Performance of care for end‐of‐life cancer patients in Tuscany: The interplay between place of care, aggressive treatments, opioids, and place of death. A retrospective cohort study

Abstract

Summary Supportive and palliative care at the end of life (EOL) is a core component of health systems. Providing care at the EOL may require the interaction of several care providers working in different settings including nursing homes, home care, hospices, and hospitals. This work aims to (a) provide evidence on the performance of EOL care for cancer patients across healthcare organizations, with a focus on the place of care, aggressive treatments, opioids, and the place of death and (b) analyze factors associated with dying in hospital. A population‐based retrospective study was performed using administrative data from Tuscany region (Italy). Thirteen thousand sixty‐six cancer patients who died in 2016 were considered. There is a marked variability in EOL care within regional areas, with the multilevel logistic regression highlighting a greater likelihood of dying in hospital for patients who were admitted to intensive care units or previously hospitalized. There is a lower probability of dying in acute care setting for patients assisted in hospices and in both hospital and hospices/home care and for patients treated with opioids. This intraregional variation highlights the need to improve EOL planning and rethink the delivery of supportive/palliative care. Further investigations on the preferences of patients may lead to more understanding.

Palliative medicine favourably influences end-of-life cancer care intensity: a large retrospective database study

“…Our study supports the evidence from previous investigations that PC admission has a relevant role in reducing various indicators of EOL aggressive care 5–14. In particular, we found that PC reduced hospitalisations by over 70%, long hospital stay by 75%, ED visit by 65%, and use of chemotherapy by 35% during the last month.…”

“…With reference to the indicators of aggressive EOL care analysed in our study, we found that about 45% of patients were hospitalised during the last 30 days of life, a value that is within the range between 40% and 65% reported in previous investigations 10–14 28. About 30% of patients with cancer in Lombardy died in hospital, a value among the lowest reported in other studies (between 30% and 70%) 4 10 11 13–15 17 28.…”

“…Patients treated with chemotherapy in our population were 8.5% in the last 30 days and 2.3% in the last 14 days. Although there is some variability in the data reported in previous studies (with values between 5% and 20% in the last 30 days, and between 2% and 10% in the last 14 days), chemotherapy exposure in our study appears quite low, particularly in the last 14 days 4 10–12 14 17 28 29. Although it is possible that we had somehow underestimated chemotherapy use, this is a favourable indicator of the practice of EOL in patients with cancer in this Italian region.…”

“…Hospice and home palliative care (PC)—which has been fostered during the last decades in many high-income countries in order to better care (cancer) patients in the EOL—have been associated to a reduction of aggressive treatments in the EOL 5–14. Evidence also indicates that the earlier the admission to PC the less aggressive EOL care 10 15–18.…”

“…Evidence also indicates that the earlier the admission to PC the less aggressive EOL care 10 15–18. Most of data, however, comes from North America and Northern European countries, whereas data in the Italian context are scanty 13 14 17…”