Impact of a multi‐professional expert team on EOL care of children with cancer

Predictors of and Trends in High-Intensity End-of-Life Care Among Children With Cancer: A Population-Based Study Using Health Services Data

Journal of Clinical Oncology ◽

10.1200/jco.2016.68.8283 ◽

2017 ◽

Vol 35 (2) ◽

pp. 236-242 ◽

Cited By ~ 23

Author(s):

Alisha Kassam ◽

Rinku Sutradhar ◽

Kimberley Widger ◽

Adam Rapoport ◽

Jason D. Pole ◽

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Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Health Services ◽

High Intensity ◽

Hematologic Malignancies ◽

Population Based ◽

Children With Cancer ◽

Eol Care ◽

Related Mortality

Purpose Children with cancer often receive high-intensity (HI) medical care at the end-of-life (EOL). Previous studies have been limited to single centers or lacked detailed clinical data. We determined predictors of and trends in HI-EOL care by linking population-based clinical and health-services databases. Methods A retrospective decedent cohort of patients with childhood cancer who died between 2000 and 2012 in Ontario, Canada, was assembled using a provincial cancer registry and linked to population-based health-care data. Based on previous studies, the primary composite measure of HI-EOL care comprised any of the following: intravenous chemotherapy < 14 days from death; more than one emergency department visit; and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included those same individual measures and measures of the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death). We determined predictors of outcomes with appropriate regression models. Sensitivity analysis was restricted to cases of cancer-related mortality, excluding treatment-related mortality (TRM) cases. Results The study included 815 patients; of these, 331 (40.6%) experienced HI-EOL care. Those with hematologic malignancies were at highest risk (odds ratio, 2.5; 95% CI, 1.8 to 3.6; P < .001). Patients with hematologic cancers and those who died after 2004 were more likely to experience the MI-EOL care (eg, intensive care unit, mechanical ventilation, odds ratios from 2.0 to 5.1). Excluding cases of TRM did not substantively change the results. Conclusion Ontario children with cancer continue to experience HI-EOL care. Patients with hematologic malignancies are at highest risk even when excluding TRM. Of concern, rates of the MI-EOL care have increased over time despite increased palliative care access. Linking health services and clinical data allows monitoring of population trends in EOL care and identifies high-risk populations for future interventions.

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Hospice use at end of life in children with cancer: The effect of insurance.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.10558 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 10558-10558

Author(s):

Emily E. Johnston ◽

Elizabeth Davis ◽

Smita Bhatia ◽

Kelly Kenzik

Keyword(s):

End Of Life ◽

Hospice Care ◽

Private Insurance ◽

Hematologic Malignancies ◽

Insurance Status ◽

Children With Cancer ◽

Location Of Death ◽

National Quality ◽

Eol Care ◽

Privately Insured

10558 Background: The National Quality Forum has endorsed hospice care as a metric of high quality end-of-life (EOL) care for adults with cancer. Specific hospice-related quality metrics include hospice enrollment, hospice enrollment for ≥3d, and death outside of the acute care setting. These metrics have been examined extensively in adults and disparities related to a number of clinical and sociodemographic factors, including insurance, have been identified. However, for children with cancer, hospice utilization data is lacking. We addressed this gap by examining location of death and hospice utilization at EOL for children with cancer and determining whether these metrics varied with insurance status. Methods: We used national insurance claims data (Truven) to conduct a population-based analysis of patients with cancer who died between 2011 and 2017 at age 0-21y. The dataset was queried for hospice claims, inpatient claims, and location of death. The association between insurance (private vs. Medicaid) and 1) location of death, 2) hospice enrollment, and 3) days between first hospice claim and death was examined using multivariable regression analysis, adjusting for age at death, gender, and cancer diagnosis (hematologic malignancies vs. solid tumor). Results: A total of 1,492 children died at a mean age of 11y (SD: 6y); 56% were privately-insured, 56% were male, and 30% had hematologic malignancies. Overall, 58% died in the hospital (privately-insured: 54% vs. Medicaid: 63%). Forty-five percent enrolled in hospice (privately-insured: 46% vs. Medicaid: 43%) with 2% returning to the hospital to die after enrolling in hospice. The average time between first hospice claim and death was 3d (privately-insured: 10d vs. Medicaid: 2d, p = < 0.001). When compared to privately-insured children, children on Medicaid had similar likelihood of hospice enrollment (RR = 1.0, 95%Cl = 0.6-1.8). However, children on Medicaid were more likely to die in the hospital (RR = 1.3, 95%CI = 1.1-1.4) and have fewer days between hospice enrollment and death if enrolled in hospice (IRR: 0.5, 95%CI = 0.3-0.8). Conclusions: In this first study to examine national hospice utilization in children with cancer, care varies significantly with insurance status. Children on Medicaid are more likely to die in the hospital and have shorter hospice enrollment duration than children with private insurance. Whether this variation represents EOL care preferences, provider biases, differences in quality and availability of hospice or home care to different insurers, or other barriers needs to be examined.

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