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Palliative Care is Associated with Reduced Aggressive End-of-Life Care in Patients with Gastrointestinal Cancer

  • Health Services Research and Global Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

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.

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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

Authors

Corresponding author

Correspondence to Shaila J. Merchant MSc, MHSc, MD, FRCSC, FACS.

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

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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

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  • DOI: https://doi.org/10.1245/s10434-018-6430-9

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