Abstract
Background
We examined the delivery of physician palliative care (PC) services and its association with aggressive end-of-life care (EOLC) in patients with gastrointestinal (GI) cancer in Ontario, Canada.
Methods
All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified. PC services within 2 years of death were classified: (1) any PC; (2) timing of first PC (≤ 7, 8–90, 91–180, and 181–730 days before death); and (3) intensity of PC measured by number of days used (1st–25th, 26th–50th, 51st–75th, and 76th–100th percentiles). Aggressive EOLC was defined as any of the following: chemotherapy, emergency department visits, hospital or intensive care unit (ICU) admissions (all ≤ 30 days of death), and death in hospital and in the ICU; these were combined as a composite outcome (any aggressive EOLC).
Results
The cohort included 34,630 patients, of whom 74% had at least one PC service. Timing of the first PC service varied: ≤ 7 (12%), 8–90 (42%), 91–180 (16%), and 181–730 (30%) days before death. Compared with patients not receiving PC, any PC was associated with a reduction in any aggressive EOLC (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.74–0.76); this association was similar regardless of timing of the first PC service. The most dramatic reduction in aggressive EOLC occurred in patients who received the greatest number of days of PC (RR 0.65, 95% CI 0.63–0.67).
Conclusions
The majority of patients received PC within 2 years of death. A larger number of days of PC was associated with a greater reduction in aggressive EOLC.
Similar content being viewed by others
References
Zimmermann C, Swami N, Krzyzanowska M, Leighl N, Rydall A, Rodin G, et al. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ. 2016;188(10):E217-27.
Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-9.
Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, et al. Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. J Clin Oncol. 2017;35(8):834-41.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42.
Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-30.
Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017;35(1):96-112.
Cherny N, Catane R, Schrijvers D, Kloke M, Strasser F. European Society for Medical Oncology (ESMO) Program for the integration of oncology and Palliative Care: a 5 year review of the Designated Centers’ incentive program. Ann Oncol. 2010;21(2):362-9.
Canadian Cancer Society. Right to Care: Palliative care for all Canadians 2016. https://www.cancer.ca/~/media/cancer.ca/CW/get%20involved/take%20action/Palliative-care-report-2016-EN.pdf?la=en.
Wentlandt K, Krzyzanowska MK, Swami N, Rodin GM, Le LW, Zimmermann C. Referral practices of oncologists to specialized palliative care. J Clin Oncol. 2012;30(35):4380-6.
Morita T, Akechi T, Ikenaga M, Kizawa Y, Kohara H, Mukaiyama T, et al. Late referrals to specialized palliative care service in Japan. J Clin Oncol. 2005;23(12):2637-44.
Osta BE, Palmer JL, Paraskevopoulos T, Pei BL, Roberts LE, Poulter VA, et al. Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med. 2008;11(1):51-7.
Iwashyna TJ, Christakis NA. Attitude and self-reported practice regarding hospice referral in a national sample of internists. J Palliat Med. 1998;1(3):241-8.
Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC. Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004;22(2):315-21.
Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC. Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol. 2011;29(12):1587-91.
Hu W, Yasui Y, White J, Winget M. Aggressiveness of end-of-life care for patients with colorectal cancer in Alberta, Canada: 2006–2009. J Pain Symptom Manag. 2014;47(2):231-44.
Liu TW, Hung YN, Earle CC, Liu TP, Liu LN, Tang ST. Characteristics and correlates of increasing use of surgery in taiwanese cancer patients’ last month of life, 2001–2010. Ann Surg. 2016;264(2):283-90.
Warren JL, Barbera L, Bremner KE, Yabroff KR, Hoch JS, Barrett MJ, et al. End-of-life care for lung cancer patients in the United States and Ontario. J Natl Cancer Inst. 2011;103(11):853-62.
Canadian Institute for Health Information. End-of-Life Hospital Care for Cancer Patients 2013. https://secure.cihi.ca/free_products/Cancer_Report_EN_web_April2013.pdf. Accessed 28 Dec 2016.
Bekelman JE, Halpern SD, Blankart CR, Bynum JP, Cohen J, Fowler R, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA. 2016;315(3):272-83.
Dumont S, Jacobs P, Fassbender K, Anderson D, Turcotte V, Harel F. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8):708-17.
Hung YN, Liu TW, Wen FH, Chou WC, Tang ST. Escalating health care expenditures in cancer decedents’ last year of life: a decade of evidence from a retrospective population-based cohort study in Taiwan. Oncologist. 2017;22(4):460-9.
Merchant SJ, Lajkosz K, Brogly SB, Booth CM, Nanji S, Patel SV, et al. The final 30 days of life: a study of patients with gastrointestinal cancer in Ontario, Canada. J Palliat Care 2017 32:92-100.
Jang RW, Krzyzanowska MK, Zimmermann C, Taback N, Alibhai SM (2015) Palliative care and the aggressiveness of end-of-life care in patients with advanced pancreatic cancer. J Natl Cancer Inst 107(3):dju424.
Triplett DP, LeBrett WG, Bryant AK, Bruggeman AR, Matsuno RK, Hwang L, et al. Effect of palliative care on aggressiveness of end-of-life care among patients with advanced cancer. J Oncol Pract. 2017;13(9):e760-e9.
Clarke EA, Marrett LD, Kreiger N. Cancer registration in Ontario: a computer approach. IARC Sci Publ. 1991;(95):246-57.
Robles SC, Marrett LD, Clarke EA, Risch HA. An application of capture-recapture methods to the estimation of completeness of cancer registration. J Clin Epidemiol. 1988;41(5):495-501.
Barbera L, Hwee J, Klinger C, Jembere N, Seow H, Pereira J. Identification of the physician workforce providing palliative care in Ontario using administrative claims data. CMAJ Open. 2015;3(3):E292-8.
Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol. 2008;26(23):3860-6.
Leveridge MJ, Siemens DR, Mackillop WJ, Peng Y, Tannock IF, Berman DM, et al. Radical cystectomy and adjuvant chemotherapy for bladder cancer in the elderly: a population-based study. Urology 2015;85(4):791-8.
Austin PC, van Walraven C, Wodchis WP, Newman A, Anderson GM. Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada. Med Care 2011;49(10):932-9.
Johns Hopkins Bloomberg School of Public Health. The Johns Hopkins ACG System 2009. Available at: https://www.healthpartners.com/ucm/groups/public/@hp/@public/documents/documents/dev_057914.pdf. Accessed 1 Dec 2016.
McMaster University. Ontario Marginalization Index 2012. https://crunch.mcmaster.ca/documents/ON-Marg_user_guide_1.0_FINAL_MAY2012.pdf. Accessed 1 Nov 2016.
Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol. 2005;162(3):199-200.
Bascioni R, Giorgi F, Rastelli F, di Pietro Paolo M, Brugni M, Basirat F, et al. Impact of hospice and palliative home care on chemotherapy use at the end of life (EOL). J Clin Oncol. 2011;29(15 Suppl):e16611.
Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33(13):1438-45.
Lamont EB, Christakis NA. Physician factors in the timing of cancer patient referral to hospice palliative care. Cancer. 2002;94(10):2733-7.
Flannery L, Ramjan LM, Peters K. End-of-life decisions in the Intensive Care Unit (ICU)—the experiences of ICU nurses and doctors: a critical literature review. Aust Crit Care. 2016;29(2):97-103.
Canadian Institute for Health Information. Health Care Use at the End of Life in Western Canada 2007. https://secure.cihi.ca/free_products/end_of_life_report_aug07_e.pdf. Accessed 28 Dec 2016.
Canadian Institute for Health Information. Health Care Use at the End of Life in Atlantic Canada 2011. https://secure.cihi.ca/free_products/end_of_life_2011_en.pdf. Accessed 28 Dec 2016.
Acknowledgments
This study was funded by the Faculty of Health Sciences Research Initiation Grant (SM) and the Department of Surgery at Queen’s University, and was supported by the ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). 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 CIHI; however, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of the CIHI.
Author Contributions
All authors contributed to the following elements of the study: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing of the original draft, and review and editing.
Disclosures
None.
Author information
Authors and Affiliations
Corresponding author
Appendix 1
Appendix 1
ICD-10 codes used to identify the study cohort
Cancer type | ICD-10 Code |
---|---|
Esophageal | C15, C150–155, C158–159 |
Gastric | C16, C160–166, C168–169 |
Colon | C18, C180–190 |
Anorectal | C20, C21, C210–212, C218 |
Codes used to identify study outcomes
Outcome | Database | Codes | Values |
---|---|---|---|
Receipt of last dose of chemotherapy within 30 days of death | OHIP | G075, G281, G381, G345, G359, G382, G388, G390 | Not available |
Any emergency department visit within 30 days of death | NACRS | SERVDATE | Not available |
Any hospital admission within 30 days of death | DAD | ADMDATE | Not available |
Any intensive care unit admission within 30 days of death | DAD | SCU, SCU 1–6 | (a) Value 10—Medical intensive care nursing unit (b) Value 20—Surgical intensive care nursing unit (c) Value 25—Trauma intensive care nursing unit (d) Value 30—Combined medical and surgical intensive care nursing unit (e) Value 35—Burn intensive care nursing unit (f) Value 40—Cardiac intensive care nursing unit, surgery (g) Value 45—Coronary intensive care nursing unit, medical |
Death in an acute-care hospital | DAD | DISDISP | (a) Value 07—died |
Death in a special care unit | DAD | DTHSCU | (a) Value 1—patient died within ≤ 48 h of admission to the unit (b) Value 2—patient died within > 48 h of admission to the unit (c) Value Y—yes |
Frequency listing of palliative care OHIP billing codes used in the studya
Fee code | Fee code description | No. of patients with code (n) | Percentage of patients with palliative care (%)a | No. of occurrences of code (n) | Percentage of all occurrences (%) |
---|---|---|---|---|---|
A901 | Housecall assessment (only when billed with B997 and B998)b | 995 | 3.9 | 3014 | 0.8 |
A902 | Housecall assessment—pronouncement of death in home (only when billed with B997 and B998)b | 1076 | 4.2 | 1079 | 0.3 |
A945 | Special palliative care consultation | 6395 | 25.1 | 7306 | 1.9 |
C882 | Palliative care subsequent visit in inpatient hospital | 6375 | 25.1 | 69,272 | 18.1 |
C945 | Special palliative care consultation | 5819 | 22.9 | 6402 | 1.7 |
C982 | Palliative care subsequent visit in inpatient hospital | 731 | 2.9 | 5181 | 1.4 |
G511 | Telephone management of palliative care at home | 1017 | 4.0 | 2870 | 0.7 |
G512 | Palliative care case management fee | 10,609 | 41.7 | 132,590 | 34.6 |
K015 | Counselling of relatives of a terminally ill patient | 9339 | 36.7 | 14,585 | 3.8 |
K023 | Palliative care support | 18,961 | 74.5 | 125,213 | 32.7 |
K700 | Palliative care out-patient case conference | 281 | 1.1 | 610 | 0.2 |
W872 | Palliative care subsequent visit in nursing home | 141 | 0.6 | 690 | 0.2 |
W882 | Palliative care subsequent visit in covalescent hospital | 1174 | 4.6 | 9922 | 2.6 |
W982 | Palliative care subsequent visit in covalescent hospital | 169 | 0.7 | 5087 | 1.3 |
Frequency listing of palliative care OHIP billing codes considered but ultimately excluded due to lack of use
Fee code | Fee code description | No. of patients with code (n) | Percentage of patients with palliative care (%)a | No. of occurrences of code (n) | Percentage of all occurrences (%) |
---|---|---|---|---|---|
G063 | Initiation of outpatient continuous nerve block infusion | < 6 | 0 | < 6 | 0 |
G064 | Management and supervision of outpatient continuous nerve block infusion | < 6 | 0 | < 6 | 0 |
K001 | Detention fee (for extra time) | 72 | 0.1 | 75 | 0.1 |
W972 | Palliative care subsequent visit in nursing home | < 6 | 0 | < 6 | 0 |
Z361 | Insertion of indwelling catheter | 64 | 0.1 | 71 | 0.1 |
Z362 | Removal of indwelling catheter | 12 | 0 | 12 | 0 |
aIncludes all patients who received palliative care, including those who received their first palliative care after the occurrence of aggressive end-of-life care
bB codes are modifier codes that indicate a palliative care service was provided when billed in conjunction with A901 and A902, as shown below:
B997 | Palliative care home visit, nights |
B998 | Palliative care home visit, days, evenings and weekends |
ICD-10 International Classification of Diseases, Tenth Revision, OHIP Ontario Health Insurance Plan Claims Database, NACRS National Ambulatory Care Reporting System, DAD discharge abstract database, NA not available
Rights and permissions
About this article
Cite this article
Merchant, S.J., Brogly, S.B., Goldie, C. et al. Palliative Care is Associated with Reduced Aggressive End-of-Life Care in Patients with Gastrointestinal Cancer. Ann Surg Oncol 25, 1478–1487 (2018). https://doi.org/10.1245/s10434-018-6430-9
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-018-6430-9