Date Published: September 25, 2018
Publisher: Public Library of Science
Author(s): Vieri Lastrucci, Sara D’Arienzo, Francesca Collini, Chiara Lorini, Alfredo Zuppiroli, Silvia Forni, Guglielmo Bonaccorsi, Fabrizio Gemmi, Andrea Vannucci, Andres Azuero.
Cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer.
To assess the extent to which the quality of EOL care received by cancer, CHF, and COPD patients in the last month of life is diagnosis-sensitive.
This is a retrospective observational study based on administrative data. The study population includes all Tuscany region residents aged 18 years or older who died with a clinical history of cancer, CHF, or COPD. Decedents were categorized into two mutually exclusive diagnosis categories: cancer (CA) and cardiopulmonary failure (CPF). Several EOL care quality outcome measures were adopted. Multivariable generalized linear model for each outcome were performed.
The sample included 30,217 decedents. CPF patients were about 1.5 times more likely than cancer patients to die in an acute care hospital (RR 1.59, 95% C.I.: 1.54–1.63). CPF patients were more likely to be hospitalized or admitted to the emergency department (RR 1.09, 95% C.I.: 1.07–1.10; RR 1.15, 95% C.I.: 1.13–1.18, respectively) and less likely to use hospice services (RR 0.08, 95% C.I.: 0.07–0.09) than cancer patients in the last month of life. CPF patients had a four- and two-fold higher risk of intensive care unit admission or of undergoing life-sustaining treatments, respectively, than cancer patients (RR 3.71, 95% C.I.: 3.40–4.04; RR 2.43, 95% C.I.: 2.27–2.60, respectively).
The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. Further studies are needed to better elucidate the extent and the avoidability of these diagnosis-related differences in the quality of EOL care.
The majority of people in high-income countries die of chronic conditions other than cancer . Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are two prominent causes of death in high-income countries [1, 2], and their prevalence and burden are expected to grow as the populations are aging [2–5]. Although the focus on improving the quality of end-of-life (EOL) care was initially directed mainly to cancer patients [6–9], in recent years awareness of the importance of improving EOL care for patients with non-malignant diseases has increased [10, 11]. Nowadays, there is a general consensus that curative treatment should be integrated with the holistic approach provided by palliative care in the advanced stages of CHF and COPD [12–16].
This is a retrospective observational study of residents in Tuscany based on data extracted from the regional healthcare administrative data system (RHCADS). The RHCADS comprises several healthcare data sources and the following databases were used for the study: enrolment registry, regional census, inpatient hospitalizations, death registry, emergency department (ED), and hospice. In the RHCADS, each resident is represented by a unique encrypted identifier that enables complete record linkage at the level of the individual across databases and over time.
A total of 30,217 decedents with cancer, CHF, and COPD met the eligibility criteria. The patients’ characteristics are presented in Table 2.
The aim of this study was to evaluate whether the quality and treatment intensity of EOL care—measured by several established outcome measures [35–38]—differ significantly among the CA and CPF cohorts. In order to assess the extent to which EOL care is diagnosis-sensitive, several potential determinants and confounders were considered through multivariable analyses. According to the multivariable analyses, the CPF patients differed significantly from the CA patients in all the quality and treatment-intensity EOL care outcomes considered.
Cancer, CHF, and COPD in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer. Although awareness of the quality and aggressiveness of EOL care in CHF and COPD patients has increased recently, research on these issues is still limited. The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. These findings suggest the presence of potential diagnosis-sensitive determinants of the quality of EOL care. Further studies that take into account patients’ preferences of care and disease severity are needed to better elucidate the extent and the avoidability of these differences in the quality of EOL care provided to different diagnosis groups.