Multicentre analysis of intensity of care at the end-of-life in patients with advanced cancer, combining health administrative data with hospital records: variations in practice call for routine quality evaluation

Abstract

Background Accessible indicators of aggressiveness of care at the end-of-life are useful to monitor implementation of early integrated palliative care practice. To determine the intensity of end-of-life care from exhaustive data combining administrative databases and hospital clinical records, to evaluate its variability across hospital facilities and associations with timely introduction of palliative care (PC). Methods For this study designed as a decedent series nested in multicentre cohort of advanced cancer patients, we selected 997 decedents from a cohort of patients hospitalised in 2009–2010, with a diagnosis of metastatic cancer in 3 academic medical centres and 2 comprehensive cancer centres in the Paris area. Hospital data was combined with nationwide mortality databases. Complete data were collected and checked from clinical records, including first referral to PC, chemotherapy within 14 days of death, ≥1 intensive care unit (ICU) admission, ≥2 emergency department visits (ED), and ≥ 2 hospitalizations, all within 30 days of death. Results Overall (min-max) indicator values as reported by facility providing care rather than the place of death, were: 16% (8–25%) patients received chemotherapy within 14 days of death, 16% (6–32%) had ≥2 admissions to acute care, 6% (0–15%) had ≥2 emergency visits and 18% (4–35%) had ≥1 intensive care unit admission(s). Only 53% of these patients met the PC team, and the median (min-max) time between the first intervention of the PC team and death was 41 (17–112) days. The introduction of PC > 30 days before death was independently associated with lower intensity of care. Conclusions Aggressiveness of end-of-life cancer care is highly variable across centres. This validates the use of indicators to monitor integrated PC in oncology. Disseminating a quality audit-feedback cycle should contribute to a shared view of appropriate end-of-life care objectives, and foster action for improvement among care providers.

Quality of End-of-Life Care for People with Advanced Non-Small Cell Lung Cancer in Ontario: A Population-Based Study

“…We found that receipt of palliative care consultation one month or more before death was associated with less aggressive care compared to patients who did not receive a palliative care consult. This finding is congruent with previous literature [ 48 , 49 ].…”

Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts

“…Chemotherapy or SACT is the most frequently used measure of quality of EOL care [4,22]. Our results align with recent studies in Australia [24] and France PLOS ONE [23], both showing similar levels of SACT use, but also local variations. Nguyen et al, 2020 [24] found an increase in use of immunotherapy, but a decrease in other forms of SACTs, among a variety of cancer patients at EOL.…”

“…There is no validated tool to measure intensity of care at EOL, but a set of measures is widely used [21,22]. Among these are; aspects of hospitalizations, emergency department (ED) visits, intensive care (ICU) care [16,22,23], late chemotherapy use (14 or 30 days before death) [24], death at acute care hospital [25] and lack of referral to palliative care [7,21].…”

Palliative care in metastatic head and neck cancer

“…For this reason, though palliative care does not exclude concurrent life‐prolonging therapies, it is likely that a decision for palliative care for incurable disease indicates a decision away from more active treatments. As such, palliative care is associated with less aggressive measures at the end of life, 29–31 and advanced stage patients undergoing inpatient radiation and/or chemotherapy are less likely to receive palliative care 16 . Our results do suggest, though, that “interventional” palliative care, such as placement of feeding tubes, radiation for tumor debulking, among others, may have slightly increased survival over “pain management only”, despite that not being the intention at that point in the disease process.…”