Patterns of End-of-Life Care as Measured by Emergency Room Visits Among Cancer Patients in Puerto Rico

2021 ◽  
pp. 104990912110257
Author(s):  
María R. Ramos-Fernández ◽  
Karen J. Ortiz-Ortiz ◽  
Carlos R. Torres-Cintrón ◽  
Guillermo Tortolero-Luna
Keyword(s):  
Puerto Rico ◽  
End Of Life ◽  
Cancer Patients ◽  
Hospice Care ◽  
Poor Quality ◽  
P Value ◽  
Study Cohort ◽  
Quality Cancer Care ◽  
Ed Visits ◽  
Adjusted Model

Background: Community palliative care (PC) services are scarce in Puerto Rico (PR). Patients with advanced cancer commonly visit the emergency department(ED) at the end of life (EoL). Recognition of patients with limited life expectancies and PC needs may improve the EoL trajectory of these patients. Our objective was to characterize ED visits of cancer patients at the EoL by examining the patterns of ED visits in PR using the PR Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD). Methods: The cohort consisted of patients aged ≥18 years with a primary invasive that died between 2011- 2017, with a recorded date of death, and who had insurance claims during their last three months. EoL indicators were ED visits, ED death, and hospice care use. Results: The study cohort included 10,755 cancer patients. 49.6% had ≥1 ED visit, 20.3% had ≥2 ED visits, and 9.7% died in the ED. In the adjusted model, female patients (aOR 0.80; 95% CI 0.68-0.93; p-value < 0.01), patients aged ≥80 years (aOR 0.47; 95% CI 0.36-0.63; p-value < 0.01), being enrolled in Medicare (aOR 0.74; 95% CI 0.61-0.90; p-value < 0.01) or being enrolled in Medicaid/Medicare (aOR 0.76; 95% CI 0.62-0.93; p-value = 0.01) were less likely to have an ED visit the date of death. Patients with distant stage are more likely to have ED ≥ 2visits ( p-value < 0.05). Conclusions: ED visits at EoL can be interpreted as poor quality cancer care and awareness of the potential of ED-initiated PC is needed in PR.

Targeted therapy at the end of life and the impact on health care utilization.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 116-116
Author(s):  
Heidi Yeung ◽  
Parsa Salehi ◽  
James Don Murphy
Keyword(s):  
Targeted Therapy ◽  
End Of Life ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Large Population ◽  
Metastatic Breast ◽  
Care Utilization ◽  
Study Cohort ◽  
Ed Visits ◽  
The Impact

116 Background: The use of targeted therapy has steadily increased over the past decade, though the impact of targeted agents on patterns of care at the end-of-life life remains unknown. The purpose of this study was to explore the influence of targeted therapy on end-of-life care in a large population-based database. Methods: We identified 14,398 patients from the SEER-Medicare linked database with metastatic breast, lung, or colorectal cancer diagnosed between 2000 and 2009 who received conventional cytotoxic chemotherapy or targeted therapy in the last 3 months of life. Multivariate logistic and linear regression models were used to determine the impact of targeted therapy on the following endpoints in the last 3 months of life: emergency department (ED) visits, hospitalizations, and hospice utilization. Analyses were adjusted for differences in patient age, gender, race, comorbidity, socioeconomic status, and geography. Results: Among the whole study cohort 83% of patients received chemotherapy alone, 12% received chemotherapy with targeted therapy, and 5% received targeted therapy alone. The delivery of any targeted therapy in the last 3 months increased across the study period, from 1.5% in 2000 to 28% in 2009. Compared to patients treated with chemotherapy alone, those treated with targeted therapy alone had lower rates of ED visits (adjusted odds ratio [aOR]=0.81, p=0.01), lower rates of hospitalization (adjusted odds ratio [aOR]=0.69, p<0.0001), no difference in overall hospice utilization rates, though had longer stays on hospice (5.1 days longer, p<0.0001). Compared to patients treated with chemotherapy alone, those treated with both chemotherapy and targeted therapy had no difference in ED visits or hospitalization admission rates, though had decreased rates of hospice utilization (aOR = 0.79, p<0.0001), and shorter stays on hospice (2.7 days longer, p<0.0001). Conclusions: This study found that targeted therapy was associated with varying patterns of healthcare utilization at the end-of-life, though these differences could be influenced by unknown confounding variables. Future research should focus on defining the specific impact of targeted therapy on quality of life at the end-of-life.

U.S. trends and racial/ethnic disparities in opioid access among patients with poor prognosis cancer at the end of life (EOL).

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 7005-7005
Author(s):  
Andrea Catherine Enzinger ◽  
Kaushik Ghosh ◽  
Nancy Lynn Keating ◽  
David M Cutler ◽  
Mary Beth Landrum ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Poor Prognosis ◽  
Ethnic Disparities ◽  
Opioid Prescription ◽  
Ed Visits ◽  
The Impact ◽  
To Receive ◽  
Racial Ethnic ◽  
Patients With Poor Prognosis

7005 Background: Heightened US opioid regulations may limit advanced cancer patients’ access to effective pain management, particularly for racial/ethnic minority and other vulnerable populations. We examined trends in opioid access, disparities in access, and pain-related emergency department (ED) visits among cancer patients near end of life (EOL). Methods: Using a 20% random sample of Medicare FFS beneficiaries, we identified 243,124 patients with poor prognosis cancers who died between 2007-2016. We examined trends in outpatient opioid prescription fills and pain-related ED visits near EOL (30 days prior to death or hospice enrollment), for the overall cohort and by race (white, black, other). Per-capita opioid supply by state was obtained from the federal Drug Enforcement Agency ARCOS database. Geographic fixed-effects models examined predictors of opioid use near EOL, opioid dose in morphine milligram equivalents (MMEs), and pain-related ED visits, adjusted for patient demographic and clinical characteristics, state, opioid supply, and year. Results: From 2007-2016 the proportion of patients with poor prognosis cancers filling an opioid prescription near EOL fell from 41.7% to 35.7%, with greater decrements among blacks (39.3% to 29.8%) than whites (42.2% to 36.5%) and other races (38.2% to 32.4%). The proportion of patients receiving long-acting opioids near EOL fell from 17% to 12% overall (15% to 9% among blacks). Among patients receiving EOL opioids, the median daily dose fell from 40MMEs (IQR 16.5-98.0) to 30MMEs (IQR 15.0–78.8). In adjusted analyses, blacks were less likely than whites to receive EOL opioids (AOR 0.85; 95% CI, 0.80 to 0.91) and on average received 10MMEs less per day (b -9.9; 95% CI -15.7 to -4.2). Patients of other race were also less likely to receive EOL opioids (AOR 0.92; 95% CI, 0.85-0.95), although their dose did not differ significantly from whites. Rates of pain-related ED visits near EOL increased from 13.2% to 18.8% over the study period. In adjusted analyses, blacks were more likely than whites to have pain-related ED visits (AOR 1.29, 95% CI, 1.16-1.37) near death, as were those of other races (AOR 1.30; 95% CI, 1.17-1.37). Conclusions: While lawmakers have sought to mitigate the impact of opioid regulations upon cancer patients, access to EOL opioids have decreased substantially over time with concomitant increases in pain-related ED visits. There are significant racial/ethnic disparities in opioid access, with blacks receiving fewer opioids at lower doses and having more ED-based care for pain near EOL.

End of life treatments and events in ovarian cancer: A comparison of short versus long-term outcomes

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 5096-5096
Author(s):  
V. E. Von Gruenigen ◽  
B. Daly ◽  
H. Frasure ◽  
J. Hutchins ◽  
A. Green
Keyword(s):  
Ovarian Cancer ◽  
Regression Analysis ◽  
Epithelial Ovarian Cancer ◽  
Survival Time ◽  
End Of Life ◽  
Cancer Patients ◽  
Hospice Care ◽  
Survival Duration ◽  
Test Statistic ◽  
Aggressive Care

5096 Background: To identify the aggressiveness of treatment and events in ovarian cancer patients during the last year of life based on survival time. Methods: Patient charts of deceased epithelial ovarian cancer patients were retrospectively reviewed from 2000–2005. All patients included had debulking surgery and received adjuvant chemotherapy. Patients were separated into groups based on survival quartiles. Aggressiveness of care was measured by chemotherapy regimens, ER visits and hospitalizations. Significant clinical events (SCE) were defined as ascites, bowel obstruction, and pleural effusion. Comparison of quartiles was done using chi-square and t-test statistic. Multiple regression analysis was done using survival duration as a dependent variable. Results: 97 patients with epithelial ovarian cancer were reviewed. There was no difference in patterns of hospitalizations and SCE between the top and bottom survival quartiles. Patients with a shorter survival time received more chemotherapy during their last 3 months of life and had increased overall aggressiveness of care measures (Table). In patients who had a remission, regression analysis revealed length of initial remission time was significant in predicting survival (p < 0.01). Time to 2nd relapse was also significant in predicting survival time (p < 0.01). Number of SCE during the last year of life events trended for predicting survival (p = 0.10). Conclusions: Duration of ovarian cancer remission is predictive of survival. Those patients with a short trajectory of disease receive more aggressive care, chemotherapy at the end of life, less hospice care; however, they die similarly to those with longer survival duration. Those patients with short remissions and / or SCE during recurrence should receive less aggressive care at the end-of-life. [Table: see text] No significant financial relationships to disclose.

Prognostic significance of the “surprise” question in cancer patients

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 9588-9588
Author(s):  
A. H. Moss ◽  
J. R. Lunney ◽  
S. Culp ◽  
M. Auber ◽  
S. Kurian ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Cancer Patients ◽  
Prognostic Significance ◽  
Cox Proportional Hazards ◽  
Cancer Center ◽  
P Value ◽  
Cancer Type ◽  
Patient Death ◽  
Surprise Question

9588 Background: In patients with advanced cancer, failure to accurately estimate and communicate prognoses can lead to overly aggressive care at the end of life with less attention to important palliative care issues such as pain and symptom management and patients’ values and goals for care. The “surprise” question—would I be surprised if this patient died in the next year?—has been recognized as an innovation to improve end-of-life care in the primary care population by identifying patients with a poor prognosis who are appropriate for palliative care. It has not been previously tested in cancer patients. The purposes of this study were to determine the feasibility and outcomes of the use of the “surprise” question in a cancer center population. Methods: Between July and November 2007, oncologists prospectively classified consecutive breast, lung, and colon cancer patients being seen at the Mary Babb Randolph Cancer Center of West Virginia University into “Yes” and “No” groups based on the surprise question. Patients were followed and their status at the end of one year-alive or dead-was determined along with patient demographics, type of cancer, and stage at presentation. A multivariate Cox proportional hazards regression analysis was used to identify variables associated with patient death. Results: Oncologists classified 826 of 853 prospective patients (97%), with 131 (16%) classified into the “No” group and 695 (84%) into the “Yes” group. At the end of the year, 71 patients had died; 41% of the “No” patients compared to 3% of the “Yes” patients (P <.001). The surprise question ‘No‘ response was more predictive of patient death than stage of cancer, cancer type, or age (hazard ratio 7.53, P value <.001). The “Yes” patients lived longer than the “No” patients (359.8±32.8 days versus 270±131.5 days, P <.001). The sensitivity of the surprise question “No” response was 75% and the specificity was 90%. Conclusions: We conclude that the surprise question is a simple, feasible, and effective tool to identify cancer patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning. No significant financial relationships to disclose.

End-of-life care for Medicare beneficiaries with ovarian cancer: Evaluation of intensity and rate of hospitalizations.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 9523-9523
Author(s):  
Alexi A. Wright ◽  
Craig Earle ◽  
Nancy Lynn Keating
Keyword(s):  
Ovarian Cancer ◽  
Medical Care ◽  
End Of Life ◽  
Cancer Patients ◽  
High Intensity ◽  
Population Based ◽  
Medicare Beneficiaries ◽  
National Cohort ◽  
Ed Visits ◽  
Over Time

9523 Background: Patients with advanced cancer are receiving increasingly aggressive medical care at the end-of-life (EOL). Population-based studies have not examined the medical care that ovarian cancer patients receive near death. Methods: We identified a national cohort of 6,956 Medicare beneficiaries who were living in Surveillance, Epidemiology, and End Results (SEER) areas, were diagnosed with epithelial ovarian cancer between 1996 and 2007, and died from ovarian cancer by December 2007. Using multivariable models, we examined rates of aggressive medical care within 30 days of death over time and examined indications for hospitalizations near death. Results: Adjusted rates of intensive care unit (ICU) admissions and emergency department (ED) visits increased significantly between 1996 and 2007 (ICU: 6.4% to 16.6%, p<0.0001 and ≥2 ED visits: 19.7% to 32.1%, p<0.0001). In contrast, late (within 7 days death) or absent hospice referrals decreased (63.1% to 47.8%, p<0.001) and chemotherapy use within 30 days of death decreased slightly (8.1% vs. 7.1%; p=0.04). Although terminal hospitalizations decreased (28.0% to 19.1%, p=0.001), rates of hospitalizations near death increased over time (41.4% vs. 45.3%, p=0.01). The most common indications for hospitalization included: bowel obstructions (20.0%), infections (10.4%), fluid or electrolyte abnormalities (9.2%), and malignant effusions (8.1%). Conclusions: Despite significant increases in the use of hospice near death, utilization of ICUs, EDs, and acute inpatient care at the EOL rose significantly between 1997 and 2007 for older ovarian cancer patients. Future studies should examine whether this high-intensity health care is avoidable given evidence that high-intensity care is associated with lower patient quality-of-life near death and increased complications in bereaved caregivers.

Racial and social disparities on aggressiveness of end-of-life cancer care in a rural academic center.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e18063-e18063
Author(s):  
Praveen Namireddy ◽  
Shravanti Macherla ◽  
James Thompson McClain ◽  
Mahvish Muzaffar
Keyword(s):  
End Of Life ◽  
Family Support ◽  
Cancer Care ◽  
Hospice Care ◽  
Hospital Admissions ◽  
Medical Center ◽  
Composite Score ◽  
Minority Population ◽  
Icu Admission ◽  
Ed Visits

e18063 Background: Aggressive cancer care at the end of life (EOL) can impact quality of life and have major economic burden. The purpose of this study was to determine the aggressiveness of EOL cancer care, and its relation to race, gender and social factors in Eastern North Carolina with a high rural and minority population. Methods: This is a retrospective analysis of 401 stage 4 solid tumor patients who died between 2011 and 2014 at Vidant Medical Center. Aggressiveness of care was calculated by a composite score adopted from Earle et al. Scores range from 0 to 7 with higher scores indicating more aggressive EOL care. 1 point was given to each indicator of aggressiveness in the last 30 days of life: ED visits ≥2, hospital admissions ≥2, any ICU admission, hospitalized days ≥14, new chemotherapy, hospice care ≤ 3 days, and any chemotherapy in the last 14 days. Results: Among 401 patients, 217 (54%) were white and 178 (44%) were black. The mean composite score for aggressiveness (CSA) for whites was 1.18 and for blacks it was 1.87 (p<0.001). In the last 30 days of life, a higher proportion of blacks had ≥ 2 ED visits 28% vs 13%(p<.0001), ≥ 2 hospital admission 23% vs 13%(p=0.001), any ICU admission 29% vs 16%(p=0.0002), chemotherapy in the last 14 days 30% vs 20%(p=0.001), and ≥ 14 hospitalized days 35% vs 21%(p<0.001) compared to whites. More whites were enrolled in hospice compared to blacks 53% vs 45% (p<0.001). Correlation analysis using Fit Y by X model showed statistically significant differences between CSA (score ≤ 3 and >3) and other variables such as whites vs blacks p <0.001, females vs males p=0.0006, not married vs married p<0.0001, and no family support vs family support p<0.0001. Conclusions: Male, unmarried and black patients were associated with higher CSA. Patients who were white, married and with family support had higher likelihood of enrolling in hospice. [Table: see text]

Symptoms and characteristics of cancer patient visits to an emergency room.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18306-e18306
Author(s):  
Michael Gallaway ◽  
Nimi Idaikkadar
Keyword(s):  
Cancer Patients ◽  
Acute Care ◽  
International Classification Of Diseases ◽  
Population Based ◽  
P Value ◽  
Surveillance Program ◽  
Cancer Type ◽  
Classification Of Diseases ◽  
Icd 10 ◽  
Ed Visits

e18306 Background: Cancer patients are increasingly likely to visit an emergency department (ED) for acute care compared to the general population. Cancer patients who visit the ED often have long wait times, increased exposure to infection, and lesser quality treatment. The Centers for Medicare & Medicaid Services (CMS) is encouraging efforts to decrease survivor acute care visits. The purpose of this study was to examine cancer-related ED visits using a national population-based sample to understand why they are seeking care in an ED. Methods: A retrospective cohort study of U.S. patients who visited EDs between June 1, 2017 and May 31, 2018 was conducted using the National Syndromic Surveillance Program (NSSP) BioSense Platform. Cancer patients were identified using International Classification of Diseases, 10th Revision (ICD-10) codes for any cancer type and specifically for cancers of the bladder, female breast, cervix, colon and rectum, kidney, liver, lung, ovary, pancreas, prostate, or uterus. Symptoms were identified using syndromic definitions and key-word queries. Significance testing (p-value ≤0.01), was used to assess differences in the prevalence of symptoms by cancer type. Results: There were 97 million visits to EDs during the study period, 710,297 (0.8%) were among cancer survivors. Slightly more were female (50.1%) than male (49.5%); more were aged 65 or older (53.6%) than 18-64 (1.4-35.3%). The most common symptoms were pain (19%), gastrointestinal (14%), respiratory (12%), neurologic (5%), fever (5%), and injury (4%). Prevalence of symptoms differed significantly by cancer type. Some symptoms were higher among those with specific cancer types compared to all cancers in aggregate: pain (cervical, liver, pancreas); gastrointestinal (pancreas, liver, colorectal); respiratory (lung); neurologic (liver, lung), fever (pancreas, liver), injury (prostate), and bleeding (colorectal, liver). Conclusions: Use of NSSP data enabled a descriptive characterization of more than half of the U.S. ED visits among cancer patients. These comprehensive findings inform best practices to reduce unplanned acute care and help inform possible modifications in treatment and care protocols among survivors of specific cancers.

Trends in the use of novel hormonal agents at the end of life in metastatic castration-resistant prostate cancer.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 40-40
Author(s):  
Jason Hu ◽  
Armen G. Aprikian ◽  
Marie Vanhuyse ◽  
Alice Dragomir
Keyword(s):  
Prostate Cancer ◽  
End Of Life ◽  
Primary Outcome ◽  
Multivariable Analysis ◽  
Poor Quality ◽  
Administrative Databases ◽  
Public Healthcare ◽  
P Value ◽  
Castration Resistant Prostate Cancer ◽  
Castration Resistant

40 Background: The approval of novel hormonal agents (NHAs), abiraterone and enzalutamide, have increased the therapeutic arsenal available in metastatic castration-resistant prostate cancer (mCRPC). However, the use of chemotherapy and other antineoplastics at the end of life has been suggested as an indicator of poor quality of care. In this study, we report the use of NHAs at the end of life in men with mCRPC in the province of Quebec, Canada. Methods: Using Quebec public healthcare administrative databases, we identified patients with prostate cancer who used an NHA (abiraterone or enzalutamide) after androgen deprivation therapy and who died between 2012 and 2016. The primary outcome was the use of an NHA in the 30 days before death. Use of an NHA in the 60 and 90 days before dying, and initiation (first prescription) of an NHA in the 30 days before death were evaluated as secondary outcomes. Multivariable analysis of the primary outcome was performed with logistic regression with results reported as odds ratios (OR) with 95% confidence intervals (95%CI). Results: The cohort consists of 1316 patients who used an NHA over the course of their disease and died at a median age of 78 years old, with 292 (22.2%), 464 (35.3%), and 575 (43.7%) having used an NHA in the 30, 60 and 90 days of life, respectively. Use of NHA 30 days before dying decreased over the study period, from 44.8% in 2012 to 17.0% in 2016 (Cochran-Armitage test p-value < 0.001). On multivariable analyses, later years of death remained associated with lower odds of NHA use 30 days before death (OR 0.74, 95%CI 0.66 to 0.81, p < 0.001). Fifty-eight (4.4%) patients initiated a NHA 30 days before dying. Conclusions: Rates of NHA use 30 days before dying were high initially but decreased over the study period. Further assessment of NHA use at the end of life is warranted to examine if the trend will be maintained given the recent approval of additional oral NHAs for prostate cancer.

Pediatric End-of-Life Care for Taiwanese Children Who Died As a Result of Cancer From 2001 Through 2006

2011 ◽  
Vol 29 (7) ◽  
pp. 890-894 ◽  
Author(s):  
Siew Tzuh Tang ◽  
Yen-Ni Hung ◽  
Tsang-Wu Liu ◽  
Dong-Tsamn Lin ◽  
Yueh-Chih Chen ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Acute Care ◽  
Pediatric Cancer ◽  
Hospice Care ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Pediatric Cancer Patients ◽  
Eol Care ◽  
To Receive

Purpose Patterns of aggressive end-of-life (EOL) care have not been extensively explored in a pediatric cancer population, especially outside Western countries. The purpose of this population-based study was to examine trends in aggressive pediatric EOL cancer care in Taiwan. Methods Retrospective cohort study that used administrative data among 1,208 pediatric cancer decedents from 2001 through 2006. Results Taiwanese pediatric cancer patients who died in 2001 through 2006 received aggressive EOL care. The majority of these patients in their last month of life continued to receive chemotherapy (52.5%), used intensive care (57.0%), underwent intubation (40.9%), underwent mechanical ventilation (48.2%), or spent greater than 14 days (69.5%) in hospital, and they died in an acute care hospital (78.8%). Of these pediatric cancer patients, one in four received cardiopulmonary resuscitation in the month before they died, and only 7.2% received hospice care. Among those who received hospice care, 21.8% started such care within the last 3 days of life. This pattern of aggressive EOL care did not change over the study period except for significantly decreased intubation in the last month of life. Conclusion Continued chemotherapy and heavy use of life-sustaining treatments in the last month of life coupled with lack of hospice care to support Taiwanese pediatric cancer patients dying at home may lead to multiple unplanned health care encounters, prolonged hospitalization at EOL, and eventual death in an acute care hospital for the majority of these patients. Future research should design interventions that enable Taiwanese pediatric cancer patients to receive EOL care that best meets the individual or the parental needs and preferences.

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