Trends in the Utilization of Palliative Care in Patients With Gynecologic Cancer Who Subsequently Died During Hospitalization

2020 ◽  
Vol 38 (2) ◽  
pp. 138-146 ◽  
Author(s):  
Anthony Milki ◽  
Amandeep Kaur Mann ◽  
Austin Gardner ◽  
Daniel Stuart Kapp ◽  
Diana English ◽  
...  
Keyword(s):  
Palliative Care ◽  
Low Socioeconomic Status ◽  
Terminal Illness ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Gynecologic Cancer ◽  
Low Socioeconomic ◽  
Logistic Regression Models ◽  
Younger Age ◽  
Chi Squared

Objective: To determine factors associated with the utilization of palliative care (PC) in patients with metastatic gynecologic cancer who died while hospitalized. Methods: Data were abstracted from the National Inpatient Sample database for patients with cervical, uterine, and ovarian cancers from 2005 to 2011. Chi-squared and logistic regression models were used for statistical analyses. Results: Of 4559 women (median age: 65 years; range: 19-102), 1066 (23.4%) utilized PC. Patients were 24.9% low socioeconomic status (SES), 23.9% low-middle, 23.7% middle-high, and 25.1% high SES. Medicare, Medicaid, and private insurance coverage were listed at 46.2%, 37.5%, 11.3% of patients; 36.2%, 21.1%, 18.1%, 24.6% were treated in the South, West, Midwest, and Northeast. Over the 7 year study period, the use of PC increased from 12% to 45%. Older age (odds ratio [OR]: 1.36; 95% CI: 1.11-1.68; P = .003), high SES (OR: 1.41; 95% CI: 1.12-1.78; P = .003), more recent treatment (OR: 9.22; 95% CI: 6.8-12.51; P < .0001), private insurance (OR: 1.81; 95% CI: 1.46-2.25; P < .001), and treatment at large-volume hospitals (OR: 1.36; 95% CI: 1.04-1.77; P = .02), Western (OR: 2.00; 95% CI: 1.61-2.49; P < .001) and Midwestern hospitals (OR: 1.35; 95% CI: 1.08-1.68; P = .001) were associated with higher utilization of PC. Conclusions: The use of inpatient PC for patients with gynecologic cancer increased over time. The lower utilization of PC for terminal illness was associated with younger age, lower SES, government-issued insurance coverage, and treatment in Southern and smaller volume hospitals, and warrants further attention.

Progress and trends in the utilization and adoption of palliative care in patients with terminal gynecologic cancer in the United States: A study of 4,264 women.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11606-11606
Author(s):  
Anthony Milki ◽  
Amandeep Kaur Mann ◽  
Daniel Stuart Kapp ◽  
John K. Chan
Keyword(s):  
Palliative Care ◽  
Terminal Illness ◽  
Private Insurance ◽  
Gynecologic Cancer ◽  
The United States ◽  
Cancer Type ◽  
Median Income ◽  
Logistic Regression Models ◽  
Lower Socioeconomic ◽  
Chi Squared

11606 Background: To determine the factors associated with the utilization of palliative care (PC) in patients with metastatic gynecologic cancer who died while hospitalized. Methods: Data were extracted from the National Inpatient Sample (NIS) database for patients with cervical, uterine, and ovarian cancers from 2005 to 2011. Chi-squared and logistic regression models were employed for statistical analyses. Results: Of 4264 women with gynecologic cancer, 983 (23.0%) utilized PC (median age: 66 years). 2633 (61.8%), 1034 (24.3%), and 597 (14.0%) patients had ovarian, uterine, and cervical cancer, respectively. The majority were white (57.9%), and the remainder were black (12.6%), Hispanic (7.8%), and Asian (3.1%). 24.9, 23.9, 23.6, and 25.2% were low, low-middle, middle-high, and high with respect to median income. Medicare, Medicaid, and private insurance was found in 46.7, 10.8, and 37.6% of patients. 36.9, 21.0, 18.0, and 24.1% of patients were treated in hospitals in the South, West, Midwest, and Northeast. 11.3, 23.9, and 64.2% of patients were treated in small, medium, and large hospitals, designated as teaching (53.1%) and nonteaching (46.3%) institutions. The utilization of PC increased from 5.2% in 2005 to 30.4% in 2011. Older age (OR: 1.34; 95% CI: 1.10-1.64; P = 0.01), high SES (OR: 1.37; 95% CI: 1.09-1.72; P = 0.01), privately insured (OR: 1.81; 95% CI: 1.46-2.24; P < 0.001), treatment at Western (OR: 1.94; 95% CI: 1.56-2.41; P < 0.001) and Midwestern hospitals (OR: 1.43; 95% CI: 1.15-1.77; P = 0.001), and depression (OR: 1.34; 95% CI: 1.00-1.80; P = 0.05) were associated with higher PC use. However, race, cancer type, hospital teaching status, and hospital location were not associated with PC use. Conclusions: The use of inpatient palliative care has increased significantly over the study period. The lower utilization of palliative care for terminal illness associated with younger, lower socioeconomic status, Southern and smaller volume hospitals warrants further attention.

scholarly journals Association of socioeconomic status with medical assistance in dying: a case–control analysis

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e043547
Author(s):  
Donald A Redelmeier ◽  
Kelvin Ng ◽  
Deva Thiruchelvam ◽  
Eldar Shafir
Keyword(s):  
Socioeconomic Status ◽  
Palliative Care ◽  
Low Socioeconomic Status ◽  
Case Control ◽  
Control Analysis ◽  
Medical Assistance ◽  
Low Socioeconomic ◽  
Medical Assistance In Dying ◽  
Income Status ◽  
Economic Constraints

ObjectivesEconomic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints.DesignPopulation-based case–control study of adults who died.SettingOntario, Canada, between 1 June 2016 and 1 June 2019.PatientsPatients receiving palliative care under universal insurance with no user fees.ExposurePatient’s socioeconomic status identified using standardised quintiles.Main outcome measureWhether the patient received medical assistance in dying.ResultsA total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design.ConclusionsPatients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

Insurance coverage and care affordability in cancer survivors in 2016-2019.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 1520-1520
Author(s):  
Justin Michael Barnes ◽  
Eric Adjei Boakye ◽  
Mario Schootman ◽  
Evan Michael Graboyes ◽  
Nosayaba Osazuwa-Peters
Keyword(s):  
United States ◽  
Cancer Survivors ◽  
Low Socioeconomic Status ◽  
Private Insurance ◽  
Insurance Coverage ◽  
The United States ◽  
Mediating Effect ◽  
Medicaid Expansion ◽  
Poverty Level ◽  
Linear Probability

1520 Background: The Affordable Care Act (ACA) led to improvements in insurance coverage and care affordability in cancer patients. However, the uninsured rate for the general US reached its nadir in 2016 and has been increasing since. We aimed to quantify the changes in insurance coverage and rate of care unaffordability in cancer survivors from 2016 to 2019. Methods: We queried data from the Behavioral Risk Factor Surveillance System (2016-2019) for cancer survivors ages 18-64 years. Outcomes of interest were the percentage of cancer survivors reporting insurance coverage and the percentage reporting cost-driven lack of care in the previous 12 months. Survey-weighted linear probability models adjusted for covariates (age, sex, race/ethnicity, income, education, marital status, and state Medicaid expansion status) were utilized to estimate the average yearly change (AYC) in the outcomes across 2016-2019. Mediation analyses evaluated the mediating effect of insurance coverage changes on changes in cost-driven lack of care. Results: A total of 178,931 cancer survivors were identified among the survey respondents. The percentage of insured cancer survivors between 2016 and 2019 decreased from 92.4% to 90.4% (AYC: -0.54, 95% CI = -1.03 to -0.06, P =.026). This translates to an estimated 164,638 cancer survivors in the United States who lost insurance coverage in the study period. There were decreases in private insurance coverage (AYC: -1.66, 95% CI = -3.1 to -0.22, P =.024) but increases in Medicaid coverage (AYC: 1.14, 95% CI = 0.03 to 2.25, P =.043). The decreases in any coverage were largest in individuals with income < 138% federal poverty level (FPL) (AYC: -1.14, 95% CI = -2.32 to 0.04, P =.059; compared to > 250% FPL, Pinteraction=.03). Cost-driven lack of care in the preceding 12 months among cancer survivors increased from 17.9% in 2016 to 20% in 2019 (AYC: 0.67, 95% CI = 0.06 to 1.27, P =.03), which translates to an estimated 167,184 survivors in the US who skipped care due to costs. Changes in insurance coverage mediated 27.5% of the observed change in care unaffordability overall (p =.028) and 65.7% in individuals with income < 138% FPL relative to > 250% FPL (p =.045). Conclusions: Between 2016 and 2019, about 165,000 cancer survivors in the United States lost their insurance coverage and a similar number may have skipped needed care due to cost. Loss of insurance coverage was mostly among individuals with low socioeconomic status. Interventions to improve health insurance coverage among cancer survivors, such as the recent executive order to strengthen the ACA and further efforts promoting Medicaid expansion in additional states, may be important factors to mitigate these trends.

scholarly journals Early-Life Adversities and Recalcitrant Smoking in Midlife: An Examination of Gender and Life-Course Pathways

2020 ◽  
Vol 54 (11) ◽  
pp. 867-879
Author(s):  
Chioun Lee ◽  
Lexi Harari ◽  
Soojin Park
Keyword(s):  
Life Course ◽  
Low Socioeconomic Status ◽  
Early Life ◽  
Financial Strain ◽  
Low Ses ◽  
Family Instability ◽  
Family Problems ◽  
Low Socioeconomic ◽  
Logistic Regression Models

Abstract Background Little is known about life-course factors that explain why some individuals continue smoking despite having smoking-related diseases. Purpose We examined (a) the extent to which early-life adversities are associated with the risk of recalcitrant smoking, (b) psychosocial factors that mediate the association, and (c) gender differences in the associations. Methods Data were from 4,932 respondents (53% women) who participated in the first and follow-up waves of the Midlife Development in the U.S. National Survey. Early-life adversities include low socioeconomic status (SES), abuse, and family instability. Potential mediators include education, financial strain, purpose in life, mood disorder, family problems/support, and marital status. We used sequential logistic regression models to estimate the effect of early-life adversities on the risk of each of the three stages on the path to recalcitrant smoking (ever-smoking, smoking-related illness, and recalcitrant smoking). Results For women, low SES (odds ratio [OR] = 1.29; 1.06–1.55) and family instability (OR = 1.73; 1.14–2.62) are associated with an elevated risk of recalcitrant smoking. Education significantly reduces the effect of childhood SES, yet the effect of family instability remains significant even after accounting for life-course mediators. For men, the effect of low SES on recalcitrant smoking is robust (OR = 1.48; 1.10–2.00) even after controlling for potential mediators. There are noteworthy life-course factors that independently affect recalcitrant smoking: for both genders, not living with a partner; for women, education; and for men, family problems. Conclusions The findings can help shape intervention programs that address the underlying factors of recalcitrant smoking.

Utilization of palliative care in patients with genitourinary malignancies.

2020 ◽  
Vol 38 (6_suppl) ◽  
pp. 669-669
Author(s):  
Arya Mariam Roy ◽  
Manojna Konda ◽  
Akshay Goel ◽  
Rashmi Verma
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Terminal Illness ◽  
Hospital Admissions ◽  
Metastatic Cancer ◽  
Private Insurance ◽  
Malignant Neoplasm ◽  
The West ◽  
Factors Affecting

669 Background: Palliative care provides support and improves the quality of life of patients who has terminal illness such as cancer. Studies have shown that integrating palliative care into cancer care soon after the diagnosis of metastatic cancer can improve the quality of life and also prolong survival. The objective of the study was to analyze the acceptance of palliative care and to determine the factors affecting the utilization of palliative care in patients with genitourinary (GU) cancers. Methods: The National Inpatient Sample Database for the year 2016 was queried for the data. Patients who were admitted with a principal diagnosis of Malignant Neoplasm of Prostate (MNP), Renal Cell Carcinoma (RCC), Malignant Neoplasm of Ureter (MNU) were identified using ICD-10 codes and those who had Encounter for Palliative Care (PC) was also identified. Results: A total of 58765 hospitalizations were identified with MNP (n=39853), RCC (n=17786), MNU (n= 1126) during the study period. The total PC utilization for the above patients were 6.4% (n= 3785). Among those, 6.7% (n=1186), 6.3% (n=2531), 6.03% (n=68) from the groups RCC, MNP, MNU respectively received PC. The mean age for the PC utilization was 73 years (MNP= 72 yrs, RCA= 63 yrs, UCC= 73 yrs). Females received more PC when compared to males (6.7% vs 6.4%). Among those who had PC 27.4% (n=1029) died in the hospital. Interestingly, patients who had Medicare and Medicaid had more PC encounters when compared to those with private insurance (OR= 1.21, P= 0.001). Patients admitted on the weekend received more PC when compared to those who admitted during weekdays (OR= 1.12, P= 0.001). Patients admitted to hospitals in the West received more PC than other regions (OR= 1.42, P=0.03). Impact of race, teaching vs non-teaching hospital admissions were not found to be statistically significant in the utilization of PC in the above GU cancers. Conclusions: Medicare and Medicaid patients, weekend admissions, admissions to hospitals in the West received more palliative care. Further studies are needed to reveal the role of socioeconomic status and insurance in the utilization of palliative care in GU malignancies.

Racial and insurance disparities in multiple myeloma management in a referral center.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18140-e18140
Author(s):  
Anne Renteria ◽  
Sundar Jagannath ◽  
Kezhen Fei ◽  
Sylvia Lin ◽  
Radhi Yagnik ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Racial Differences ◽  
Private Insurance ◽  
Insurance Coverage ◽  
Autologous Stem Cell Transplant ◽  
Categorical Variables ◽  
Cell Transplant ◽  
Continuous Variables ◽  
Logistic Regression Models ◽  
Referral Center

e18140 Background: Multiple Myeloma (MM) management has significantly improved disease-free and overall (OS) survival but disparities among racial groups still exist. After the Affordable Care Act, the extent to which induction, autologous stem cell transplant (ASCT), and maintenance therapies are used are uncertain. We sought to describe underuse of induction, ASCT and maintenance in a large referral center. Methods: Between 2010 and 2014, 3101 patients were diagnosed with MM via ICD-9 code from the Data Warehouse and certified hospital tumor registry. NCCN 2014 and CMS guidelines were used to define the categories of treatment underuse, and define transplant eligibility. Demographics including insurance, Charlson Comorbidity Index and treatments received were determined via chart abstraction. To date, 393 confirmed MM from 697 charts were abstracted. Comparison by groups used Chi-square for categorical variables, t-test and ANOVA for continuous variables. Multivariate logistic regression models were applied to predict underuse of induction, harvest, ASCT, and maintenance. Results: Patients were 62 ±11.3 years-old, with no racial differences in age and insurance coverage. More minorities had Medicaid (Black [B] 13%, White [W] 7%, Hispanic [H] 25%; p = 0.001). Almost all patients (97%) received induction (B 99%, W 96%, H 100%; p = 0.3), with no difference by insurance. Among transplant eligible patients, 93% underwent harvest, 87% underwent ASCT, with no racial differences. Patients with Medicare or self-pay were less likely to undergo harvest compared to patients with Medicaid or private insurance (p = 0.01). No difference in ASCT rates by insurance were noted. B patients were less likely to receive maintenance than non-B (73% vs 86%; p = 0.03), with no difference by insurance. OS was 73%, with no racial differences. In multivariate model, older age predicted induction underuse (aOR = 1.15, 95% CI: 1.06-1.25) (c = 0.9, p = 0.005), and B patients experienced more maintenance underuse (aOR = 2.22, 95% CI: 1.09-4.54) (c = 0.61, p = 0.1), controlling for age and comorbidity. Conclusions: While there were no racial or insurance differences in access to induction therapy, fewer Black patients received maintenance therapy. Interviews are underway to understand reasons for observed differences.

The Healthcare Journey of Women With Advanced Gynecological Cancer From Diagnosis Through Terminal Illness: Qualitative Analysis of Progress Note Data

2021 ◽  
pp. 104990912110642
Author(s):  
Ellis C. Dillon ◽  
Vidita Chopra ◽  
Elizabeth Mesghina ◽  
Anthony Milki ◽  
Ava Chan ◽  
...  
Keyword(s):  
Palliative Care ◽  
Terminal Illness ◽  
Hospice Care ◽  
Gynecological Cancer ◽  
Gynecologic Cancer ◽  
Stage Iv ◽  
Urgent Care ◽  
Psychosocial Needs ◽  
Goals Of Care ◽  
Progress Notes

Objective To examine women’s journeys with gynecologic cancer from before diagnosis through death and identify elements of their healthcare experience that warrant improvement. Methods This exploratory study used longitudinal progress notes data from a multispecialty practice in Northern California. The sample included women with stage IV gynecological cancer diagnosed after 2011 and who died before 2018. Available progress notes from prior to diagnosis to death were qualitatively analyzed. Results We identified 32 women, (median age 61 years) with mostly uterine (n=17) and ovarian (n=9) cancers and median survival of 9.2 months (min:2.9 and max:47.5). Sixteen (50%) received outpatient palliative care and 18 (56%) received hospice care. The analysis found wide variation in documentation about communication about diagnosis, prognosis, goals of care, stopping treatment, and starting hospice care. Challenges included escalating/severe symptoms, repeated urgent care/emergency department/hospital encounters, and lack of or late access to palliative and hospice care. Notes also illustrated how patient background and goals influenced care trajectory and communication. Documentation styles varied substantially, with palliative care notes more consistently documenting conversations about goals of care and psychosocial needs. Conclusion This analysis of longitudinal illness experience of women with advanced gynecological cancer suggests that clinicians may want to (1) prioritize earlier discussion about goals of care; (2) provide supplemental support to patients with higher needs, possibly through palliative care or navigation; and (3) write notes to enhance patient understanding now that patients may access all notes.

The Stylisation of Internet Life?: Predictors of Internet Leisure Patterns Using Digital Inequality and Status Group Perspectives

2008 ◽  
Vol 13 (5) ◽  
pp. 27-39 ◽  
Author(s):  
Roderick Graham
Keyword(s):  
Low Socioeconomic Status ◽  
Binary Logistic Regression ◽  
The United States ◽  
Digital Inequality ◽  
Low Socioeconomic ◽  
Life Project ◽  
Logistic Regression Models ◽  
Status Group ◽  
Different Types ◽  
Nationally Representative

This research addresses the question: What are the predictors of internet leisure patterns? With the barriers to internet access receding the question can be asked: Whether or not social groups are beginning to distinguish themselves through different types of internet activities? This research will focus on the domain of internet leisure and entertainment within the United States population. Internet leisure is measured in this study by playing games, doing hobbies, reading, watching videos and listening to music. Predictors are drawn from a digital inequality and a Weberian status group perspective. Binary logistic regression models are run on a nationally representative survey from the Pew Research Center's Internet and American Life Project (N = 2013). This research suggests that: (1) both digital inequality and status group perspectives tend to work together to explain all internet activities, but a status group perspective provides more explanation for leisure patterns, (2) internet leisure is best conceptualised as a form of popular culture with minorities and people of low socioeconomic status consuming leisure at higher rates.

The STEM Selfing Process: Nondigital and Digital Determinants of Aspirational STEM Futures

2020 ◽  
Vol 64 (7) ◽  
pp. 950-972
Author(s):  
Laura Robinson
Keyword(s):  
High School ◽  
High School Students ◽  
Qualitative Analysis ◽  
Low Socioeconomic Status ◽  
Regression Models ◽  
Identity Work ◽  
Public High School ◽  
School Students ◽  
Low Socioeconomic ◽  
Logistic Regression Models

This article takes a fresh approach to analyzing the nondigital and digital sources of STEM (science, technology, engineering, and math) intent among low–socioeconomic status (SES) high school students attending a Title I public high school in agricultural California. Through a hybrid quantitative–qualitative analysis of data, STEM intent is examined vis-à-vis the selfing process. STEM intent is conceptualized as the product of identity work that can be supported by digital engagements of diverse types. STEM identity is built and reinforced by exposure to digital resources at home, aspirations related to computer programming, and digital activities, particularly programming and/or gaming for at least one hour per week. The linkages are demonstrated quantitatively through logistic regression models and qualitatively with excerpts from in-depth interviews with matched STEM intent students. The regression models show that both nondigital factors and digital engagements influence the odds of expressing STEM intent among high school seniors. As the qualitative analysis demonstrates, these determinants are intimately linked to identity work in which STEM intent students imagine themselves as creators in STEM fields. Digital engagements such as programming, gaming, and internet exposure all play a crucial part in the STEM selfing process in which students imagine their future STEM selves by bringing to life the role of STEM creator. In the article’s concluding discussion these findings are developed in a new theoretical direction as evidence for the agentic technological self.

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