Abstract
Background
As cancer incidences are increasing, the means to provide effective palliative care (PC) are called for. There is evidence, that PC may prevent futile treatment at the end of life (EOL) thus implicating that PC decreases resource use at the EOL, however, the effects of outpatient PC units remain largely unknown. We surveyed the national use of Finnish tertiary care PC units and their effects on resource use at the EOL in real-life environments.
Patients and Methods
Cancer patients treated in the departments of Oncology at all five Finnish university hospitals in 2013 and deceased by 31 December 2014 were identified; of the 6010 patients 2007 were randomly selected for the study cohort. The oncologic therapies received and the resource usage of emergency services and hospital wards were collected from the hospitals’ medical records.
Results
A PC unit was visited by 37% of the patients a median 112 days before death. A decision to terminate all life-prolonging cancer treatments was more often made for patients visiting the PC unit (90% vs. 66%, respectively). A visit to a PC unit was associated with significantly fewer visits to emergency departments (ED) and hospitalization during the last 90 days of life; the mean difference in ED visits decreased by 0.48 (SD 0.33 − 0.62, p < 0.001), and the mean inpatient days by 7.1 (SD 5.93 − 8.25, p < 0.001). A PC visit unit was independently associated with decreased acute hospital resource use during the last 30 and 90 days before death in multivariable analyses.
Conclusion
Cancer patients’ contact with a PC unit was significantly associated with the reduced use of acute hospital services at the EOL, however; only one-third of the patients visited a PC unit. Thus, systematic PC unit referral practices for patients with advanced cancer are called for.
Background
Cancer care has taken strides in the last decades, but the importance of palliative care (PC) has also been recognized. Whilst age-adjusted cancer mortality is on the decline, cancer incidence is increasing, as is the absolute number of PC patients and the need for good quality end-of-life (EOL) care [Citation1]. Integration of PC into oncology improves the quality of life and reduces the risk of aggressive treatments at the EOL [Citation2,Citation3]. Furthermore, PC interventions seem to lower the costs compared to usual care [Citation4]. The availability of PC varies greatly for patients with cancer at the EOL [Citation5]. We studied the effect of PC units on tertiary hospital resource use in Finland.
In Finland, PC has gradually been integrated into tertiary care departments of oncology as outpatient units and hospital palliative care teams, and these departments were responsible for the study population’s care at the time of this study. In previous Finnish studies, an appointment to a PC outpatient clinic enhanced connections to primary care PC providers [Citation6], and a decision to focus on PC decreased the number of ED visits and inpatient days in a secondary/tertiary care hospital [Citation7]. From the patient’s perspective a visit to the ED is often frustrating and exhausting for a cancer patient at their EOL.
In a recent Cochrane review the evidence suggests that when compared to normal care, hospital-based specialist palliative care (HSPC) may increase a patient’s quality of life and patient satisfaction with the care, as well as decreasing symptom burden [Citation8]. No difference was found in both hospital days or ED visits between the HSPC and the control group [Citation9], although patients in the HSPC group received less chemotherapy during the last 30 days of life [Citation10,Citation11]. Interestingly, Zimmermann et al. found no difference in the amounts of chemo- or radiotherapy at the EOL in these groups [Citation12].
In this register study we surveyed the use of all the Finnish tertiary care PC units and their effects on hospital resource use and intensity of cancer treatment at the EOL in real life environment.
Methods
Cohort selection
Patients with a cancer diagnosis (ICD-10 C00-96) treated in the Department of Oncology from the 1st
January 2013 – 31December 2013 and deceased by 31 December 2014 were identified (N = 6010) in the databases of the University Hospitals in Finland (Helsinki, Tampere, Turku, Oulu, and Kuopio). Of these patients, 2007 out of 6010 were randomly selected for the study cohort.
This historic registry-based study was done with the permission of the authorities of the university hospitals. According to the Finnish legislation for registry research, no ethics committee approval was needed.
The majority of Finnish cancer patients are initially treated at public universities and central hospitals. Helsinki University Hospital (HUS), Turku University Hospital (TYKS), Tampere University Hospital (TAYS), Oulu University Hospital (OYS), and Kuopio University Hospital (KUH) are the five Finnish university hospitals that provide tertiary cancer care for the entire population of Finland, and they provide all cancer treatment assessed in this study to a catchment area of approximately 3,4 million inhabitants. During the time of this study, the departments of oncology of these university hospitals were responsible for the radiation therapy treatments and the systemic cancer treatment of the study population, except for some gynecological and lung cancer patients, who had systemic cancer treatments in other units. All the departments of oncology had at least a limited palliative care outpatient service, but the municipalities were responsible for EOL care.
At the time of this study, the university hospitals PC units were multiprofessional specialized daytime outpatient units with specialized nurses and physicians providing specialist PC and consultation services for hospital wards and primary care units. The PC units made advanced care plans and enhanced patient contacts with primary care wards, hospices, and home-hospice units.
Data sources and collection
The data for this study were collected from the hospital’s medical records; structured data was directly exported from hospital patient data and supplemented with a manual search if necessary. The data sources used in the study are the same as in the studies by Hirvonen et al. [Citation7,Citation13] for the HUS cases, and new comparable data has been introduced from the other university hospitals. The cohort patients were identified from electronic medical records. The patient-level data included age, cancer diagnosis, oncological systemic treatments, radiation therapy, visits to the palliative care unit, palliative care decision, DNR decision, university hospital where treated, visits to the emergency department (ED) in tertiary hospitals, inpatient episodes in tertiary hospitals and the date of death. The information on the PC decision and DNR decision were manually extracted. The PC decision was defined to be the moment of termination of life prolonging anti-cancer treatments and a focus only on symptom centered PC, whether it was decided by the oncologist or elected by the patient. The cancer diagnoses were grouped into 13 groups: (1) Breast cancer, (2) Cancers of the urinary tract, (3) Colorectal cancers, (4) Gynecological cancers, (5) Head and Neck cancers, (6) Invasive skin cancers, (7) Lung, (8) Lymphomas, (9) Primary CNS malignancies, (10) Prostate cancer, (11) Sarcoma, (12) Upper gastrointestinal cancers, and (13) Other. When the patient had more than one malignancy, the cancer diagnosis was recorded to be the first main cancer diagnosis on record for the patient in the dataset.
Palliative care visits and service usage
Patients were divided into three groups based on the timing of the first palliative unit visits: (1) No visit to a PC unit or a visit in the last 30 days of life, (2) A visit to a PC unit before 30 days to death, and (3) A visit to a PC unit before 90 days to death. The service use of the last 30 and 90 days of life of the patients and the effect of a palliative care visit on the service usage were studied. Service usage was enumerated by two measures: the number of visits to an ED and the number of nights spent in the hospital (inpatient days).
Classification into the different categories was operated in a dynamic fashion in the analyses in order to ensure a correct chronology of the events. For example, if a patient had a visit to the PC unit 40 days before death, they would be categorized as someone who had a PC visit for analysis of service usage 30 days before death but also be categorized as a no PC visit for analyses of service usage 90 days before death, ergo patient could be categorized in different groups depending on the time of observation.
Statistical analysis
Means, standard deviations and distributions were used for the descriptive analyses of the cohort. A linear regression model was fitted for the data with service usage as the dependent variable to study the effect of palliative unit visits on ED visits and inpatient days; a multivariable regression analysis was performed. The diagnosis group and age group were chosen as control variables for the regression since different cancers and different aged patients are known to utilize services in differing amounts [Citation13]. Student’s t-test was used to analyze the differences in mean service usage between the different groups. All analyses were conducted using R-studio version 2021.09.0 Build 351 and its packages.
Results
The data consisted of 2007 patients, 75% of which had had a palliative care decision (PC decision) in effect, and 37% had visited the PC unit at the hospital (). A PC decision was made more often for patients that visited the PC unit (90% vs. 66%, respectively). The mean age of the patients was 67 years at the time of the first contact to the department of oncology. Upper gastrointestinal malignancies, breast cancer, lung cancer and colorectal cancer were the most common diseases among the patients.
Table 1. Characteristics of the patient population.
The majority of the patients, who had visited the PC unit, had had the first appointment over 90 days prior to death (). The median survival time after the PC unit visit was 112 days (IQR 204.75). The mean amount of visits among the PC unit visitors was 5.9 (SD 7.63) and the median was 3 (IQR 6). Only a few patients received systemic cancer treatments or radiotherapy during the last 30 days of life. However, there was a statistically significant difference (p < 0.001) in the number of received systemic cancer treatments, as PC unit visitors received treatments less frequently ().
Table 2. Timing of the patients’ appointments to the PC unit with respect to death.
Table 3. Proportions of PC unit visitors and non-visitors in systemic cancer treatment and radiotherapy recipients during the last 30 days of life.
The patients, who had visited the PC unit, had fewer visits to the ED and fewer inpatient days in tertiary care during the last 30 and 90 days before death. The use of emergency care services was reduced by 30% among patients with a PC unit visit, and the use of inpatient care was 60% less for the PC unit visitors in the last 90 days of life (). We also studied the EOL resource use of non-visitors of PC unit, where 838 patients had no palliative decision and 431 had a palliative decision in effect, but no difference in ED visits or inpatient days was detected.
Table 4. Number of visits to the emergency department and inpatient days 30 and 90 days before death.
Visiting a PC unit was independently associated with fewer ED visits and inpatient days in a multivariable regression analysis (). In addition, only patients with CNS malignancies had generally less ED visits within the last 30 days of life, and prostate cancer patients visited the ED more frequently during the last 90 days of life; the reference used in the diagnosis group analysis was breast cancer patients. The type of cancer had no significant effect on any of the resource use variables. Young age (below 60) was associated with a higher use of emergency care services in the last 30 and 90 days of life. Lymphomas were associated to an increased number of inpatient days both 30 and 90 days before death, while patients over 80 years of age spent fewer days hospitalized.
Table 5. Results of the regression analyses of factors associated with emergency and inpatient care services use in the last 30 and 90 days of life.
Discussion
In this retrospective cohort study of cancer patients, we investigated the effect of the services of specialized multiprofessional palliative outpatient units and consultation teams on acute hospital resource use in tertiary care hospitals in Finland. We found that PC unit visits independently reduced the number of emergency care visits and inpatient days at the EOL. However, only approximately one-third of the patients were referred to a PC unit before death.
There are very few studies investigating outpatient PC unit impact on hospital resource use except for studies on early integrated palliative care being implemented at the same time as life prolonging anticancer treatments. Earp et al. demonstrated in a large retrospective cohort study using administrative data, that early specialized palliative care (>90 days before death) was associated with decreased acute hospital service use among patients with cancer during the last month of life [Citation14]. Among cancer patients, even late specialized palliative care exposure (8-90 days before death) reduced the risk of hospital-based acute care service use, but no effect was found with very late contact, during the last week of life. In a small study by Blackhall et al. referral to a specialized outpatient PC unit within the last three months of life improved hospice utilization and reduced hospitalizations at the end-of-life and the risk of dying at an academic medical center [Citation15]. Early PC referrals were associated with a lower number of ED visits, ED-related charges documented for pancreatic cancer patients in a recent study by Bevins et al. [Citation16], and beneficial effects on less aggressive EOL care reported by Merchant et al. [Citation17]. In the present study patients were referred to outpatient PC units a median 112 days before death. The use of emergency care services was reduced by 30% among patients with a PC unit visit, and the use of inpatient care was 60% less for PC unit visitors in the last 90 days of life. It is possible that this decrease in resource use could be partly transferred to primary care providers, as the contacts to primary care were enhanced in the PC unit in our previous work [Citation6]. This could also be in the best interest of the patient, as a study by Elmstedt et al. implies that EOL care in hospitals was associated with inferior EOL care quality, when compared to primary care among cancer patients in Sweden [Citation18].
The resource use data of this study enables the calculation of a monetary estimate of a possible cost reduction in tertiary health care costs for comparison with the national average cost data [Citation19]. The patients that did not visit the PC unit accrued between 73 € and 2142 € more inflation corrected costs per patient in ED visits and inpatient days, respectively, during the last 30 days of life compared to the PC unit visitors’ costs. For the last 90 days, the estimated inflation corrected cost reduction was 167 € for ED visits and 6157 € for inpatient days per patient in the group of PC unit visitors. These numbers present a meaningful cost reduction, even though they are only numerical estimates, which should be interpreted cautiously. In a meta-analysis by Yadav et al. significant differences were found to exist in cost savings across different palliative care models [Citation20]. In prior studies, the effect of PC interventions on resource use has varied [Citation21]. In a study by May et al. the main cost driver diminishing the health care cost is the shortening length of hospital stays by PC interventions [Citation3], which is in line with our findings.
In our study, only approximately one third of the patients visited the outpatient PC unit, even though a PC decision, i.e., decision to terminate anticancer treatments was made for 75% of the patients. As most of the patients were referred to a PC unit only after termination of life-prolonging cancer specific treatments (90%), the time frame for palliative care was marginal. According to our previous study, late (< 30 days before death) or no palliative care decision increased the risk of not receiving a referral to the PC unit [Citation13] and the risk of continuing anti-cancer treatments at the end-of-life. Thus, to reach the majority of the patients the referral to PC unit should occur early in the course of the disease trajectory.
We found some variation in access to PC units between the hospitals. The development of the outpatient PC unit differed, which can partly explain these variations, and in addition, during the study time frame, there were also no standardized criteria for referral to a PC unit. In line with our findings the Blackhall et al. study [Citation15] found that only half of the patients with incurable cancer were referred to an outpatient PC clinic. The lack of clear criteria for PC unit referral can be seen as a confounding factor of this study, as some of the resource use may only reflect the different disease trajectories of the patients.
There was also variation between the different cancer groups in access to PC units in the present study. Lung cancer, lymphoma and CNS tumor patients tended to visit the PC unit more seldom. We have previously shown that the length of the palliative care period varies between the different cancer types [Citation22], which could at least partially explain the variation in access to PC units. Thus, we strongly support the standardized criteria proposed for referral to outpatient PC unit by Hui et al. [Citation23] to ensure equal access to PC for all patients.
In a register study, such as ours, a selection bias in referral practices to the PC unit could affect the results. During the study period, the referral practice was need-based, depending on the intuition of the individual oncologists, which affects the selection of patients for PC units locally and nationally. In our prior publication on a subgroup of this study population [Citation13], two-thirds of the PC unit visitors had a PC decision before the first visit, indicating a possible selection bias. However, in the multivariable analysis the PC unit visit, not the PC decision, was independently associated with less resource use, implying that alone a PC decision would not achieve the decrease, but instead the actions of the PC unit were meaningful. Also the indifference in the resource use of the groups of patients not visiting the PC unit, with or without a PC decision, favors the effect of the PC unit.
Due to data availability, the exact cause of death of the patients could not be confirmed. In an earlier study on a similar population by Hirvonen et al. [Citation7] 5% of the study population was excluded because of other causes of death. Under similar circumstances and as previously stated, the effect of this on our results can be estimated to be marginal. The strength of this study is the relatively large sample size and a nationwide cohort of patients from all five tertiary care hospitals in Finland, which strengthens the generalizability of our results.
Conclusions
Referral to an outpatient PC unit, even after the termination of cancer-specific care, significantly reduces the use of acute hospital services. This is achieved through a decrease in ED visits and inpatient hospital days at the EOL. Nevertheless, only a proportion of the patients with advanced cancer are referred to a PC unit. Therefore, patients with advanced cancer should be referred to outpatient PC units systematically, before systemic treatments are terminated to enable the early integration of PC into patients’ care. There are implications that monetary savings may be accrued through PC unit actions, but further research is called for with the aim of evaluating health care utilization.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data that support the findings of this study are available from the corresponding author, O.H., upon reasonable request.
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