Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment

Abstract

GroupIMPORTANCE Functional outcomes are central to cancer care decision-making by older adults.OBJECTIVE To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure. DESIGN, SETTING, AND PARTICIPANTSThis population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018. MAIN OUTCOMES AND MEASURESThe main outcome was time at home, dichotomized as high time at home (defined as Յ14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used.RESULTS A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (Ն85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (

Healthy days at home: A population‐based quality measure for cancer patients at the end of life

“…Much of the literature on these patient-centered outcome measures focus on specific cancers, such as hematologic cancers. 18,21 We found that HDAH varied substantially by cancer type, with patients with hematologic cancers experiencing the fewest HDAH compared with the other types of cancer studied, consistent with prior research evaluating days at home at the EOL for cancer patients. 17 This finding is Cancer November 15, 2021 also consistent with literature showing that those with hematologic malignancies are more likely to visit the ED, be admitted to the hospital or ICU, and use chemotherapy in the last 30 days of life, suggesting that these patients experience more aggressive EOL cancer care.…”

“…[45][46][47] Second, many studies using these outcome measures were conducted in Canada; therefore, it is important to analyze these measures in the US population of cancer patients. Finally, many measures focus primarily on interactions with inpatient services and long-term care, 17,18,21 and very few include factors such as inpatient hospice care 15 and observation stays. By including days in a range of hospital and postacute care settings, our measure aimed comprehensively to capture these patients' interactions with the health care system at the EOL.…”

“…Recently, there has been a shift toward patient-centered outcomes that better reflect patient values at the EOL, with increasing attention on time spent at home for cancer patients. [15][16][17][18] Although many of these measures focus solely on time spent in the acute setting at the EOL, [19][20][21] there is a growing interest in measures that capture how often patients interact with the health care system more broadly, 17,18,22 such as visiting emergency departments (EDs) or spending time in postacute care facilities rather than at home. Recently, the Medicare Payment Advisory Commission developed a new Cancer November 15, 2021 measure, Healthy Days at Home (HDAH).…”

Maximizing Home Time for Persons With Cancer

“…[4][5][6][7][8][9] In contrast, formal analyses of home time within oncology-or even acknowledgments that unnecessary time expenditures may be an inherent toxicity of modern cancer carehave been comparatively limited. 10,11 Home time is perhaps considered most frequently for patients with impaired mobility and for patients with limited life expectancies (which explains why home time may be cited as a specific benefit of hospice care during endof-life discussions). 12 However, as oncologists and as patient advocates, we believe strongly that home time should be a consideration during earlier phases of cancer treatment as well.…”

Heart, home, and frailty: new risk scores and outcomes for cardiac surgery patients

“…4 Another metric related to DAH is days alive and out of hospital, 10 which only includes acute hospital care; therefore, a patient admitted to rehabilitation would be regarded as out-of-hospital, but is not at home. From a patient perspective, DAH is likely to be a more valuable metric, and has been validated in older adults (>70 yr old) after surgery, 12 but is harder to measure accurately. 11 In their study, McIsaac and colleagues examined the association of patient frailty, measured via a preoperative frailty index (pFI), with DAH after major cardiac surgery.…”