Receipt Of Palliative Care Research Articles

Differential outcome of females with uterine versus extra-uterine leiomyosarcomas, a retrospective analysis.

e23557 Background: Leiomyosarcomas, are aggressive sarcomas with survival rates among the lowest of all soft tissue sarcomas. Patients with uterine leiomyosarcoma (ULMS) have worse overall survival (OS) than those with extra-uterine leiomyosarcoma (EULMS). The effect of several clinical factors on OS have been investigated, including age, tumor size, grade, stage, and use of chemotherapy. Looking at the epigenetics of the 2 diseases, differentially methylated regions (DMRs) were statistically significant between the 2 groups. Methods: The 2004-2016 National Cancer Database was queried for females with ULMS and EULMS. We investigated several factors as predictors of binary survival status (alive or dead): patient’s age, race, year at diagnosis, tumor grade, size and stage, receipt of surgical treatment, chemotherapy, palliative care, surgical margins and time to treatment in days. Univariate and backward stepwise multivariate logistic regression models were used to determine prognostic factors associated with survival in each group. Kaplan-Meier (KM) method with log-rank test was used to compare OS rates between the 2 groups. All analyses were conducted using Stata/SE 15.1. Results: The total number of subjects was 16883. The median OS was 36.7 months in ULMS vs 57.2 in EULMS (P < 0.001). Older age was associated with a lower likelihood of survival in both groups (OR = 0.95, P = 0.018 in ULMS; OR = 0.97, P < 0.001 in EULMS). Lymphovascular invasion and receipt of palliative care were associated with a relatively large decrease in survival in ULMS only (OR = 0.25, P < 0.001; OR = 0.13, P = 0.015 respectively). In the EULMS group, increased likelihood of survival was associated with later years of diagnosis (OR = 1.27; P < 0.001). Larger tumor size (OR = 0.39; P = 0.001), stages II-IV or unstageable disease (OR = 0.56; P < 0.001), positive surgical margins or margins that were unevaluable (OR = 0.87; P = 0.009) and receipt of systemic therapy (OR = 0.85; P = 0.016) were associated with a lower likelihood of survival. Conclusions: Our study reiterated that females with ULMS had worse OS than those with EULMS. this difference can be attributed to certain clinical risk factors, however, it may also be secondary to genetic and epigenetic factors. Surprisingly, the use of palliative care in this study was associated with poorer OS in the EULMS group. Further studies are needed to investigate the genetic map of these diseases and highlight certain potentially targetable prognostic and predictive factors. Study limitations: Our study did not stratify ULMS and EULMS according to the stage to examine if the aforementioned factors would still be relevant in the limited versus metastatic setting.

Disparities in palliative care utilization in cholangiocarcinoma patients: A National Cancer Database (NCDB) study.

e24077 Background: Cholangiocarcinoma is an adenocarcinoma of the intra- and extrahepatic bile duct epithelial cells. Although cases of cholangiocarcinoma in the US are rare, there is a low 5-year survival rate for these patients. The preferred treatment option for all subtypes is surgical resection. Alternative options include palliative care (PC) treatments such as chemotherapy, radiotherapy and locoregional treatments. There are many obstacles in accurately diagnosing cholangiocarcinoma, including obtaining adequate tumor samples for histology and determining what is malignant vs. benign in patients with primary sclerosing cholangitis (an important risk factor of cholangiocarcinoma). Such delays in diagnosis can lead to delays in treatment, which in turn results in a poor prognosis and worse outcome for patients. To the authors’ knowledge, there is no current study assessing PC disparities in patients with cholangiocarcinoma. Methods: A total of 46,751 patients who had a diagnosis with cholangiocarcinoma were identified utilizing the National Cancer Database (NCDB) ICD-O-3 histology code 8160. The 5-year survival of PC use was analyzed via a Kaplan-Meier curve. Demographic factors (race, biological sex, income, facility type, insurance, geographic location, and Charlson-Deyo co-morbidity score) were studied in relation to the receipt of PC. Results: Approximately 15.16% of our cohort received PC (7,089/46,751). There was a statistically significant difference in the staging of those patients that received palliative care, with 52% of our cohort being stage IV (p < 0.001). The sex of patients who received PC was equally distributed between men and women (51.0% to 49.0%). The majority of PC recipients were white (83.6%) individuals making under $63,000 (69.6%) with a reported Charlson-Deyo score of 0 (64.9%). Many patients who received PC had Medicare (57.6%) and were treated at either an academic/research program (45.4%) or at a comprehensive community cancer program (33.6%). Facility locations were predominantly located in the Mid-South Atlantic and East North Central regions, compared to the Pacific regions (56.3% vs 8.4%), and patients who received PC lived mainly in urban areas (98.2%). The median survival for PC patients was shorter compared to patients that did not receive PC (5.32 months vs 9.23 months). Conclusions: This is one of the most comprehensive studies that identifies the demographic disparities of patients who received PC for cholangiocarcinoma. The typical PC patient is a white individual with Medicare, living in an urban area in the Mid-South Atlantic and East North Central region making under $63,000. By highlighting the disparities that exist, our study can aid clinicians in addressing PC under-utilization in specific demographics to help provide more comprehensive care.

Designing Palliative Care Facilities to Better Support Patient and Family Care: A Staff Perspective.

To contribute staff perspectives on the design of palliative care facilities to better align with the philosophy of palliative care, in support of patient, family, and staff well-being. The receipt of palliative care differs from other inpatient experiences owing to its distinct philosophy of care, longer lengths of stay, a greater presence of family members, and more frequent end-of-life events. While research regarding the optimal design of palliative care environments recognizes these differences, this knowledge has been slow to exert change on the guidelines and procurement processes that determine the design solutions possible within these settings. Sustained research attention is required. An online survey, comprising a series of open-ended questions, elicited the perceptions of palliative care staff regarding the relationship between the physical environment and the distinct philosophy of palliative care. Responses from 89 Australian-based palliative care professionals confirmed the high value that staff place on environments that offer privacy, homeliness, safety, and access to gardens to assist the delivery of optimum care. Our findings illustrate that the implications of privacy and homeliness extend far beyond the patient room and that homeliness is about more than an aesthetic of comfort. This highlights a broader capacity for design to better support the philosophy of palliative care. Importantly, the data reveal a key relationship between staff well-being and the environments in which they work; environments that are unable to match the quality of care that staff aspire to deliver can engender frustration and distress.

Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study.

Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.

Prevalence and Predictors of Palliative Care Utilization among Hospitalized Patients with Diffuse Large B-Cell Lymphoma.

Objective: Research has shown that palliative care improves the quality of life of cancer patients; however, there is no literature on specific factors that predict its use in diffuse large b-cell lymphoma (DLBCL) patients. Therefore, the prevalence of palliative care utilization and predictors of palliative care utilization among patients with DLBCL were examined. Methods: Data from the National Inpatient Sample (NIS) collected between 2016 to 2018 were used for all analyses. Multivariable logistic regression models were used to examine the predictors of palliative care utilization among hospitalized patients with DLBCL. Descriptive analyses were used to explore the overall prevalence of palliative care receipt in this population. Results: Of the 41,789 hospitalizations, 7.1% of patients used palliative care during hospitalization, while 4.8% utilized palliative care and were discharged alive. DLBCL patients aged 70 and older had 1.3 times (95% CI: 1.14-1.41) higher odds of utilizing palliative care compared to those less than 70 years. Relative to Medicare/Medicaid patients, those with other types of insurance were 1.7 times (95% CI: 1.34-2.05) more likely to receive palliative care. Those who were either transferred to a facility/discharged with home health (AOR: 6.23; 95% CI: 5.21-7.44) or died during hospitalization (AOR: 45.17; 95% CI: 36.98-55.17) had higher odds of receiving palliative care when relative to those with a routine hospital discharge. Other associated factors were type of admission, length of stay, chemotherapy receipt, and number of comorbidities. Conclusions: The prevalence of palliative care utilization was low and factors predicting utilization in our population were identified. Our findings highlight the need to increase awareness among medical oncologists on the need to involve the palliative care team early in the management of hospitalized patients with DLBCL.

Co-Design of an Evidenced Informed Service Model of Integrated Palliative Care for Persons Living with Severe Mental Illness: A Qualitative Exploratory Study.

Background: Globally, close to one billion people are living with a mental health disorder, and it is one of the most neglected areas in Public Health. People with severe mental illness have greater mortality risk than the general population, experience health care inequalities throughout life and represent a vulnerable, under-served and under-treated population, who have been overlooked in health inequality research to date. There is currently a dearth of evidence in relation to understanding the palliative care needs of people with severe mental illness and how future care delivery can be designed to both recognise and respond to those needs. This study aims to co-design an evidenced informed service model of integrated palliative care for persons living with a severe mental illness. Methods: This qualitative sequential study underpinned by interpretivism will have six phases. An expert reference group will be established in Phase 1, to inform all stages of this study. Phase 2 will include a systematic literature review to synthesise current evidence in relation to palliative care service provision for people with severe mental illness. In Phase 3, qualitative interviews will be undertaken with both, patients who have a severe mental illness and in receipt of palliative care (n = 13), and bereaved caregivers of people who have died 6–18 months previously with a diagnosis of severe mental illness (n = 13), across two recruitment sties in the United Kingdom. Focus groups (n = 4) with both mental health and palliative care multidisciplinary staff will be undertaken across the two recruitment sites in Phase 4. Phase 5 will involve the co-design of a service model of integrated palliative care for persons living with severe mental illness. Phase 6 will develop practice recommendations for this client cohort. Discussion: Palliative care needs to be available at all levels of care systems; it is estimated that, globally, only 14% of patients who need palliative care receive it. Reducing inequalities experienced by people with severe mental illness is embedded in the National Health Service Long Term Plan. Internationally, the gap between those with a mental illness needing care and those with access to care remains considerable. Future policy and practice will benefit from a better understanding of the needs of this client cohort and the development of a co-designed integrated care pathway to facilitate timely access to palliative care for people with a severe mental illness.

Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study

SummaryBackgroundInclusive universal health coverage requires access to quality health care without financial barriers. Receipt of palliative care after advanced cancer diagnosis might reduce household poverty, but evidence from low-income and middle-income settings is sparse.MethodsIn this prospective study, the primary objective was to investigate total household costs of cancer-related health care after a diagnosis of advanced cancer, with and without the receipt of palliative care. Households comprising patients and their unpaid family caregiver were recruited into a cohort study at Queen Elizabeth Central Hospital in Malawi, between Jan 16 and July 31, 2019. Costs of cancer-related health-care use (including palliative care) and health-related quality-of-life were recorded over 6 months. Regression analysis explored associations between receipt of palliative care and total household costs on health care as a proportion of household income. Catastrophic costs, defined as 20% or more of total household income, sale of assets and loans taken out (dissaving), and their association with palliative care were computed.FindingsWe recruited 150 households. At 6 months, data from 89 (59%) of 150 households were available, comprising 89 patients (median age 50 years, 79% female) and 64 caregivers (median age 40 years, 73% female). Patients in 55 (37%) of the 150 households died and six (4%) were lost to follow-up. 19 (21%) of 89 households received palliative care. Catastrophic costs were experienced by nine (47%) of 19 households who received palliative care versus 48 (69%) of 70 households who did not (relative risk 0·69, 95% CI 0·42 to 1·14, p=0·109). Palliative care was associated with substantially reduced dissaving (median US$11, IQR 0 to 30 vs $34, 14 to 75; p=0·005). The mean difference in total household costs on cancer-related health care with receipt of palliative care was −36% (95% CI −94 to 594; p=0·707).InterpretationVulnerable households in low-income countries are subject to catastrophic health-related costs following a diagnosis of advanced cancer. Palliative care might result in reduced dissaving in these households. Further consideration of the economic benefits of palliative care is justified.FundingWellcome Trust; National Institute for Health Research; and EMMS International.

Factors associated with palliative care utilization in advanced and metastatic renal cell carcinoma.

146 Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with Stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC among the overall cohort and treatment-based cohorts. Results: Among 20,122 and 42,014 patients with Stage III and IV RCC, 329 and 9,317 patients received PC, respectively. From 2004 to 2014, PC utilization was stable at ̃1% for Stage III RCC and minimally increased from 17% to 20% for Stage IV RCC. Multivariable analysis demonstrated that increased comorbidities, insurance status, higher education status, facility location, care at a comprehensive cancer program or integrated network, sarcomatoid histology, and prior treatments significantly increased likelihood of palliative care utilization. We uncover socioeconomic and clinical factors that are associated with receipt of palliative care use in a treatment-specific manner. Conclusions: While PC utilization has minimally increased for Stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC use, especially in a treatment-specific manner, among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma.

Patients with metastatic hepatocellular carcinoma (HCC) suffer symptoms of both end-stage liver disease and cancer. Palliative care (PC) enhances the quality of life via symptom control and even improves survival for some cancers. Our study characterized rates of PC utilization among metastatic HCC patients and determined factors associated with PC receipt. We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2016. Chi-square tests were used to analyze two cohorts: those who received PC and those who did not. Logistic regression was performed to assess the impact of clinicodemographic factors on the likelihood of receiving PC. PC utilization was low at just 17%. Later yearof diagnosis, insured status, and higher education level were associated with an increased likelihood of receiving PC. Treatment at academic centers or integrated network cancer programs increased the likelihood of receiving PC compared to treatment at a community center (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03-1.33 and OR = 1.25, 95% CI = 1.07-1.45; respectively). Hispanics were significantly less likely to received PC than non-Hispanic Whites (OR = 0.73, 95% CI = 0.64-0.82). PC utilization among patients with metastatic HCC remains low. Targeted efforts should be enacted to increase the delivery of PC in this group.

PD38-09 FACTORS ASSOCIATED WITH PALLIATIVE CARE UTILIZATION IN ADVANCED AND METASTATIC RENAL CELL CARCINOMA

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety III (PD38)1 Sep 2021PD38-09 FACTORS ASSOCIATED WITH PALLIATIVE CARE UTILIZATION IN ADVANCED AND METASTATIC RENAL CELL CARCINOMA Hiren Patel, Sinae Kim, Arnav Srivastava, Brian Shinder, Joshua Sterling, Biren Saraiya, Tina Mayer, Isaac Kim, Saum Ghodoussipour, Thomas Jang, and Eric Singer Hiren PatelHiren Patel More articles by this author , Sinae KimSinae Kim More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , Brian ShinderBrian Shinder More articles by this author , Joshua SterlingJoshua Sterling More articles by this author , Biren SaraiyaBiren Saraiya More articles by this author , Tina MayerTina Mayer More articles by this author , Isaac KimIsaac Kim More articles by this author , Saum GhodoussipourSaum Ghodoussipour More articles by this author , Thomas JangThomas Jang More articles by this author , and Eric SingerEric Singer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002048.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. METHODS: Using the National Cancer Database (NCDB), we abstracted patients with Stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC among the overall cohort and treatment-based cohorts. RESULTS: Among 20,122 and 42,014 patients with Stage III and IV RCC, 329 and 9,317 patients received PC, respectively. From 2004 to 2014, PC utilization was stable at ∼1% for Stage III RCC and minimally increased from 17% to 20% for Stage IV RCC. Multivariable analysis demonstrated that increased comorbidities, insurance status, higher education status, facility location, care at a comprehensive cancer program or integrated network, sarcomatoid histology, and prior treatments significantly increased likelihood of palliative care utilization. We uncover socioeconomic and clinical factors that are associated with receipt of palliative care use in a treatment-specific manner. CONCLUSIONS: While PC utilization has minimally increased for Stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC use, especially in a treatment-specific manner, among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC. Source of Funding: This work is supported by a grant from the National Cancer Institute (P30CA072720) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e665-e666 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiren Patel More articles by this author Sinae Kim More articles by this author Arnav Srivastava More articles by this author Brian Shinder More articles by this author Joshua Sterling More articles by this author Biren Saraiya More articles by this author Tina Mayer More articles by this author Isaac Kim More articles by this author Saum Ghodoussipour More articles by this author Thomas Jang More articles by this author Eric Singer More articles by this author Expand All Advertisement Loading ...

Association of Palliative Care with Days at Home and Healthcare Use in Patients with Advanced Chronic Obstructive Pulmonary Disease: A Cohort Study.

Rationale: Palliative care focuses on improving quality of life for patients with life-limiting conditions. Although previous studies have shown palliative care to be associated with reduced acute healthcare use in people with cancer and other illnesses, these findings may not generalize to patients with chronic obstructive pulmonary disease (COPD). Objectives: We examined the association between palliative care and rates of days at home, locations of death, and acute healthcare use in patients with COPD. Methods: We used health administrative databases in Ontario, Canada, to identify patients with advanced COPD hospitalized between April 2010 and March 2017 and followed up until March 2018. Patients who received palliative care were matched 1:1 with those who did not receive palliative care in terms of age, sex, long-term oxygen, previous COPD hospitalizations and propensity scores. Rate ratios (RR) were estimated by using Poisson models with generalized estimating equations to account for matching. Results: Among 35,492 patients, 1,788 (5%) received palliative care. In the matched cohort (1,721 pairs), people with COPD receiving palliative care had similar rates of days at home (RR, 1.01; 95% confidence interval [CI], 0.97-1.05) but were more likely to die at home (16.4% vs. 10.0%; P < 0.001) compared with those who did not receive palliative care. Rates of healthcare use were similar except for increased hospitalizations in the palliative care group (RR, 1.09; 95% CI, 1.01-1.18). Conclusions: Receipt of palliative care did not reduce days at home or healthcare use but was associated with a modest increase in the proportion who died at home. Future work should evaluate palliative care strategies designed specifically for patients with COPD.

Palliative care use among bladder cancer patients treated with radical cystectomy

Practice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution. A retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model. Over the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025). Rates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.

Health care disparities and barriers to palliative care among metastatic renal cell carcinoma patients: An NCDB analysis.

4545 Background: Palliative care improves quality of life for both patients and caregivers but may be underutilized due to socioeconomic barriers to access. An NCDB analysis was performed to analyze the effect of socioeconomics on palliative care receipt among patients with metastatic renal cell carcinoma. Methods: A retrospective hospital-based analysis was performed using the National Cancer Database to identify variables that significantly affect receipt of palliative care among patients diagnosed with metastatic renal cell carcinoma diagnosed between 2004 and 2016. Sub-cohort analysis was also performed among patients with the most severe disease. Multivariate binominal logistic regression was performed to determine the association of underlying socioeconomics with receipt of palliative care. The odds of receiving palliative care based on socioeconomic factors was reported as odds ratios (OR) with 95% CI. Results: There were 50405 patients meeting inclusion criteria with 40448 (80.2%) undergoing no palliation and 9957 (19.8%) undergoing palliative care. Both Black and Spanish/Hispanic patients had decreased odds of receiving palliative care (OR, 0.816, 95% CI, 0.753 to 0.885 and OR, 0.599, 95% CI, 0.540 to 0.665, respectively). Increasing age, papillary histology, increasing income, and increasing distance were also significantly associated with decreased odds of receiving palliation while treatment at an integrated network cancer program or comprehensive community cancer program and higher educational attainment were associated with increased odds of receiving palliative care. Similar findings were demonstrated among patients with the most severe disease. Limitations include the retrospective design and potential underlying selection biases of this study. Conclusions: Significant associations between receipt of palliative care and socioeconomic factors exist among patients with metastatic renal cell carcinoma. In this study among patients with metastatic renal cancer, we found associations between socioeconomics and palliative care access including age, race, Spanish/Hispanic origin, income, education, and other factors.

Impact of Medicaid expansion on pancreatic cancer care: A difference-in-difference analysis.

e18567 Background: The Affordable Care Act (ACA) increased insurance coverage for low-income individuals, which should potentially lead to better access to care and improved oncological outcomes. This study seeks to evaluate the impact of Medicaid expansion (ME) on care for pancreatic ductal adenocarcinoma (PDAC). Methods: Patients who were uninsured or on Medicaid and diagnosed with PDAC between 2004 and 2017 were queried from the National Cancer Database (NCDB). Two different expansion cohorts were included: early expansion states and 2014 expansion states. For early expansion states, the time period of pre-expansion was 2004-2009 and post-expansion was 2010-2017. As for the 2014 expansion states, the pre-expansion period was from 2004-2013 and post-expansion period was from 2014-2017. Patients in non-expansion states formed the control group. A difference-in-difference (DID) analysis was used to assess the association of ME with stage of diagnosis, treatment and survival for each expansion cohort. Results: In both early and January 2014 expansion states, there was an increase in overall Medicaid coverage (Early: DID = 0.29, 2014: DID = 0.37; P &lt; 0.001), in particular for non-Hispanic Black and Hispanic Black patients (Non-Hispanic Black: Early: DID = 0.11, 2014: DID = 0.11; P &lt; 0.001, Hispanic-Black: 2014: DID = 0.20; P = 0.003). There were no differences in early stage diagnosis (Early: DID = 0.02, 2014: DID = -0.02; P &gt; 0.05). There was an increase in the number of patients receiving surgery (Early: DID = 0.05; P = 0.001, 2014: DID = 0.03; P = 0.029) but no difference in time to surgery among patients receiving surgery upfront (Early: DID = 1.75, 2014: DID = 0.38; P &gt; 0.05). There was no difference in 30-day readmission post-surgery (Early: DID = 0.003; 2014: DID = -0.00007; P &gt; 0.05) or 90-day mortality (Early: DID = -0.007, 2014: DID = -0.035; P &gt; 0.05). Moreover, there was no difference in receipt of chemotherapy (Early: DID = 0.01, 2014: DID = 0.005; P &gt; 0.05) or time to chemotherapy for patients receiving neoadjuvant chemotherapy (Early: Early: DID = 9.62, 2014: DID = 0.01; P &gt; 0.05). Finally, there was no difference in receipt of palliative care among stage IV patients in both cohorts (Early: DID = -0.004, 2014: DID = 0.004; P &gt; 0.05). Conclusions: This study suggests that after ME, PDAC patients were more likely to be insured and had increased access to surgical care. Future, studies should evaluate the implications of improved surgical access on clinical outcomes such as mortality.

Receipt of palliative care (PC) in acute myeloid leukemia (AML) using data from the National Cancer Database (NCDB).

12087 Background: AML is an aggressive disease with high mortality and significant impact on quality of life. Palliative care (PC) services have become integral in managing patient’s symptoms during treatment as well as at the end of life. We hypothesize that socioeconomic factors such as achieving higher levels of education, and higher incomes, increases the odds of receiving PC. Methods: This is a retrospective analysis using NCDB data of 124,988 newly diagnosed non-M3 AML patients over 18 yrs from 2004-2016. Unadjusted and multivariate adjusted logistic regression analysis (MVA) evaluated the impact of socioeconomic variables on the receipt of PC. In the MVA, we adjusted for demographic variables and facility characteristics including facility type, facility volume, age, sex, race, Hispanic origin, income, education, urban/rural residence, Charlson-Deyo score, great circle distance, Medicaid expansion status state group, and insurance status. Patients with Medicaid expansion &lt; 39yrs were excluded due to low patient numbers. Results: For the 124,988 patients, median age was 63 years (range 18-90) with 54% males and 86% White. 25% of patients lived in regions with the highest education level defined as &lt; 6.3% of adults over 25 without a high school diploma. 35% of patients had a household income bracket of ≥ $63,333. A total of 3% of patients received PC. MVA showed that patients within the highest income bracket of ≥ $63,333 were less likely to have used PC services (OR 0.82, p &lt; 0.01). More educated patients residing in regions with &lt; 6.3% of adults without a high school diploma had higher odds of receiving PC treatment compared with patients with less education (OR 1.23, p &lt; 0.01). Residence in states with Medicaid expansion in January 2014 or later was associated with greater utilization of PC services (Jan 2014 expansion states: OR 1.33 and late expansion states/after Jan 2014: OR 1.43, p &lt; 0.01) compared to residence in non-expansion states. No difference was seen across races; except Hispanics with decreased use of PC services(OR 0.8, p = 0.022). Conclusions: In this large cohort, a small percentage of patients received PC. Higher education was associated with higher likelihood of using PC, while, surprisingly, higher income was associated with a lower likelihood of PC. Additionally, the higher use of PC services with Medicaid expansion suggests a broad impact of public health insurance in providing increased access to PC services.

The association between varying levels of palliative care involvement on costs during terminal hospitalizations in Canada from 2012 to 2015

BackgroundInpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs.MethodsRetrospective cohort study using data from the Discharge Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital.ResultsThere were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement).ConclusionsIncreased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

Background: Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. Aim: The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. Settings and participants: We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person’s hospitalization in which they died. Results: Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. Conclusions: Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Evaluating palliative opportunities in pediatric patients with leukemia and lymphoma.

BackgroundDespite favorable prognoses, pediatric patients with hematologic malignancies experience significant challenges that may lead to diminished quality of life or family stress. They are less likely to receive subspecialty palliative care (PC) consultation and often undergo intensive end‐of‐life (EOL) care. We examined “palliative opportunities,” or events when the integration of PC would have the greatest impact, present during a patient's hematologic malignancy course and relevant associations.MethodsA single‐center retrospective review was conducted on patients aged 0–18 years with a hematologic malignancy who died between 1/1/12 and 11/30/17. Demographic, disease, and treatment data were collected. A priori, nine palliative opportunity categories were defined. Descriptive statistics were performed. Palliative opportunities were evaluated over temporal quartiles from diagnosis to death. Timing and rationale of pediatric PC consultation were evaluated.ResultsPatients (n = 92) had a median of 5.0 (interquartile range [IQR] 6.0) palliative opportunities, incurring 522 total opportunities, increasing toward the EOL. Number and type of opportunities did not differ by demographics. PC consultation was most common in patients with lymphoid leukemia (50.9%, 28/55) and myeloid leukemia (48.5%, 16/33) versus lymphoma (0%, 0/4, p = 0.14). Forty‐four of ninety‐two patients (47.8%) received PC consultation a median of 1.8 months (IQR 4.1) prior to death. Receipt of PC was associated with transplant status (p = 0.0018) and a higher number of prior palliative opportunities (p = 0.0005); 70.3% (367/522) of palliative opportunities occurred without PC.ConclusionPatients with hematologic malignancies experience many opportunities warranting PC support. Identifying opportunities for ideal timing of PC involvement may benefit patients with hematologic cancers and their caregivers.

The Association Between Varying Levels of Palliative Care Involvement on Costs During Terminal Hospitalizations in Canada from 2012–2015 (F405C)

1.Assess the association between inpatient palliative care and costs during a terminal hospitalization.2.Determine the relationship between inpatient palliative care and costs, stratified by disease trajectory, and Canadian province.3.Discuss the value of using varied levels of palliative care to assess relationship with costs rather than dichotomous predictors of receiving palliative care vs. not. Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs. Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. Canadian adults (age ≥18 years) who died in hospital between April 1, 2012, and March 31, 2015 (N=250,640). Level of palliative care involvement defined as: medium-high, low, or no palliative care. Acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n (%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital. There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1,359 (95% CI 1,323: 1,397) (no involvement), $1,175 (95% CI 1,146: 1,206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement). We observed an inverse dose-response relationship between palliative care involvement and costs.

Frequency and Timing of Palliative Opportunities in Pediatric Patients with Leukemia and Lymphoma (SCI931)

1.Define and recognize palliative opportunities throughout the disease course of pediatric patients with leukemia or lymphoma.2.Describe timing and associated factors of palliative opportunities among pediatric patients with leukemia or lymphoma. Pediatric patients with hematologic malignancies are less likely to receive palliative care (PC), die at home, and often undergo intensive end-of-life care. Despite their favorable prognoses, patients experience significant challenges throughout their disease course that may lead to diminished quality of life or family stress. These challenges can be viewed as “palliative opportunities,” or events when integration of subspecialty PC would have the greatest impact. Examine the palliative opportunities present during a patient’s course with a hematologic malignancy and relevant associations. A priori, nine palliative opportunity categories were defined (disease progression or relapse, admission for symptoms, social concerns or end of life, intensive care or bone marrow transplant (BMT) admission, phase 1 trial or hospice enrollment, do-not-resuscitate status). A single-center retrospective review was conducted on patients aged 0-18 years with leukemia or lymphoma who died from 1/1/12-11/30/17. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated over quartiles from diagnosis to death. Patients with leukemia/lymphoma (n=96) had a median of 4.5 (IQR=6.0) palliative opportunities, incurring 535 total opportunities. The majority occurred in the last quartile of the disease course or without PC support (64.9%). Except for religion (p=0.0002), number and type of opportunities did not differ by demographics. PC consultation was most common in patients with lymphoid malignancies (29.2%) vs myeloid leukemia (18.8%) or lymphoma (0%, p=0.09). 46 patients (47.9%) received PC consultation a median of 1.9 months (IQR=10.5) prior to death; receipt of PC was associated with BMT status and a higher number of palliative opportunities (p=0.003 and p=0.003, respectively). Patients with leukemia/lymphoma experience many events warranting PC support, which increase toward the end of life. Defining palliative opportunities helps identify ideal timing and candidates for PC involvements.