Effectiveness of two types of palliative home care in cancer and non-cancer patients: A retrospective population-based study using claims data

Abstract

Background: Comparative effectiveness of different types of palliative homecare is sparsely researched internationally—despite its potential to inform necessary decisions in palliative care infrastructure development. In Germany, specialized palliative homecare delivered by multi-professional teams has increased in recent years and factors beyond medical need seem to drive its involvement and affect the application of primary palliative care, delivered by general practitioners who are supported by nursing services. Aim: To compare effectiveness of primary palliative care and specialized palliative homecare in reducing potentially aggressive interventions at the end-of-life in cancer and non-cancer. Design: Retrospective population-based study with claims data from 95,962 deceased adults in Germany in 2016 using multivariable regression analyses. Settings/participants: Patients having received primary palliative care or specialized palliative homecare (alone or in addition to primary palliative care), for at least 14 days before death, differentiating between cancer and non-cancer patients. Results: Rates of potentially aggressive interventions in most indicators were higher in primary palliative care than in specialized palliative homecare ( p < 0.01), in both cancer and non-cancer patients: death in hospital (odds ratio (OR) 4.541), hospital care (OR 2.720), intensive care treatment (OR 6.749), chemotherapy (OR 2.173), and application of a percutaneous endoscopic gastrostomy (OR 4.476), but not for parenteral nutrition (OR 0.477). Conclusion: Specialized palliative homecare is more strongly associated with reduction of potentially aggressive interventions than primary palliative care in the last days of life. Future research should identify elements of specialized palliative homecare applicable for more effective primary palliative care, too. German Clinical Trials Register (DRKS00014730).

Palliative medicine favourably influences end-of-life cancer care intensity: a large retrospective database study

“…Our study supports the evidence from previous investigations that PC admission has a relevant role in reducing various indicators of EOL aggressive care 5–14. In particular, we found that PC reduced hospitalisations by over 70%, long hospital stay by 75%, ED visit by 65%, and use of chemotherapy by 35% during the last month.…”

“…With reference to the indicators of aggressive EOL care analysed in our study, we found that about 45% of patients were hospitalised during the last 30 days of life, a value that is within the range between 40% and 65% reported in previous investigations 10–14 28. About 30% of patients with cancer in Lombardy died in hospital, a value among the lowest reported in other studies (between 30% and 70%) 4 10 11 13–15 17 28.…”

“…Patients treated with chemotherapy in our population were 8.5% in the last 30 days and 2.3% in the last 14 days. Although there is some variability in the data reported in previous studies (with values between 5% and 20% in the last 30 days, and between 2% and 10% in the last 14 days), chemotherapy exposure in our study appears quite low, particularly in the last 14 days 4 10–12 14 17 28 29. Although it is possible that we had somehow underestimated chemotherapy use, this is a favourable indicator of the practice of EOL in patients with cancer in this Italian region.…”

“…Hospice and home palliative care (PC)—which has been fostered during the last decades in many high-income countries in order to better care (cancer) patients in the EOL—have been associated to a reduction of aggressive treatments in the EOL 5–14. Evidence also indicates that the earlier the admission to PC the less aggressive EOL care 10 15–18.…”

Association of a home-based nursing service during chemotherapy with the transfer to home care immediately after the last chemotherapy treatment in patients with advanced cancer

“…A previous qualitative study mentioned that the home care nurses who are involved with patients during cancer treatment needed to explain the treatment in understandable terms ( 13 ). Moreover, a recent study has suggested that palliative home care reduces chemotherapy at the end of life and in-hospital death ( 21 ). From these studies, it was hypothesized that the early utilization of the home-based nursing service during chemotherapy might lead to the reduction of in-hospital death by avoiding chemotherapy near the end of life, but this study did not demonstrate the hypothesis.…”