Hospital-based acute care in the last 30 days of life among patients with chronic disease that received early, late or no specialist palliative care: a retrospective cohort study of eight chronic disease groups

Abstract

ObjectiveFor eight chronic diseases, evaluate the association of specialist palliative care (PC) exposure and timing with hospital-based acute care in the last 30 days of life.DesignRetrospective cohort study using administrative data.SettingAlberta, Canada between 2007 and 2016.Participants47 169 adults deceased from: (1) cancer, (2) heart disease, (3) dementia, (4) stroke, (5) chronic lower respiratory disease (chronic obstructive pulmonary disease (COPD)), (6) liver disease, (7) neurodegenerative disease and (8) renovascular disease.Main outcome measuresThe proportion of decedents who experienced high hospital-based acute care in the last 30 days of life, indicated by ≥two emergency department (ED) visit, ≥two hospital admissions,≥14 days of hospitalisation, any intensive care unit (ICU) admission, or death in hospital. Relative risk (RR) and risk difference (RD) of hospital-based acute care given early specialist PC exposure (≥90 days before death), adjusted for patient characteristics.ResultsIn an analysis of all decedents, early specialist PC exposure was associated with a 32% reduction in risk of any hospital-based acute care as compared with those with no PC exposure (RR 0.69, 95% CI 0.66 to 0.71; RD 0.16, 95% CI 0.15 to 0.17). The association was strongest in cancer-specific analyses (RR 0.53, 95% CI 0.50 to 0.55; RD 0.31, 95% CI 0.29 to 0.33) and renal disease-specific analyses (RR 0.60, 95% CI 0.43 to 0.84; RD 0.22, 95% CI 0.11 to 0.34), but a~25% risk reduction was observed for each of heart disease, COPD, neurodegenerative diseases and stroke. Early specialist PC exposure was associated with reducing risk of four out of five individual indicators of high hospital-based acute care in the last 30 days of life, including ≥two ED visit,≥two hospital admission, any ICU admission and death in hospital.ConclusionsEarly specialist PC exposure reduced the risk of hospital-based acute care in the last 30 days of life for all chronic disease groups except dementia.

Health Care Utilization in the Last Year of Life in Parkinson Disease and Other Neurodegenerative Movement Disorders

“…We retrospectively evaluated health care utilization in the last year of life by individuals with neurodegenerative movement disorders Compared with published data on individuals who died of cancer in Calgary, Alberta, we found that fewer individuals with neurodegenerative movement disorders received specialist palliative care (17% vs 86%). 7 Those with neurodegenerative movement disorders had lower rates of hospitalbased acute care in the last 30 days of life: 6.8% had more than one ED visit vs 11% of those with cancer, and 16.1% spent >14 days in hospital compared with 25% of those with cancer. The rate of death in hospital for those with neurodegenerative movement disorders in our study was 45.9%, compared with 41% of individuals who died of cancer.…”

“…Early palliative care was defined as beginning ≥90 days before death, a cut point commonly used in the palliative care literature. 7,8…”

“…Early palliative care was defined as beginning ≥90 days before death, a cut point commonly used in the palliative care literature. 7,8 Statistical Analyses Baseline quantitative variables were analyzed using t-tests and categorical data using Wilcoxon rank sum tests. Wilcoxon signed-rank comparisons for nonparametric data were used to compare groups.…”

A prospective cohort study assessing aggressive interventions at the end-of-life among patients with solid metastatic cancer

“…We asked patients to trade-off life extension with health care cost- “ If you had to make a choice now, would you prefer treatment that extends life as much as possible, or would you want treatment that costs you less?” Patients responded on scale of 1 to 9, with 1 representing - extend life as much as possible at high cost and 9 representing no life extension at less cost. Responses were classified as maximal life extension [ 1 – 4 ], moderate life extension [ 5 ] and no life extension [ 6 – 9 ].…”

“…Global advancements in cancer treatments have led to more than 50% of patients being treated aggressively [ 1 – 6 ] in some developed countries during their last month of life with 30 to 50% dying in the hospital [ 1 , 2 , 4 – 8 ]. This is concerning because such care represents low value for the health system, is often inconsistent with patients’ and caregivers’ end-of-life (EOL) preferences and negatively influences caregivers’ perceptions of quality of EOL care received, thereby making adjustment difficult during bereavement [ 7 , 9 – 14 ].…”