Factors associated with the aggressiveness of end-of-life care for patients dying of cancer in hospitals: A nationwide cohort study.

Abstract

68 Background: There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL). Recognizing the most affected patients is a cornerstone to improve this public health unmet need. Our aim is to identify factors associated with ACCEoL for cancer patients dying in hospitals. Methods: Cohort study of adults with ICD9CM diagnosis of cancer, who died in public hospitals in mainland Portugal (Jan'10 - Dec'15), identified from the hospital morbidity database (HMD). HMD provided individual clinical and demographic data. The primary outcome is a composite ACCEoL measure of 16 indicators, expanding an earlier framework, validated by an expert panel. We obtained hospital and area-level variables from a hospital survey and National Statistics. We used multilevel random effects logistic regression modelling (p < 0.05). Results: We included 92,155 patients: median age 73 yo; 61.9% male; 53.0% metastatic. ACCEoL prevalence was 71.1%. The most prevalent indicators were > 14 days in hospital (42.7%) and surgery in last 30 days (27.8%). Older age (p < 0.001), breast cancer (OR 0.83; 95%CI 0.76-0.91) and metastatic disease (0.54; 0.50-0.58) were associated with less ACCEoL. In contrast, higher Deyo-Charlson comorbidity index (p < 0.001), gastrointestinal (GI) and hematological malignancies (p < 0.001), and death at a cancer center (1.31; 1.01-1.72) or hospital with medical oncology (MO) dept. (1.29; 1.02-1.63) were associated with higher ACCEoL. There was no association between existence of hospital palliative care services (HPCS) at the hospital of death and ACCEoL. Conclusions: Our study confirmed that clinical factors related with better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and GI malignancies might represent groups with complex needs, and hematological patients may be at increased risk because of unpredictable prognosis. It is important to better understand how to reduce ACCEoL in cancer centers and hospitals with MO dept.; improvement of HPCS could be an answer as these services are usually under-resourced, thus reaching few.