Which cancer patients are admitted to specialised palliative care

​Ph.d. Thesis

Summary

Background

Specialised palliative care (SPC) have been found to be valuable for patients and bereaved caregivers and furthermore, economical analyses have indicated lower costs for patients admitted to SPC. In Denmark the knowledge about admittance to SPC is sparse and in the international literature, conflicting results have been found in studies of various size and quality, especially in relation to sex, cohabitation status and socioeconomic position (education, income). With the development of Danish Palliative Care Database (DPD), it was possible to investigate: which cancer patients are admitted to SPC in Denmark.

Aims

In Denmark, SPC institutions include hospital-based palliative care teams/units and hospices. In this thesis admittance to SPC was measured as overall admittance, including both hospital-based palliative care teams/units and hospices, and institution type specific admittance including each institution type separately.

Among patients who died from cancer in Denmark in 2010-12, the following research questions were investigated.

  • Are overall and institution type specific admittance to SPC associated with sex, age or diagnosis? (Paper 1)
  • Are overall and institution type specific admittance to SPC associated with cohabitation status? (Paper 2)
  • Are overall and institution type specific admittance to SPC associated with education or income? (Paper 3)
  • Is overall admittance to SPC - among those referred to SPC – associated with sex, age, geographic region, diagnosis or referral unit? (Paper 4)

Methods and materials

In Denmark it is possible to link data from several different nation-wide registers by the unique personal identification number. The following six registers were the data sources for this thesis: DPD, Danish Register of Causes of Death, Danish Cancer Registry, Danish Civil Registration System, The Population's Education Register and The Income Statistics Register. Very high completeness and validity were found in the registers, only the Population's Education Register had a lower completeness (missing data for 6%). 

Logistic regression analyses were used to investigate the associations between overall admittance to SPC and the different exposures unadjusted and adjusted. Further, institution type specific admittance to hospital-based palliative care team/unit and hospice, respectively, was investigated. In paper 2 standardised absolute prevalences of admittance to SPC were also applied, standardised in relation to sex, age, diagnosis and geographic region.

Results

In paper 1, 44,548 patients were included and 37.4% of the patients were admitted to SPC (overall), 26.8% were admitted to hospital-based palliative care team/unit, 17.3% to hospice and 6.8% of the patients were admitted to both types of institutions. Overall admittance to SPC was higher for women (OR=1.23; 95%CI: 1.17-1.28), younger patients (OR=6.44 for patients <40 vs 80+ years old) and for patients with sarcoma, pancreas and stomach cancer, whereas lower admittance was found for patients with haematological cancer diagnoses (Hodgkin's disease OR: 0.33 (95%CI: 0.17-0.63), leukaemia 0.34 (0.29-0.40)). Differences in admittance to type of institutions were especially found for patients with cancer in the brain and prostate and the sex difference was most pronounced in relation to hospice (for women OR=1.45; 95%CI: 1.37-1.54).

In paper 2, 44,480 patients were included. In the study population 50% was cohabiting. Patients living alone had lower overall admittance to SPC (e.g., cohabiting 41% vs. never married 30%). The institution type specific admittance showed higher admittance to hospice for patients living alone (e.g., divorced OR=1.41 95%CI: 1.31-1.52) and lower admittance to hospital-based palliative care team/unit (e.g., divorced OR=0.81 95%CI: 0.75-0.87). Sex, region and diagnosis affected the association between cohabitation status and admittance to hospital-based palliative care team/unit and hospice, respectively.

In paper 3, 41,741 patients were included. Education and income were associated with overall and institution type specific admittance, with lower admittance for the most disadvantaged. Compared with patients with primary school only the odds ratio of overall admittance for patients with an academic education was 1.69 (95% CI: 1.51-1.89). Comparing lowest with highest income quartile the association was stronger for hospice OR=1.67 (95% CI: 1.54-1.81). In the analysis taking both variables into account, admittance to SPC was found to increase for each education level with increasing income, although among academics highest admittance was found for the academics in the lowest and highest income quartile (OR=1.97 (95%CI:1.27-3.06); OR=1.96 (95%KI:1.71-2.25)).

In paper 4, 21,597 referred patients were included. Higher admittance to SPC was found among younger patients (OR=5.35; 95%CI 3.24-8.83) and, patients living in two of the geographic regions (Region Zealand OR=1.81; 95%CI: 1.62-2.03, North Denmark Region OR=2.26; 95%CI: 1.99-2.57). The lowest admittance was found among patients with haematological diseases (e.g. leukaemia OR=0.55; 95%CI: 0.42-0.73). Lower admittance found for men and patients referred from hospital departments was explained by later referral (e.g., the mean number of days from referral to death was 67 for women and 62 for men).

Conclusion and perspectives

Nation-wide data of high quality from DPD and several Danish registers made it possible to investigate admittance to SPC in relation to overall and institution type specific (hospital-based palliative care team/unit and hospice) admittance to SPC. In the study it was possible for the first time to investigate admittance to SPC among patients referred to SPC who were judged to have a need of SPC by both the referring physician and the SPC institution. Admittance to SPC was found to vary with several patients characteristics. This study indicates inequity with respect to social factors (disfavouring patients living alone, with short education and low income), and efforts to address this should be carried out.

A practical implication of this thesis would be to increase the capacity of SPC in Denmark in order to ensure a more even geographical distribution: with the limited capacity of SPC in Denmark today it will be difficult to prevent that admittance to SPC is associated with SEP factors. Furthermore, it is important that health care professionals are aware of SPC needs among the most disadvantaged patients, to ensure that all patients with a need of SPC have the possibility to be referred and admitted to SPC.

Read the thesis here, M. adsersen, Which cancer patietns are admitted to specialised pallaitive care? Afhandling_Mathilde_Adsersen.pdf

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