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

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.

Download Full-text

End-Of-Life Discussions Reduce The Utilization of Life-Sustaining Treatments During The Last Three Months of Life in Cancer Patients : A Nationwide Population-Based Cohort Study

10.21203/rs.3.rs-634427/v1 ◽

2021 ◽

Author(s):

Shang-Yih Chan ◽

Yun-Ju Lai ◽

Yu-Yen Hsin Chen ◽

Shuo-Ju Chiang ◽

Yi-Fan Tsai ◽

...

Keyword(s):

Cohort Study ◽

Cardiopulmonary Resuscitation ◽

End Of Life ◽

Cancer Patients ◽

Medical Records ◽

Population Based ◽

Lower Likelihood ◽

The Mean ◽

The Impact ◽

To Receive

Abstract Purpose Studies to examine the impact of end-of-life (EOL) discussions on the utilization of life-sustaining treatments near death were limited and had inconsistent findings. This nationwide population-based cohort study determined the impact of EOL discussions on the utilization of life-sustaining treatments in the last three months of life in Taiwanese cancer patients. Methods This cohort study included adult cancer patients from 2012–2018, which were confirmed by pathohistological reports. Life-sustaining treatments during the last three months of life included cardiopulmonary resuscitation, intubation, and defibrillation. EOL discussions in cancer patients were confirmed by their medical records. Association of EOL discussions with utilization of life-sustaining treatments were assessed using multiple logistic regression. Results Of 381,207 patients, the mean age was 70.5 years and 19.4% of the subjects utilized life-sustaining treatments during the last three months of life. After adjusting for other covariates, those who underwent EOL discussions were less likely to receive life-sustaining treatments during the last three months of life compared to those who did not (Adjusted odds ratio [AOR]: 0.82; 95% confidence interval [CI]: 0.80–0.84). Considering the type of treatments, EOL discussions correlated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR = 0.43, 95% CI: 0.41–0.45), endotracheal intubation (AOR = 0.87, 95%CI: 0.85–0.89), and defibrillation (AOR = 0.52, 95%CI: 0.48–0.57). Conclusion EOL discussions correlated with a lower utilization of life-sustaining treatments during the last three months of life among cancer patients. Our study supports the importance of providing these discussions to cancer patients to better align care with preferences during the EOL treatment.

Download Full-text

Racial-Ethnic Disparities in End-of-Life Care Quality among Lung Cancer Patients: A SEER-Medicare–Based Study

Journal of Thoracic Oncology ◽

10.1016/j.jtho.2018.04.014 ◽

2018 ◽

Vol 13 (8) ◽

pp. 1083-1093 ◽

Cited By ~ 10

Author(s):

Siddharth Karanth ◽

Suja S. Rajan ◽

Gulshan Sharma ◽

Jose-Miguel Yamal ◽

Robert O. Morgan

Keyword(s):

Lung Cancer ◽

End Of Life ◽

Cancer Patients ◽

End Of Life Care ◽

Ethnic Disparities ◽

Care Quality ◽

Life Care ◽

Lung Cancer Patients ◽

Racial Ethnic

Download Full-text

EPR19-069: Opioid Use Among Cancer Patients Undergoing Surgery and Their Associated Risk of Re-admissions and Emergency Department Visits in the 1-Year Postsurgical Period

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2018.7231 ◽

2019 ◽

Vol 17 (3.5) ◽

pp. EPR19-069 ◽

Cited By ~ 1

Author(s):

Siyana Kurteva ◽

Robyn Tamblyn ◽

Ari Meguerditchian

Keyword(s):

Emergency Department ◽

Cancer Patients ◽

Healthcare System ◽

Emergency Department Visits ◽

Administrative Claims ◽

Opioid Use ◽

Opioid Prescription ◽

Ed Visits ◽

Opioid Users ◽

The Impact

Background: Prescription opioid use and overdose has steadily increased over the past years, resulting in a dramatic increase in opioid-related emergency department (ED) visits and hospitalizations. Methods: This study used a prospective cohort of cancer patients having undergone surgery in Montreal (Quebec) to describe their post-discharge opioid use and identify potential patterns of unplanned health service use (ED visits, hospitalizations). Provincial health administrative claims were used to measure opioid dispensation as well as hospital re-admissions and ED visits. The hospital warehouse, patient chart and patient interview will be used to further describe patient’s medical profile. Marginal structural models will be used to model the association between use of opioids and risk of ED visits and hospitalizations. Inverse probability of treatment and censoring weights will be constructed to properly adjust for confounders that may be unbalanced between the opioid and non–opioid users as well as to account for competing risk due to mortality. Reasons for the re-admissions will also be presented as part of the analyses. Covariates will include patient comorbidities, medication history, and healthcare system characteristics such as nurse-to-patient and attending physician-to-patient ratios. Results (interim): A total of 821 were included in the study; of these, 73% (n=597) were admitted for a cancer procedure. At postoperative discharge, 605 (74%) of patients had at least one opioid dispensation, of which the majority (67%) were oxycodone with hydromorphone being the second most prescribed (28%). Among those who filled a prescription, mean age was 66 (13.4), 68% had no previous history of opioid use, and 10% have had 3 or more dispensing pharmacies in the year prior to admission, compared to less than 1% for the non–opioid users. Overall, 343 people refilled their opioid prescription at least once and 128 at least twice during the 1-year postoperative period. Among cancer patients who were opioid users, 214 ED visits occurred in the 1 year after surgery compared to only 40 for the non-cancer opioid users. Conclusion: This study will help to identify the risk profile of cancer patients who are most likely to continue using opioids for prolonged periods following surgical procedures as well as quantify the impact of opioid use and its associated burden on the healthcare system in order to identify areas for possible interventions.

Download Full-text

Impact of Race and Ethnicity on End-of-Life Experiences for Children With Cancer

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909119836939 ◽

2019 ◽

Vol 36 (9) ◽

pp. 767-774 ◽

Cited By ~ 4

Author(s):

Erica C. Kaye ◽

Courtney A. Gushue ◽

Samantha DeMarsh ◽

Jonathan Jerkins ◽

Chen Li ◽

...

Keyword(s):

End Of Life ◽

Pediatric Cancer ◽

Race And Ethnicity ◽

Life Experiences ◽

Ethnic Disparities ◽

Racial And Ethnic Disparities ◽

Children With Cancer ◽

Hispanic Patients ◽

The Impact ◽

To Receive

Background: Racial and ethnic disparities in the provision of end-of-life care are well described in the adult oncology literature. However, the impact of racial and ethnic disparities at end of life in the context of pediatric oncology remains poorly understood. Objective: To investigate associations between end-of-life experiences and race/ethnicity for pediatric patients with cancer. Methods: A retrospective cohort study was conducted on 321 children with cancer enrolled on a palliative care service at an urban pediatric cancer who died between 2011 and 2015. Results: Compared to white patients, black patients were more likely to receive cardiopulmonary resuscitation (CPR; odds ratio [OR]: 4.109, confidence interval [CI]: 1.432-11.790, P = .009) and underwent 3.136 (CI: 1.433-6.869, P = .004) CPR events for every 1 white patient CPR event. The remainder of variables related to treatment and end-of-life care were not significantly correlated with race. Hispanic patients were less likely to receive cancer-directed therapy within 28 days prior to death (OR: 0.493, CI: 0.247-0.982, P = .044) as compared to non-Hispanic patients, yet they were more likely to report a goal of cure over comfort as compared to non-Hispanic patients (OR: 3.094, CI: 1.043-9.174, P = .042). The remainder of variables were not found to be significantly correlated with ethnicity. Conclusions: Race and ethnicity influenced select end-of-life variables for pediatric palliative oncology patients treated at a large urban pediatric cancer center. Further multicenter investigation is needed to ascertain the impact of racial/ethnic disparities on end-of-life experiences of children with cancer.

Download Full-text

US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life

Journal of Clinical Oncology ◽

10.1200/jco.21.00476 ◽

2021 ◽

pp. JCO.21.00476

Author(s):

Andrea C. Enzinger ◽

Kaushik Ghosh ◽

Nancy L. Keating ◽

David M. Cutler ◽

Mary Beth Landrum ◽

...

Keyword(s):

End Of Life ◽

Poor Prognosis ◽

The United States ◽

Sensitivity Analyses ◽

Administrative Claims ◽

Fee For Service ◽

Opioid Use ◽

Opioid Prescription ◽

Ed Visits ◽

Long Acting

PURPOSE Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. METHODS Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL. RESULTS Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization. CONCLUSION Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.

Download Full-text

A Case–Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life

Journal of Palliative Care ◽

10.1177/08258597211037436 ◽

2021 ◽

pp. 082585972110374

Author(s):

Jee Y. You ◽

Lie D. Ligasaputri ◽

Adarsh Katamreddy ◽

Kiran Para ◽

Elizabeth Kavanagh ◽

...

Keyword(s):

Palliative Care ◽

Critical Care ◽

High Risk ◽

End Of Life ◽

Poor Prognosis ◽

Medical Interventions ◽

Risk Of Death ◽

Before And After ◽

The Difference ◽

The Impact

Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.

Download Full-text

Endoprosthetic Reconstruction for a Displaced Atypical Femoral Fracture in a Cancer Patient with Poor Prognosis

Case Reports in Orthopedics ◽

10.1155/2018/7862516 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5

Author(s):

Hironari Tamiya ◽

Hiroki Hagizawa ◽

Takaaki Nakai ◽

Yoshinori Imura ◽

Takaaki Tanaka ◽

...

Keyword(s):

Cancer Patient ◽

Activities Of Daily Living ◽

Cancer Patients ◽

Femoral Fracture ◽

Daily Living ◽

Poor Prognosis ◽

Femoral Fractures ◽

Endoprosthetic Reconstruction ◽

Atypical Femoral Fractures ◽

Patients With Poor Prognosis

Zoledronate or denosumab treatment is beneficial for cancer patients with bone metastasis. However, each agent may trigger atypical femoral fractures. Incomplete atypical femoral fractures can be successfully treated with prophylactic intramedullary nailing. On the other hand, intramedullary nailing for displaced atypical femoral fractures occasionally causes problems with regard to bone healing, resulting in long-term treatment. In cancer patients with poor prognosis who experience atypical femoral fractures, improvement in activities of daily living should be the priority. Thus, we performed endoprosthetic reconstruction for a displaced atypical femoral fracture in a breast cancer patient with poor prognosis to enable walking in the early stage after the operation. Two weeks after the operation, she could successfully walk. The postoperative Musculoskeletal Tumor Society score was 47%, and it had improved to almost the preoperative level before injury (50%). In conclusion, endoprosthetic reconstruction for displaced atypical femoral fractures may be a first-line treatment approach to acquire early postoperative walking ability for improving activities of daily living in cancer patients with poor prognosis.

Download Full-text

Reductions in US life expectancy from COVID-19 by Race and Ethnicity: Is 2021 a repetition of 2020?

10.1101/2021.10.17.21265117 ◽

2021 ◽

Author(s):

Theresa Andrasfay ◽

Noreen Goldman

Keyword(s):

Life Expectancy ◽

Race And Ethnicity ◽

Ethnic Disparities ◽

White Population ◽

Widespread Distribution ◽

Life Expectancy At Birth ◽

The Us ◽

The Impact ◽

Racial Ethnic ◽

Black And Latino

COVID-19 had a huge mortality impact in the US in 2020 and accounted for the majority of the 1.5-year reduction in 2020 life expectancy at birth. There were also substantial racial/ethnic disparities in the mortality impact of COVID-19 in 2020, with the Black and Latino populations experiencing reductions in life expectancy at birth over twice the reduction experienced by the White population. Despite continued vulnerability of the Black and Latino populations, the hope was that widespread distribution of effective vaccines would mitigate the overall impact and reduce racial/ethnic disparities in 2021. In this study, we use cause-deleted life table methods to estimate the impact of COVID-19 mortality on 2021 US period life expectancy. Our partial-year estimates, based on provisional COVID-19 deaths for January-early October 2021 suggest that racial/ethnic disparities have persisted and that life expectancy at birth in 2021 has already declined by 1.2 years from pre-pandemic levels. Our projected full-year estimates, based on projections of COVID-19 deaths through the end of 2021 from the Institute for Health Metrics and Evaluation, suggest a 1.8-year reduction in US life expectancy at birth from pre-pandemic levels, a steeper decline than the estimates produced for 2020. The reductions in life expectancy at birth estimated for the Black and Latino populations are 1.6-2.4 times the impact for the White population.

Download Full-text

Abstract 13150: Racial/Ethnic Disparities of the Impact of the COVID-19 Pandemic Out-of-Hospital Cardiac Arrest (OHCA) in Texas

Circulation ◽

10.1161/circ.144.suppl_2.13150 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Summer Chavez ◽

Ryan Huebinger ◽

Kevin Schulz ◽

Hei Kit Chan ◽

Micah Panczyk ◽

...

Keyword(s):

Cardiac Arrest ◽

Hospital Admission ◽

Minority Groups ◽

Ethnic Disparities ◽

Mixed Effect ◽

Neurological Outcomes ◽

Random Intercept ◽

Hispanic Patients ◽

The Impact ◽

Racial Ethnic

Introduction: Prior research shows a greater disease burden, lower BCPR rates, and worse outcomes in Black and Hispanic patients after OHCA. The CDC has declared that the COVID-19 pandemic has disproportionately affected many racial and ethnic minority groups. However, the influence of the COVID-19 pandemic on OHCA incidence and outcomes in different races and ethnicities is unknown. Purpose: To describe racial/ethnic disparities in OHCA incidence, processes of care and outcomes in Texas during the COVID-19 pandemic. Methods: We used data from the Texas Cardiac Arrest Registry to Enhance Survival (CARES) comparing adult OHCA from the pre-pandemic period (March 11 - December 31, 2019) to the pandemic period (March 11- December 31, 2020). The racial and ethnic categories were White, Black, Hispanic or Other. Outcomes were rates of BCPR, AED use, sustained ROSC, prehospital termination of resuscitation (TOR), survival to hospital admission, survival to discharge and good neurological outcomes. We fit a mixed effect logistic regression model, with EMS agency designated as the random intercept to obtain aORs. We adjusted for the pandemic and other covariates. Results: A total of 8,070 OHCAs were included. The proportion of cardiac arrests increased for Blacks (903 to 1, 113, 24.9% to 25.5%) and Hispanics (935 to 1,221, 25.8% to 27.5%) and decreased for Whites (1 595 to 1,869, 44.0% to 42.1%) and Other (194 to 220, 5.4% to 5.0%) patients. Compared to Whites, Black (aOR = 0.73, 95% CI 0.65-0.82) and Hispanic patients (aOR = 0.78, 95% CI 0.68-0.87) were less likely to receive BCPR. Compared to Whites, Blacks were less likely to have sustained ROSC (aOR = 0.81, 95% CI 0.70-0.93%), with lower rates of survival to hospital admission (aOR = 0.87, 95% CI 0.75-1.0), and worse neurological outcomes (aOR = 0.45, 95% 0.28-0.73). Hispanics were less likely to have prehospital TOR compared to Whites (aOR = 0.86, 95% CI = 0.75-0.99). The Utstein bystander survival rate was worse for Blacks (aOR = 0.72, 95% CI 0.54-0.97) and Hispanics (aOR = 0.71, 95% 0.53-0.95) compared to Whites. Conclusion: Racial and ethnic disparities persisted during the COVID-19 pandemic in Texas.

Download Full-text