TY - JOUR
T1 - Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness
T2 - Population based matched cohort study
AU - Quinn, Kieran L.
AU - Stukel, Therese
AU - Stall, Nathan M.
AU - Huang, Anjie
AU - Isenberg, Sarina
AU - Tanuseputro, Peter
AU - Goldman, Russell
AU - Cram, Peter
AU - Kavalieratos, Dio
AU - Detsky, Allan S.
AU - Bell, Chaim M.
N1 - Funding Information:
1Department of Medicine, University of Toronto, Toronto, ON, Canada 2Institute for Clinical Evaluative Sciences (ICES), Toronto and Ottawa, ON, Canada 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada 4Department of Medicine, Sinai Health System, Toronto, ON, Canada 5Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada 6Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada 7Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada 8Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada 9Temmy Latner Centre for Palliative Care, Toronto, ON, Canada 10Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada 11School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada 12Bruyère Research Institute, Ottawa, ON, Canada 13Department of Medicine, University of Ottawa, Ottawa, ON, Canada 14Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada 15Department of Medicine, Emory University, Atlanta, GA, USA Contributors: KLQ, TS, NMS, SI, PT, RG, PC, ASD, and CMB contributed to the study concept and design. AH was responsible for the acquisition of data. KLQ performed analyses of all data in this study. KLQ, TS, NMS, AH, SI, PT, RG, PC, DK, ASD, and CMB contributed to the interpretation of data. KLQ, TS, NMS, AH, SI, PT, RG, PC, DK, ASD, and CMB drafted the manuscript. KLQ, TS, NMS, AH, SI, PT, RG, PC, DK, ASD, and CMB contributed to the critical revision of the manuscript for important intellectual content. KLQ did the statistical analysis. KLQ and CMB obtained funding. KLQ is guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from
Funding Information:
disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the Institute for Clinical Evaluative Sciences (ICES) for the submitted work; the analysis was supported by a research grant KLQ and CMB received from the Sinai Health System Research Foundation to perform this work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Funding Information:
the Ontario Ministry of Health and Long term Care (MOHLTC). 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. 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). 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. 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.
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). 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. 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). 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. 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.
Publisher Copyright:
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2020/7/6
Y1 - 2020/7/6
N2 - AbstractObjective 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.
AB - AbstractObjective 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.
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U2 - 10.1136/bmj.m2257
DO - 10.1136/bmj.m2257
M3 - Article
C2 - 32631907
AN - SCOPUS:85087617330
SN - 0959-8146
VL - 370
JO - The BMJ
JF - The BMJ
M1 - m2257
ER -