A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life.

BACKGROUND: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life. OBJECTIVE: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults. DESIGN: Population-based cohort study. PARTICIPANTS: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada. EXPOSURES: Chinese ethnicity. MAIN MEASURES: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation. KEY RESULTS: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38). CONCLUSIONS: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.

Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia.

BACKGROUND: Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS: The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION: We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION: NCT05371782.

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study.

OBJECTIVES: In Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative care use following ALC designation in Ontario, Canada. METHODS: We conducted a population-based retrospective cohort study of adult, acute care hospital admissions in Ontario with an ALC designation between January and December 2021. Our follow-up window was until 90 days post-ALC designation or death. Setting of discharge and death was determined using admission and discharge dates from multiple databases. We measured palliative care using physician billings, inpatient palliative care records and palliative home care records. We compared the characteristics of ALC patients by 90-day survival status and compared palliative care use across settings of discharge and death. RESULTS: We included 54 839 ALC patients with a median age of 80 years. Nearly one-fifth (18.4%) of patients died within 90 days. Patients who died were older, had more comorbid conditions and were more likely to be male. Among those who died, 35.1% were never discharged from hospital and 20.3% were discharged but ultimately died in the hospital. The majority of people who died received palliative care following their ALC designation (68.1%). CONCLUSIONS: A significant proportion of patients experiencing delayed discharge die within 3 months, with the majority dying in hospitals despite being identified as ready to be discharged. Future research should examine the adequacy of palliative care provision for this population.

Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada.

IMPORTANCE: Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown. OBJECTIVE: Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic. DESIGN, SETTING AND PARTICIPANTS: Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic. EXPOSURE: Annual service volume of a person's attending physician in the preceding year. MAIN OUTCOMES AND MEASURES: Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians. RESULTS: Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic. CONCLUSIONS AND RELEVANCE: Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.

Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review.

BACKGROUND: It is unclear whether antibiotics impact delirium outcomes in older adults with pyuria or bacteriuria in the absence of systemic signs of infection or genitourinary symptoms. METHODS: We registered our systematic review protocol with PROSPERO (CRD42023418091). We searched the Medline and Embase databases from inception until April 2023 for studies investigating the impact of antimicrobial treatment on the duration and severity of delirium in older adults (≥60 years) with pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on urine culture) and without systemic signs of infection (temperature > 37.9C [>100.2F] or 1.5C [2.4F] increase above baseline temperature, and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms). Two reviewers independently screened search results, abstracted data, and appraised the risk of bias. Full-text randomized controlled trials (RCTs) and observational study designs were included without restriction on study language, duration, or year of publication. RESULTS: We screened 984 citations and included 4 studies comprising 652 older adults (mean age was 84.6 years and 63.5% were women). The four studies were published between 1996 and 2022, and included one RCT, two prospective observational cohort studies, and one retrospective chart review. None of the four studies demonstrated a significant effect of antibiotics on delirium outcomes, with two studies reported a worsening of outcomes among adults who received antibiotics. The three observational studies included had a moderate or serious overall risk of bias, while the one RCT had a high overall risk of bias. CONCLUSIONS: Our systematic review found no evidence that treatment with antibiotics is associated with improved delirium outcomes in older adults with pyuria or bacteriuria and without systemic signs of infection or genitourinary symptoms. Overall, the evidence was limited, largely observational, and had substantial risk of bias.

Association of virtual end-of-life care with healthcare outcomes before and during the COVID-19 pandemic: A population-based study.

The use of virtual care for people at the end-of-life significantly increased during the COVID-19 pandemic, but its association with acute healthcare use and location of death is unknown. The objective of this study was to measure the association between the use of virtual end-of-life care with acute healthcare use and an out-of-hospital death before vs. after the introduction of specialized fee codes that enabled broader delivery of virtual care during the COVID-19 pandemic. This was a population-based cohort study of 323,995 adults in their last 90 days of life between January 25, 2018 and December 31, 2021 using health administrative data in Ontario, Canada. Primary outcomes were acute healthcare use (emergency department, hospitalization) and location of death (in or out-of-hospital). Prior to March 14, 2020, 13,974 (8%) people received at least 1 virtual end-of-life care visit, which was associated with a 16% higher rate of emergency department use (adjusted Rate Ratio [aRR] 1.16, 95%CI 1.12 to 1.20), a 17% higher rate of hospitalization (aRR 1.17, 95%CI 1.15 to 1.20), and a 34% higher risk of an out-of-hospital death (aRR 1.34, 95%CI 1.31 to 1.37) compared to people who did not receive virtual end-of-life care. After March 14, 2020, 104,165 (71%) people received at least 1 virtual end-of-life care visit, which was associated with a 58% higher rate of an emergency department visit (aRR 1.58, 95%CI 1.54 to 1.62), a 45% higher rate of hospitalization (aRR 1.45, 95%CI 1.42 to 1.47), and a 65% higher risk of an out-of-hospital death (aRR 1.65, 95%CI 1.61 to 1.69) compared to people who did not receive virtual end-of-life care. The use of virtual end-of-life care was associated with higher acute healthcare use in the last 90 days of life and a higher likelihood of dying out-of-hospital, and these rates increased during the pandemic.

Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19.

Importance: The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes. Objective: To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes. Design, Setting, and Participants: In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre-COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023. Exposure: COVID-19-related hospital restrictions starting March 16, 2020. Main Outcomes and Measures: Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic. Results: Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre-COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, -6.3% to -4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, -1.0% to 3.5%]). Conclusions and Relevance: These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.