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      Hospital utilization and disposition among patients with malignant bowel obstruction: a population-based comparison of surgical to medical management

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          Abstract

          Background

          Malignant bowel obstruction (MBO) is often a terminal event in end-stage cancer patients. The decision to intervene surgically is complex, given the risk of harm in patients with a limited lifespan. Therefore, we sought to compare clinically meaningful outcomes in MBO patients treated with surgical versus medical management using population-based data.

          Methods

          We performed a retrospective analysis of hospitalized patients with MBO from 2006 to 2010 using the California Office of Statewide Health Planning and Development dataset. Hospital-free days (HFDs) at 30-, 90-, and 180-days were calculated accounting for all hospitalization, emergency department visit, and skilled nursing facility lengths of stay. Adjusted regression models were used to compare HFDs, disposition, complications, in-hospital death, and survival for surgical versus medical MBO cohorts, using inverse probability of treatment weighting with propensity scores.

          Results

          Of 4576 MBO patients, 3421 (74.8%) were treated medically and 1155 (25.2%) were treated surgically. Surgical patients had higher rates of complications (44.0% vs. 21.3%, p < 0.0001) and in-hospital death (9.5% vs. 3.9%, p < 0.0001) with lower rates of disposition to home (76.3% vs. 89.8%, p < 0.0001). Surgical patients had fewer 30- and 90-day HFDs compared to medical patients ( p < 0.01). However, at 180-days, there were no differences in HFDs between treatment groups. There was no difference in overall survival between surgical and medical patients (median 6.5 vs. 6.4 months).

          Conclusion

          In this population-based analysis, medical management was associated with less hospital utilization at 30- and 90-days, fewer in-hospital deaths, and more frequent discharges to home. These data underscore the potential benefits of medical management for MBO patients at the end-of-life.

          Electronic supplementary material

          The online version of this article (10.1186/s12885-018-5108-9) contains supplementary material, which is available to authorized users.

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          Most cited references36

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          Methods for constructing and assessing propensity scores.

          To model the steps involved in preparing for and carrying out propensity score analyses by providing step-by-step guidance and Stata code applied to an empirical dataset.
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            Identifying Increased Risk of Readmission and In-hospital Mortality Using Hospital Administrative Data: The AHRQ Elixhauser Comorbidity Index.

            We extend the literature on comorbidity measurement by developing 2 indices, based on the Elixhauser Comorbidity measures, designed to predict 2 frequently reported health outcomes: in-hospital mortality and 30-day readmission in administrative data. The Elixhauser measures are commonly used in research as an adjustment factor to control for severity of illness.
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              Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers' mental health.

              To determine whether the place of death for patients with cancer is associated with patients' quality of life (QoL) at the end of life (EOL) and psychiatric disorders in bereaved caregivers. Prospective, longitudinal, multisite study of patients with advanced cancer and their caregivers (n = 342 dyads). Patients were followed from enrollment to death, a median of 4.5 months later. Patients' QoL at the EOL was assessed by caregiver report within 2 weeks of death. Bereaved caregivers' mental health was assessed at baseline and 6 months after loss with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the Prolonged Grief Disorder interview. In adjusted analyses, patients with cancer who died in an intensive care unit (ICU) or hospital experienced more physical and emotional distress and worse QoL at the EOL (all P ≤ .03), compared with patients who died at home with hospice. ICU deaths were associated with a heightened risk for posttraumatic stress disorder, compared with home hospice deaths (21.1% [four of 19] v 4.4% [six of 137]; adjusted odds ratio [AOR], 5.00; 95% CI, 1.26 to 19.91; P = .02), after adjustment for caregivers' preexisting psychiatric illnesses. Similarly, hospital deaths were associated with a heightened risk for prolonged grief disorder (21.6% [eight of 37] v 5.2% [four of 77], AOR, 8.83; 95% CI, 1.51 to 51.77; P = .02), compared with home hospice deaths. Patients with cancer who die in a hospital or ICU have worse QoL compared with those who die at home, and their bereaved caregivers are at increased risk for developing psychiatric illness. Interventions aimed at decreasing terminal hospitalizations or increasing hospice utilization may enhance patients' QoL at the EOL and minimize bereavement-related distress.
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                Author and article information

                Contributors
                sbbateni@ucdavis.edu
                agingrich@ucdavis.edu
                slstewart@ucdavis.edu
                rjbold@ucdavis.edu
                (916) 734-5907 , rjcanter@ucdavis.edu
                Journal
                BMC Cancer
                BMC Cancer
                BMC Cancer
                BioMed Central (London )
                1471-2407
                26 November 2018
                26 November 2018
                2018
                : 18
                : 1166
                Affiliations
                [1 ]ISNI 0000 0004 0413 7653, GRID grid.416958.7, Division of Surgical Oncology, , UC Davis Cancer Center, ; 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
                [2 ]ISNI 0000 0004 1936 9684, GRID grid.27860.3b, Department of Public Health Sciences, Division of Biostatistics, , UC Davis School of Medicine, ; 4800 2nd Ave, Suite 2209, Sacramento, CA 95817 USA
                [3 ]ISNI 0000 0000 9752 8549, GRID grid.413079.8, Division of Hematology/Oncology, Department of Internal Medicine, , UC Davis Medical Center, ; 4610 X Street, Suite 3016, Sacramento, CA 95817 USA
                Author information
                http://orcid.org/0000-0002-3331-5418
                Article
                5108
                10.1186/s12885-018-5108-9
                6258444
                30477454
                be719a0d-e85f-4951-8bdb-3e719387e231
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 26 July 2018
                : 19 November 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100006108, National Center for Advancing Translational Sciences;
                Award ID: UL1TR001860
                Funded by: FundRef http://dx.doi.org/10.13039/100000133, Agency for Healthcare Research and Quality;
                Award ID: T32HS022236
                Award Recipient :
                Funded by: University of California Cancer Research Coordinating Committee
                Award ID: CTR#-18-524770
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Oncology & Radiotherapy
                malignant bowel obstruction,bowel obstruction,surgery,disposition,hospital utilization,palliative surgery

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