Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients.

BACKGROUND: Limited data are available on how the timing and setting of palliative care (PC) referral can affect end-of-life care. In this retrospective cohort study, the authors examined how the timing and setting of PC referral were associated with the quality of end-of-life care. METHODS: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had a PC consultation were included. Data were retrieved on PC referral and quality of end-of-life care indicators. RESULTS: Among 366 decedents, 120 (33%) had an early PC referral (>3 months before death), and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs 68%; P<.001), fewer hospitalizations (48% vs 81%; P<.003), and fewer hospital deaths (17% vs 31%; P5.004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs 68%; P<.001), fewer hospital admissions (52% vs 86%; P<.001), fewer hospital deaths (18% vs 34%; P5.001), and fewer intensive care unit admissions (4% vs 14%; P5.001). In multivariate analysis, outpatient PC referral (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.28-0.66; P<.001) was independently associated with less aggressive end-of-life care. Men (OR, 1.63; 95% CI, 1.06-2.50; P5.03) and hematologic malignancies (OR, 2.57; 95% CI, 1.18-5.59; P5.02) were associated with more aggressive end-of-life care. CONCLUSIONS: Patients who were referred to outpatient PC had improved end-of-life care compared with those who received inpatient PC. The current findings support the need to increase the availability of PC clinics and to streamline the process of early referral.

Quality of end-of-life care in patients with hematologic malignancies: a retrospective cohort study.

BACKGROUND: To the authors' knowledge, only limited data are available regarding the quality of end-of-life care for patients with hematologic malignancies. In this retrospective cohort study, the quality of end-of-life care was compared between patients with hematologic malignancies and those with solid tumors. METHODS: All adult patients who died of advanced cancer between September 1, 2009 and February 28, 2010 while under the care of the study institution were included. The authors collected baseline demographics and end-of-life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life. RESULTS: Of a total of 816 decedents, 113 (14%) had hematologic malignancies. In the last 30 days of life, patients with hematologic malignancies were more likely to have emergency room visits (54% vs 43%; P = .03), hospital admissions (81% vs 47%; P < .001), ≥ 2 hospital admissions (23% vs 10%; P < .001), > 14 days of hospitalization (38% vs 8%; P < .001), intensive care unit admissions (39% vs 8%; P < .001) and death (33% vs 4%; P < .001), chemotherapy use (43% vs 14%; P < .001), and targeted therapy use (34% vs 11%; P < .001) compared with patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs 17%; P = .02). The composite score for aggressiveness of care (with 0 indicating the best and 6 indicating the worst) was significantly higher among patients with hematologic malignancies compared with those with solid tumors (median, 2 vs 0; P < .001). On multivariate analysis, hematologic malignancy was found to be a significant factor associated with aggressive end-of-life care (odds ratio, 6.6; 95% confidence interval, 4.1-10.7 [P < .001]). CONCLUSIONS: The results of the current study indicate that patients with hematologic malignancies received more aggressive care at the end of life.

Impact of safety concerns and regulatory changes on the usage of erythropoiesis-stimulating agents and RBC transfusions.

PURPOSE: Safety concerns raised in the recent oncology trials with erythropoiesis-stimulating agents (ESAs) have led to regulatory restrictions on their use. We wished to determine the impact of these changes on the use of ESAs and RBC transfusions. METHODS: In a retrospective observational study of patients treated at a comprehensive cancer center in 2006-2008, data on all ESA doses dispensed, RBCs transfused, and hemoglobin levels on the days of transfusions and ESA initiations were analyzed. RESULTS: Compared with 2006, the total patients treated was 14% higher (28,339 versus 24,806) in 2007 and 22% higher (30,254) in 2008. Patients receiving ESAs decreased by 26% and 61%, and ESA units dispensed decreased by 29% (from 30,206 units to 21,409 units) and 80% (6,102 units) in 2007 and 2008, respectively. However, RBC transfusions increased by only 2% (from 38,218 units to 38,948 units) in 2007 and by 8% (41,438) in 2008. The mean hemoglobin on the day of transfusion was the same for each year (8.4 g/dl); however, an increasing proportion of patients initiated ESAs at lower hemoglobin (< 10 g/dl) levels. After adjusting for demographics and diagnostic variables for 3 years (n = 83,399), a multivariate logistic regression showed a significant decline in ESA use (p < .0001) without an increase in RBC transfusions. CONCLUSIONS: Recent ESA safety concerns and regulatory restrictions have significantly decreased ESA use. The lack of a significant impact on transfusions may be related to a lower hemoglobin threshold used to initiate ESAs or treatment of patients less likely to respond.