Four dimensions for the provision of end-of-life care by clinicians were identified from a review and synthesis of the Canadian family physician and palliative care literatures. These dimensions are: clinician-patient continuity, timing and location of care, community-centred services, and multidisciplinary care. Indicators of each dimension are presented along with criteria for indicator selection. The analytic framework was refined during the linkage of population-based administrative databases to identify patterns of family physician service provision in the last months of life for persons dying from cancer in Nova Scotia, Canada. Data analysis was framed to inform palliative care policy and programs, as well as to enable comparison among geographic areas within and beyond Canada.
Quality indicators (QIs) are tools designed to measure and improve quality of care. The objective of this study was to assess stakeholder acceptability of QIs of end-of-life (EOL) care that potentially were measurable from population-based administrative health databases.
After a literature review, the authors identified 19 candidate QIs that potentially were measurable through administrative databases. A modified Delphi methodology, consisting of multidisciplinary panels of cancer care health professionals in Nova Scotia and Ontario, was used to assess agreement on acceptable QIs of EOL care (n = 21 professionals; 2 panels per province). Focus group methodology was used to assess acceptability among patients with metastatic breast cancer (n = 16 patients; 2 groups per province) and bereaved family caregivers of women who had died of metastatic breast cancer (n = 8 caregivers; 1 group per province). All sessions were audiotaped, transcribed verbatim, and audited, and thematic analyses were conducted.
Through the Delphi panels, 10 QIs and 2 QI subsections were identified as acceptable indicators of quality EOL care, including those related to pain and symptom management, access to care, palliative care, and emergency room visits. When Delphi panelists did not agree, the principal reasons were patient preferences, variation in local resources, and benchmarking. In the focus groups, patients and family caregivers also highlighted the need to consider preferences and local resources when examining quality EOL care.
The findings of this study should be considered when developing quality monitoring systems. QIs will be most useful when stakeholders perceive them as measuring quality care.
Prescription of opioid analgesics is a key component of pain management among persons with cancer at the end of life.
To use a population-based method to assess the use of opioid analgesics within the community among older persons with colorectal cancer (CRC) before death and determine factors associated with the use of opioid analgesics.
Data were derived from a retrospective, linked administrative database study of all persons who were diagnosed with CRC between January 1, 2001 and December 31, 2005 in Nova Scotia, Canada. This study included all persons who 1) were 66 years or older at the date of diagnosis; 2) died between January 1, 2001 and April 1, 2008; and 3) resided in health districts with formal palliative care programs (PCPs) (n=657). Factors associated with having filled at least one prescription for a so-called "strong" opioid analgesic in the six months before death were examined using multivariate logistic regression.
In all, 36.7% filled at least one prescription for any opioid in the six months before death. Adjusting for all covariates, filling a prescription for a strong opioid was associated with enrollment in a PCP (odds ratio [OR]=3.18, 95% CI=2.05-4.94), residence in a long-term care facility (OR=2.19, 95% CI=1.23-3.89), and a CRC cause of death (OR=1.75, 95% CI=1.14-2.68). Persons were less likely to fill a prescription for a strong opioid if they were older (OR=0.97, 95% CI=0.95-0.99), male (OR=0.59, 95% 0.40-0.86), and diagnosed less than six months before death (OR=0.62, 95% CI=0.41-0.93).
PCPs may play an important role in enabling access to end-of-life care within the community.
Despite cancer patients preferring to spend their last days out-of-hospital, many make difficult visits to the emergency department (ED). Family physician continuity of care has been shown in some clinical situations to reduce ED utilization.
To determine if greater family physician continuity of care for cancer patients during the end-of-life is associated with less ED utilization.
This retrospective, population-based study involved secondary analysis of linked administrative data files for 1992 to 1997. Sources included the Nova Scotia Cancer Registry, Vital Statistics, the Queen Elizabeth II Health Sciences Center Oncology Patient Information System and Palliative Care Program (PCP), Hospital Admissions/Separation data, and Physician Services information. Subjects included adults with a recorded date of cancer diagnosis who died of cancer and who had made at least three visits to a family physician during their last 6 months of life. The relationship between total ED visits and family physician continuity of care, developed using the Modified Modified Continuity Index (MMCI), was examined using negative binomial regression with adjustments for survival, year of death, sex, age, cancer type, region, PCP admission, specialty visits, hospital days, death location, income quintile, and total ambulatory visits.
In total, 8702 subjects made 11,551 ED visits (median = 1.0); median MMCI was 0.83. Adjusted results indicate those experiencing low continuity (MMCI or = 0.8) and patients experiencing moderate continuity (MMCI = 0.5-0.8) made twice as many ED visits (RR = 2.28; CI = 2.15-2.42).
Given this significant association between family physician continuity of care and ED visits during the end-of-life, and given international trends to reform primary care, active planning of strategies to facilitate such continuity should be encouraged.
Few data are available on the costs occurring during the palliative phase of care and on the sharing of these costs in rural areas. This study aimed to evaluate the costs related to all resources used by rural palliative care patients and to examine how these costs were shared between the public healthcare system (PHCS), patients' families, and not-for-profit organizations (NFPOs). A prospective longitudinal study was undertaken of 82 palliative care patients and their main informal caregivers in rural areas of four Canadian provinces. Telephone interviews were completed at two-week intervals. The mean total cost per patient for a six-month participation in a palliative care program was CA$31,678 +/- 1,160. A large part of this cost was attributable to inpatient hospital stays and was assumed by the PHCS. The patient's family contributed less than a quarter of the mean total cost per patient, and this was mainly attributable to caregiving time.
Continuity of primary care is known to be associated with both improved processes and outcomes of care. Despite continuity being a desired attribute of end-of-life care and despite the desire by most patients with cancer to die at home, there has been no health services research examining this relationship.
To examine the association between family physician continuity of care and the location of death for patients with cancer.
A retrospective population-based study involving secondary data analysis of four linked administrative health databases spanning 6 years of information (1992-1997).
Nova Scotia, Canada Participants: All those who died of cancer from 1992 to 1997 and had made at least three ambulatory visits to a family physician.
The relationship of provider continuity of care and an out-of-hospital death was examined using logistic regression.
Out-of-hospital deaths accounted for 31.6% of the 9714 deaths in the study population. The mean provider continuity of care was 0.78 (standard deviation [SD] 0.22). Those who died out-of-hospital had a greater odds of having received high provider continuity (adjusted odds ratio [OR] = 1.54, 95% confidence interval [CI] = 1.22, 1.93) when compared to those who died in-hospital. There appears to be a modification of this effect by gender with a significant association found for males and not for females. The trends in the point estimates are, however, similar for both sexes.
This study demonstrates an association between family physician continuity of care and the location of death for those with advanced cancer. Such continuity should be fostered in the development of models of integrated service delivery for end-of-life care.
Although many patients with cancer would prefer to die at home, most die in hospital. We carried out a study to describe the yearly trends in the place of death between 1992 and 1997 and to determine predictors of out-of-hospital death for adults with cancer in Nova Scotia.
In this population-based study, we linked administrative health data from 2 databases - the Nova Scotia Cancer Centre Oncology Patient Information System and the Queen Elizabeth II Health Sciences Centre Palliative Care Program - for all adults in Nova Scotia who died of cancer from 1992 to 1997. We also used grouped neighbourhood income information from the 1996 Canadian census. Death out of hospital was defined as death in any location other than an acute care hospital facility. We used logistic regression analysis to identify the odds of dying out of hospital over time and to identify factors predictive of out-of-hospital death.
A total of 14 037 adults died of cancer during the study period. The data for 101 people were excluded because of missing information regarding place of death. Of the remaining 13 936 people, 10 266 (73.7%) died in hospital and 3670 (26.3%) died out of hospital. Over the study period the proportion of people who died out of hospital rose by 52%, from 19.8% (433/2182) in 1992 to 30.2% (713/2359) in 1997. Predictors associated with out-of-hospital death included year of death (for 1997 v. 1992, adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.5-2.0), female sex (adjusted OR 1.2, 95% CI 1.1-1.3), age (for > or = 85 v. 18-44 years, adjusted OR 2.2, 95% CI 1.7-2.8), length of survival (for 61-120 v.