Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

• Type of Material: Article
• Authors: Kieran L. Quinn, University of Toronto; Therese Stukel, Institute for Clinical Evaluative Sciences; Nathan M. Stall, University of Toronto; Anjie Huang, Institute for Clinical Evaluative Sciences; Sarina Isenberg, Lunenfeld Tanenbaum Research Institute; Peter Tanuseputro, Institute for Clinical Evaluative Sciences; Russell Goldman, Temmy Latner Centre for Palliative Care; Peter Cam, University of Toronto; Dio Kavalieratos, Emory University; Allan S. Detsky, University of Toronto; Chaim M. Bell, University of Toronto
• Language: English
• Date: 2020-07-06
• Publisher: BMJ Publishing Group
• Publication Version: Final Published Version
• Copyright Statement: © 2020 BMJ Publishing Group Ltd.
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1136/bmj.m2257
• Title of Journal or Parent Work: BMJ: British Medical Journal
• Volume: 370
• Start Page: m2257
• End Page: m2257
• Grant/Funding Information: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long term Care (MOHLTC).; No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI).; KLQ and NMS receive funding from the CIHR Vanier Scholarship Program, the Eliot Phillipson Clinician-Scientist Training Program, and the Clinician Investigator Program at the University of Toronto.; DK receives research funding from the National Institutes of Health (K01HL133466), the Cystic Fibrosis Foundation, and the Milbank Foundation.; The analysis was supported by a research grant KLQ and CMB received from the Sinai Health System Research Foundation to perform this work. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources.; However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI. We thank IMS Brogan for use of their Drug Information Database.
• Keywords: Burden; General & Internal Medicine; Patient; Trajectories; Disease; End; Place; Medicine, General & Internal; Heart failure; Randomized trial; Life Sciences & Biomedicine; Science & Technology; Indicators; Quality of life
• Research Categories: Health Sciences, Health Care Management; Health Sciences, Public Health; Health Sciences, Epidemiology; Health Sciences, Medicine and Surgery

Abstract

Objective To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level. Design Population based matched cohort study. Setting Ontario, Canada between 2010 and 2015. Participants 113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex. Main outcome measures Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities). Results In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home. Conclusions These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.