Quality of End-of-Life Care in Gastrointestinal Cancers: A 13-Year Population-Based Retrospective Analysis in Ontario, Canada

Abstract

Population-based quality indicators of either aggressive or supportive care at end of life (EOL), especially when specific to a cancer type, help to inform quality improvement efforts. This is a population-based, retrospective cohort study of gastrointestinal (GI) cancer decedents in Ontario from 1 January 2006–31 December 2018, using administrative data. Quality indices included hospitalizations, emergency department (ED) use, intensive care unit admissions, receipt of chemotherapy, physician house call, and palliative home care in the last 14–30 days of life. Previously defined aggregate measures of both aggressive and supportive care at end of life were also used. In our population of 69,983 patients who died of a GI malignancy during the study period, the odds of experiencing aggressive care at EOL remained stable, while the odds of experiencing supportive care at EOL increased. Most of our population received palliative care in the last year of life (n = 65,076, 93.0%) and a palliative care home care service in the last 30 days of life (n = 45,327, 70.0%). A significant number of patients also experienced death in an acute care hospital bed (n = 28,721, 41.0%) or had a new hospitalisation in the last 30 days of life (n = 33,283, 51.4%). The majority of patients received palliative care in the last year of life, and a majority received a palliative care home service within the last 30 days of life. The odds of receiving supportive care at EOL have increased over time. Differences in care exist according to income, age, and rurality.

Sex-Based Analysis of Quality Indicators of End-of-Life Care in Gastrointestinal Malignancies

“…Further, our previous work found that younger age, residency in the three lowest-income quintile neighbourhoods, and rurality were associated with increased odds of experiencing aggressive care at EOL. However, sex was not included as a predictor in this model [ 16 ]. In this secondary analysis, we found that the female population may be driving the associations between increased odds of aggressive care at EOL and younger age.…”

“…The same relationship, however, may not appear for females, who, despite education level, may have lower incomes due to the longstanding gender wage gap in addition to traditional gender norms driving increased caregiver responsibilities and less income-generating work outside the home [42,43]. Other studies showed an association between increased risk of aggressive EOL care and lower income [16,[44][45][46], though, to our knowledge, this is the first study to directly compare how income may affect the aggressiveness of care for each sex.…”

“…This is a secondary analysis of data from a previously described population-based, retrospective cohort study of GI malignancy decedents in Ontario, Canada, from 1 January 2006 to 31 December 2018 [ 16 ].…”

“…Covariates in the model included age at death, DCCI, survival, cancer type, income quintile, year of death (which was divided into three periods for ease of interpretation), and rurality. Covariates were chosen on the basis of previous studies and the authors’ clinical experience [ 16 , 26 , 27 , 28 , 29 ].…”

“…Our objective was to examine the impact of sex on the receipt of aggressive or supportive EOL care through a secondary analysis of previously published data in patients with gastrointestinal (GI) malignancies [ 16 ]. We found that overall, the quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.…”