

A B S T R A C T PurposeTo compare prospectively and retrospectively defined benchmarks for the quality of end-of-life care, including a novel indicator for the use of opiate analgesia. MethodsLinked claims and cancer registry data from 1994 to 2003 for New Jersey and Pennsylvania were used to examine prospective and retrospective benchmarks for seniors with breast, colorectal, lung, or prostate cancer who participated in state pharmaceutical benefit programs. ResultsUse of opiates, particularly long-acting opiates, was low in both the prospective and retrospective cohorts (9.1% and 10.1%, respectively), which supported the underuse of palliative care at the end-of-life. Although hospice was used more commonly in the retrospective versus prospective cohort, admission to hospice within 3 days of death was similar in both cohorts (28.8% v 26.4%), as was the rate of death in an acute care hospital. Retrospective and prospective measures identified similar physician and hospital patterns of end-of-life care. In multivariate models, a visit with an oncologist was positively associated with the use of chemotherapy, opiates, and hospice. Patients who were cared for by oncologists in small group practices were more likely to receive chemotherapy (retrospective only) and less likely to receive hospice (both) than those in large groups. Compared with patients who were cared for in teaching hospitals, those in other hospitals were more likely to receive chemotherapy (both) and to have toxicity (prospective) but were less likely to receive opiates (both) and hospice (retrospective). ConclusionRetrospective and prospective measures, including a new measure of the use of opiate analgesia, identify some similar physician and hospital patterns of end-of-life care.

Quality of End-of-Life Care Between Medical Oncologists and Other Physician Specialists for Taiwanese Cancer Decedents, 2001–2006

“…Indicators for quality of EOL cancer care in the last month of life included chemotherapy, prolonged hospitalization, multiple ER visits, ICU care, and administering CPR, intubation, and mechanical ventilation. Taiwanese cancer patients cared for by a medical oncologist in the last month of life were more likely than patients whose primary physicians were other specialists to be treated closer to death with chemotherapy, consistent with recent reports from western countries [3,16,26,35]. Medical oncologists had a better knowledge of the role of chemotherapy in metastatic cancer than other specialist groups [36] and held more optimistic attitudes toward adjuvant chemotherapy [18,37] and the palliative benefit of chemotherapy [36,38].…”

“…These findings are different from the majority of published reports in the literature. Although one study demonstrated that generalists and oncologists showed similar care practices for referral to hospice care [25], other studies indicated that cancer patients cared for by a medical oncologist were significantly more likely to be enrolled in hospice care [14,17,23,26] but to be referred to hospice care closer to death [14,24] than cancer patients whose primary physician was another specialist. The discrepancy between our findings and those in the literature may come from two counterbalancing forces related to the characteristics and experiences of medical oncologists in Taiwan.…”

“…Specialized care has been associated with superior quality care early in the trajectory of cancer treatment (i.e., thorough staging, appropriately aggressive surgery, and subsequent guideline-recommended adjuvant treatments) [15, 19 -22] and possibly better outcomes [15,19,22]. However, EOL care practices have been infrequently studied, with conflicting results [16,[23][24][25][26]. Furthermore, many studies that compared practice patterns and outcomes of generalist care with those of specialist care in systematic reviews [19,22] suffered from inadequate case-mix adjustment and failed to address the characteristics of health care systems.…”

End of life care in high-grade glioma patients in three European countries: a comparative study

“…As 39 % of all relatives did not return the questionnaire, the results could be subjected to selection bias as well [18]. Nonetheless, a retrospective approach is a well-accepted study design in the examination of care at the EOL [19,20].…”

End‐of‐life care for older cancer patients in the Veterans Health Administration versus the private sector

“…Yet, these measures are well suited for comparing systems of care, 34 and recent data suggest that they provide comparable information to measures collected from medical record abstractions, collected either prospectively or retrospectively. 35,36 Moreover, some have questioned the validity of retrospective studies of end-of-life care for cancer patients because it is not always possible to identify the point at which physicians perceive patients' terminal status. 37 However, we studied patients diagnosed with metastatic lung and colorectal cancer, so all patients were known to have poor prognoses and limited life expectancy.…”