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      Unplanned hospitalizations for metastatic cancers: The changing patterns of inpatient palliative care, discharge to hospice care, and in-hospital mortality in the United States

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          Objective: To describe the rates and temporal trends of inpatient end-of-life care among patients hospitalized with metastatic cancer in the United States.

          Methods: We used data from the Nationwide Inpatient Sample to conduct a cross-sectional analysis of unplanned inpatient hospitalizations of patients aged 18 years or older with metastatic cancer from 2002 to 2011. Multivariable logistic regression was used to assess patient-and hospital-level predictors of discharge to hospice care, palliative care, and in-hospital mortality. Temporal trends in outcomes were characterized with use of joinpoint regression.

          Results: There were an estimated 350,241 unplanned hospitalizations per year of patients with a diagnosis of metastatic cancer. During their inpatient stay, 5.8% of patients received palliative care, and among those discharged alive, 12.2% were referred to hospice care. The rate of inpatient palliative care increased from 2.3% to 13.6%, the rate of discharge to hospice care increased from 4.1% to 15.6%, and the in-hospital mortality rate decreased from more than 14.0% to 9.8%. These patterns were consistent across cancer subtypes, and were most pronounced among patients with extreme risk of mortality.

          Conclusion: Despite increases in the provision of comfort-oriented care to patients with metastatic cancer, few receive such services. We recommend screening protocols in hospitals to identify patients who are good candidates for palliative care consultation and hospice referral.

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          Most cited references 28

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          Are regional variations in end-of-life care intensity explained by patient preferences?: A Study of the US Medicare Population.

          We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 11.7%; P = 0.875). Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.
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            End-of-life care discussions among patients with advanced cancer: a cohort study.

            National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients with cancer whose life expectancy is less than 1 year. To evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions take place. Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005. Participants lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites. 2155 patients with stage IV lung or colorectal cancer. End-of-life care discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis. 73% of patients had EOL care discussions identified by at least 1 source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death. The depth and quality of EOL care discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained. Although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness. National Cancer Institute and Department of Veterans Affairs.
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              End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely.

              Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.

                Author and article information

                Family Medicine and Community Health
                Compuscript (Ireland )
                May 2017
                May 2017
                : 5
                : 1
                : 13-28
                1Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
                Author notes
                CORRESPONDING AUTHOR: Jason L. Salemi, PhD, MPH Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA Tel.: +1-713-7984698 E-mail: jason.salemi@ 123456bcm.edu
                Copyright © 2017 Family Medicine and Community Health

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

                Self URI (journal page): http://fmch-journal.org/
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