The Association between Individual Income and Aggressive End-of-Life Treatment in Older Cancer Decedents in Taiwan

Huang, Chih‐Yuan; Hung, Yeh-Ting; Chang, Chin-Chun; Juang, Shiun-Yang; Lee, Ching‐Chih

doi:10.1371/journal.pone.0116913

Cited by 10 publications

(9 citation statements)

References 38 publications

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“…Although the deep-rooted traditional Chinese cultural values and beliefs, i.e., Confucianism with characteristics of filial piety and family staying-together, played an important role in determining the place of death, other factors, such as individual demographic and socioeconomic characteristics, personal ethnic affiliation, underlying disease, the healthcare system, practical and operational issues [3], also played a role. The observation for most of the deaths occurred at home in our study was consistent with previous studies conducted in the Chinese population [4,5,7,8,11]. However, against the background of rapid expansion of hospital beds per capita and increased hospital admission rates [15,18], such a constant proportion of home deaths was unexpected.…”

Section: Discussionsupporting

confidence: 92%

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

Weng

Sun

et al. 2022

The Lancet Regional Health - Western Pacific

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Summary Background China is embracing an ageing population without sustainable end-of-life care services. However, changes in place of death and trends of going home to die (GHTD) from the hospital remains unknown. Methods A total of 42,956 participants from the China Kadoorie Biobank, a large Chinese cohort, who died between 2009 and 2017 was included into analysis. GHTD was defined as death at home within 7 days after discharge from the hospital. A modified Poisson regression was used to investigate temporal trends of the place of death and GHTD, and estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association of GHTD with health insurance (HI) schemes. Findings From 2009 to 2017, home remained the most common place of death (71·5%), followed by the hospital (21·6%). The proportion of GHTD for Urban and Rural Residents’ Basic Medical Insurance (URRBMI) beneficiaries was around six times higher than that for Urban Employee Basic Medical Insurance (UEBMI) beneficiaries (66·0% vs 11·6%). Besides, a substantial increase in the proportion of GHTD throughout the study period was observed regardless of HI schemes (4·4% annually for URRBMI, and 5·4% for UEBMI). Compared with UEBMI beneficiaries, URRBMI beneficiaries were more likely to experience GHTD, with an adjusted PR (95% CI) of 1·19 (95% CI: 1·12, 1·27) ( P <0·001). Interpretation In China, most of deaths occurred at home, with a large proportion of decedents GHTD from the hospital, especially for URRBMI beneficiaries. Substantial variation in the phenomenon of GHTD across HI schemes indicates inequalities in end-of-life care utilization. Funding The National Natural Science Foundation of China, the Kadoorie Charitable Foundation, the National Key R&D Program of China, the Chinese Ministry of Science and Technology.

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Section: Discussionsupporting

confidence: 92%

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

Weng

Sun

et al. 2022

The Lancet Regional Health - Western Pacific

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“…Education is an indicator of socioeconomic status and health literacy level. Studies have shown that patients with lower socioeconomic status and health literacy are more likely to receive aggressive care at the end of life . It is possible that these disparities in health care use are due in part to beliefs about curability, although other explanations are plausible, such as distrust of physicians .…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown that patients with lower socioeconomic status and health literacy are more likely to receive aggressive care at the end of life. [29][30][31][32] It is possible that these disparities in health care use are due in part to beliefs about curability, 4 although other explanations are plausible, such as distrust of physicians. 33 Similarly, nonwhite patients have been shown to be more likely to believe they can be cured, 4 and this may partially explain the higher use of aggressive care in those with advanced stage cancer.…”

Section: Discussionmentioning

confidence: 99%

Willingness to bear adversity and beliefs about the curability of advanced cancer in older adults

Loh

Mohile

Epstein

et al. 2019

Cancer

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Background Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors’ knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. Methods Cross‐sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, “What do you believe are the chances that your cancer will go away and never come back with treatment?” Response options were 100% (coded as ACC), >50%, 50/50, <50%, 0%, and uncertain. The willingness to bear adversity in exchange for longevity was assessed by asking patients to consider trade‐offs between survival and 2 clinical outcomes that varied in abstractness: 1) maintaining quality of life (QOL; an abstract outcome); and 2) specific treatment‐related toxicities (eg, nausea/vomiting, worsening memory). Logistic regression was used to assess the independent associations between willingness to bear adversity and ACC. Results Of the 524 patients aged 70 to 96 years, approximately 5.3% reported that there was a 100% chance that their cancer would be cured (ACC). ACC was not found to be significantly associated with willingness to bear treatment‐related toxicities, but was more common among patients who were willing to trade QOL for survival (adjusted odds ratio, 4.08; 95% CI, 1.17‐14.26). Conclusions Patients who were more willing to bear adversity in the form of an abstract state, namely decreased QOL, were more likely to demonstrate ACC. Although conversations regarding prognosis should be conducted with all patients, those who are willing to trade QOL for survival may especially benefit from conversations that focus on values and emotions.

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“…Regarding general medical services, individuals of lower SES are typically treated similarly [ 64 – 66 ] or less intensively [ 67 , 68 ]; however, we determined that they were likely to receive a higher intensity of EOL care. An earlier study on Taiwanese cancer decedents also reported that lower income was associated with more aggressive treatments [ 69 ]. Such inequality in EOL care across income groups is troubling because individuals and households with low SES are particularly vunerable to the potential financial harm caused by medical bills [ 34 ].…”

Section: Discussionmentioning

confidence: 99%

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

Chen¹,

Fan

Chou

et al. 2017

BMC Nephrol

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BackgroundDespite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.MethodsWe conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.ResultsDuring the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.ConclusionsOverall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

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The Association between Individual Income and Aggressive End-of-Life Treatment in Older Cancer Decedents in Taiwan

Cited by 10 publications

References 38 publications

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

Place of death and phenomenon of going home to die in Chinese adults: A prospective cohort study

Willingness to bear adversity and beliefs about the curability of advanced cancer in older adults

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

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