Taiwanese Cancer Decedents Research Articles

Effect of hospice care on health-care costs for Taiwanese patients with cancer during their last month of life in 2004-2011: A trend analysis.

Objective:End-of-life cancer care imposes a heavy financial burden on patients, their families, and their health insurers. The aim of this study was to explore the 8-year (2004–2011) trends in health-care costs for Taiwanese cancer decedents in their last month of life and, specifically, to assess the association of these trends with hospice care.Materials and Methods:We conducted a population-based longitudinal study and analyzed data from Taiwan's National Health Insurance Research Database. The data consisted of not only claims information – costs of hospitalization and outpatient department visits – but also the associated patient characteristics, catastrophic illness status, hospice patient designation, and insurance system exit date (the proxy for death).Results:A total of 11,104 cancer decedents were enrolled, and 2144 (19.3%) of these patients received hospice care. The rate of hospice service use increased from 14.9% to 21.5% over 8 years. From 2004 to 2011, the mean health-care cost per day in the last month of life increased 8.2% (from US$93 ± $108 in 2004 to US$101 ± $110 in 2011; P = 0001). We compared three groups of patients who received hospice care for more than 1 month (long-H group), received hospice care for 30 days or less (short-H group), and did not receive hospice care (non-H group). Compared to non-H group, long-H group had a significantly lower mean health-care cost per day during their last month of life (US$85.7 ± 57.3 vs. US$102.4 ± 120) (P < 0001). Furthermore, compared to short-H and non-H groups, patients in the long-H group had lower probabilities of receiving chemotherapy and visiting the emergency department more than once. They also incurred lower health-care costs (US$77.1 ± 58.1 vs. US$92.2 ± 56.0 for short-H group and US$102.4 ± 120 for non-H group) (P < 0001).Conclusion:Health-care costs in the last month of life are increasing over time in Taiwan. Nonetheless, health-care costs for patients receiving hospice can be as much as 16.3% lower than patients not receiving hospice care. Patients receiving hospice care for more than 30 days also had lower health-care costs than those receiving care for <30 days.

Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study

ContextEvidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months. ObjectiveThe association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated. MethodsIn this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001–2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations. ResultsThe unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared. ConclusionHospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings.

Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients' Last Month of Life, 2001-2010.

Surgery offers the potential to relieve symptoms for patients with cancer at the end of life (EOL) but at significant physiological and economic costs. However, the characteristics and correlates of surgery in last month of life (EOL surgery) of patients with cancer have not been comprehensively explored. This population-based study characterized EOL surgery use and identified its correlates. This retrospective cohort study examined administrative data among 339,546 Taiwanese cancer decedents, 2001 to 2010. We classified procedures according to their likely intent. Approximately 1 in 10 (11.44%, range: 11.08%-11.86%) patients underwent EOL surgery with an increasing utilization over time. The intention for EOL surgery was primarily palliative, followed by cancer-directed, nonmalignancy-directed, and diagnostic. EOL surgery for palliative intent increased whereas other intents decreased significantly over time. EOL surgery was more likely among those who were male, younger, and married; not diagnosed with hepatic-pancreatic or lung cancers; had no comorbidity or documented metastatic codes; and survived less than 1 year from diagnosis. The likelihood of EOL surgery use was higher for patients who received care in a teaching hospital with more acute care hospital beds and higher EOL care intensity. Rates of EOL surgery are lower in Taiwan than those reported in the United States. The increasing use of EOL surgery in Taiwan is primarily for palliative intent. Appropriateness of EOL surgery should be carefully evaluated to avoid underutilizing potentially beneficial, palliative-intent surgery and overutilizing cancer-directed and other surgical procedures, especially for physicians working in hospitals with abundant health care resources and a tendency to treat at-risk patients with cancer aggressively.

Gap in the Intensity of End-of-Life Care between Younger and Older Taiwanese Adult Cancer Patients may not Reflect Younger Patients’ Preferences

BackgroundStudies on age-related differences in preferences for end-of-life (EOL) care have generally concluded that increasing age predisposes patients to prefer less aggressive EOL care. However, these studies seldom are adjusted for healthcare needs, health behaviors, and healthcare system characteristics. PurposeTo evaluate the impact of age on terminally ill cancer patients’ preferences for EOL care while adjusting for healthcare needs, health behaviors and the characteristics of the healthcare system. MethodsWe obtained our research data for this study from a cross-sectional survey of 2329 terminally ill cancer patients sampled by convenience from 23 hospitals throughout Taiwan. ResultsThe preferences of Taiwanese terminally ill cancer patients did not differ significantly by age in their choices regarding comfort-oriented treatments as their goal for EOL care, receiving cardiac pulmonary resuscitation (CPR) when their life was in danger, or undergoing aggressive life-sustaining treatments at EOL (including cardiac massage, intubation, and mechanical ventilation support). However, terminally ill cancer patients ≤ 44 years of age were significantly more likely than those ≥75 years of age to prefer prolonging life as their goal of EOL care and receiving intensive care unit (ICU) care. Furthermore, patients 45-64 years of age were 1.44 (95% CI: 1.06, 1.95) more and 0.60 (0.47, 0.77) times less likely than those ≥75 years of age to prefer hospice care and dying at home, respectively. ConclusionsExcept for EOL-care goals, ICU care, hospice care, and place of death, preferences for specific aggressive life-sustaining treatments did not differ by age group of Taiwanese terminally ill cancer patients. We speculate that the age-related gap in intensity of EOL care among Taiwanese cancer decedents (younger cancer decedents received more life-sustaining treatments, i.e., ICU care, CPR, and intubation with mechanical ventilation support in the last month of life) may not reflect the preferences of younger patients.

Use of chemotherapy at the end of life among Taiwanese cancer decedents, 2001–2006

Introduction. The availability of new chemotherapeutic agents has lengthened the treatment timeline for advanced cancers and increases the likelihood of receiving chemotherapy near death. Use of chemotherapy near the end of life may not benefit cancer patients. However, no population-based study has examined the determinants for continuing chemotherapy at the end of life for all ages and cancer groups as well as for a whole country. This population-based study assessed the association between continuation of chemotherapy in the last month of life and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and healthcare resource availability at the hospital and regional levels. Materials and methods. Retrospective population-based cohort study using administrative data among 204 850 Taiwanese cancer decedents in 2001–2006. Results. Rates of continued chemotherapy in the last month of life for each study year were 17.5%, 17.4%, 17.3%, 19.0%, 20.0%, and 21.0%, respectively and have remained steady since 2001. Taiwanese cancer patients had greater odds for continuation of chemotherapy in the last month of life if they were male [adjusted odds ratio (AOR) 1.19, 95% confidence interval (CI) 1.13–1.25], younger, single [1.21 (1.09–1.35)], had lower comorbidity levels, were diagnosed with hematologic malignancies [1.90 (1.09–1.35)] and breast cancer [1.24 (1.08–1.43)], had metastatic disease [1.36 (1.27–1.46)], and survived < 1 year but longer than two months post-diagnosis. The odds for continued chemotherapy in patients’ last month was significantly increased by being cared for by a medical oncologist [3.49 (3.04–3.99)] or in a teaching hospital [1.39 (1.11–1.74)] and with the highest intensity of total inpatient hospital beds [1.63 (0.99–2.68)], but was not influenced by regional healthcare resources (total hospital and hospice beds). Conclusion. The relative risk for continuation of chemotherapy in the last month of life was determined by patient demographics and disease characteristics, physician specialty, and healthcare resources at the primary hospital level.

3025 POSTER Use of Chemotherapy at the End of Life Among Taiwanese Cancer Decedents, 2001-2006

3025 POSTER Use of Chemotherapy at the End of Life Among Taiwanese Cancer Decedents, 2001-2006

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001–2006

Background: With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated. Purpose: To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients. Methods: Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001–2006. Age was categorized as 18–64, 65–74, 75–84, and ≥85 years. Results: Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18–64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life. Conclusion: Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

Impact of Availability of an Inpatient Hospice Unit on the Parent Hospital’s Quality of Palliative Care for Taiwanese Cancer Decedents, 2001–2006

Context Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals. Objectives To investigate the impact of an inpatient hospice unit on the parent hospital’s quality of palliative care. Methods This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001–2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend. Results Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit. Conclusion Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients’ characteristics.

Determinants of ICU Care in the Last Month of Life for Taiwanese Cancer Decedents, 2001 to 2006

Use of the hospital ICU is rising rapidly for end-of-life care. The purpose of this population-based study was to determine the prevalence of ICU care in the last month of life of patients with cancer and the associations between ICU care and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of health-care resources at the hospital and regional levels in Taiwan. This retrospective cohort study used administrative data for 204,850 cancer decedents from 2001 to 2006. Rates of hospital ICU care in the last month of life did not change significantly from 2001 to 2006 (11.27%-12.71%). ICU use in the last month of life was more likely for single male patients aged < 65 years who had hematologic malignancies or esophageal cancer and more comorbidities or a nononcologist as primary-care physician. Patients with cancer were one-third less likely to use ICU care in their last month of life if they received care in a private hospital than if they were cared for in a public hospital. Patient propensity to receive ICU care in the last month of life was positively associated with increasing quartile of total hospital beds in their primary hospital's region. Slightly more than one-tenth of Taiwanese patients with cancer received ICU care in their last month of life. ICU use was strongly influenced by receiving care in hospitals and regions with abundant health-care resources. Resources should be devoted to ensure that ICU care at the end of life best meets patients' individual needs and interests.

A population‐based study on the determinants of hospice utilization in the last year of life for Taiwanese cancer decedents, 2001–2006

No population-based studies conducted outside Western countries have identified determinants of hospice utilization for all ages and cancer groups. To evaluate associations between hospice utilization in the last year of life and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels in Taiwan. Retrospective cohort study using administrative data among 204, 850 Taiwanese cancer decedents, 2001-2006. Rates of hospice utilization increased significantly (12.99-17.24%) over the study period. Hospice utilization was more likely for cancer patients who were female; over 65 years old; currently or formerly married; with ≤1 concurrent disease; diagnosed with breast cancer or cancer having a poorer prognosis; with distant metastasis, and longer illness duration (>2 months since diagnosis); receiving care in a teaching hospital or hospital with an inpatient-hospice unit; and receiving care in a region with greater density of inpatient-hospice beds. However, patients with hematological malignancies and esophageal cancer were less likely to use hospice care. Despite the 1.33 times increase in hospice utilization among cancer patients who died from 2001 to 2006, only one in six Taiwanese cancer decedents used hospice care in their last year of life. Our findings regarding determinants of hospice utilization should be used by healthcare professionals and policy makers to guide the development of policies and interventions that facilitate prognosis disclosure and EOL care discussions between physicians and patients, especially younger patients, to help the transition from curative to palliative care.

Aggressive End-of-Life Care Significantly Influenced Propensity for Hospice Enrollment Within the Last Three Days of Life for Taiwanese Cancer Decedents

Late hospice enrollment exacts a substantial toll from patients, families, hospices, and society. The relationship between the propensity for late hospice enrollment and aggressive health services received at the end of life (EOL) has been underinvestigated. To identify determinants of hospice enrollment within the last three days of life. Retrospective population-based cohort study using administrative data for 31,529 Taiwanese cancer decedents who used hospice care in their last year of life. Rates of hospice enrollment within the last three days of life (16.80%-18.73%) remained constant over 2001-2006. After adjustment for patient demographics and disease characteristics, physician specialty, availability of health care resources at the hospital and regional levels, and historical trends, late hospice enrollment was more likely if Taiwanese cancer patients received chemotherapy, had multiple emergency room visits or hospital admissions, and used the intensive care unit in their last month of life (adjusted odds ratio [95% confidence interval] (AOR [95% CI]): 1.61 [1.44-1.80], 1.40 [1.29-1.52], 1.78 [1.51-2.09], and 1.45 [1.19-1.76], respectively). Late hospice enrollment was less likely for patients with hospital stays>14 days or who received cardiopulmonary resuscitation in their last month of life (AOR [95% CI]: 0.51 [0.45-0.58] and 0.41 [0.25-0.65], respectively). Aggressive EOL care played a more significant role than patient, physician, or hospital characteristics in determining the propensity of Taiwanese cancer patients to be enrolled in hospice care within their last three days of life. Clinical and health policies should aim to avoid aggressive care when it will not benefit patients but may preclude timely hospice enrollment.

Propensity for Home Death Among Taiwanese Cancer Decedents in 2001–2006, Determined by Services Received at End of Life

The discrepancy between patients' preferred and actual place of death highlights the dilemma inherent in achieving their preferences for home death. Research on determinants of home death has been limited largely by focusing on individual-level factors and somewhat on health care resources at the primary hospital and regional levels. To investigate factors associated with home death, specifically, services received by cancer patients at the end of life (EOL). This was a retrospective cohort study using administrative data from 201,201 Taiwanese cancer decedents in the period 2001-2006. Rates of home death decreased significantly over time (from 35.67% to 32.39%). Dying at home was associated with patient demographics (gender, age, and marital status) and disease characteristics (cancer type, metastatic status, postdiagnosis survival time, and comorbidity level). Taiwanese cancer patients were less likely to die at home if they received care from a medical oncologist and in hospitals or regions with abundant health care resources. Furthermore, Taiwanese cancer patients were less likely to die at home if they used life-sustaining treatments (intensive care unit care, cardiopulmonary resuscitation, intubation, and mechanical ventilation) in the last month of life. However, multiple emergency room visits in the last month of life and receiving hospice care increased Taiwanese cancer patients' propensity to die at home. Despite the causal ambiguity in interpreting our research findings, they indicate that using life-sustaining treatments at EOL not only exacts a substantial toll from patients, family members, and society, but also decreases the likelihood of dying at home.

Quality of End-of-Life Care Between Medical Oncologists and Other Physician Specialists for Taiwanese Cancer Decedents, 2001–2006

Oncologists play a significant role in cancer care throughout the cancer trajectory and have traditionally emphasized underuse of procedures/treatments with well-established effectiveness as the source of poor care quality with little attention to overusing end-of-life (EOL) care. The purpose of this population-based study was to compare the quality of EOL care between medical oncologists and other physician specialists. This retrospective cohort study compared indicators of poor quality EOL care by examining administrative data for 204,850 Taiwanese cancer decedents in 2001-2006. Taiwanese cancer patients whose primary physician was a medical oncologist were significantly more likely than patients of other physician specialists to receive chemotherapy and to spend >14 days in a hospital in the last month of life. However, they were significantly less likely than patients of other physician specialists to visit the emergency room (ER) more than once and to use intensive care unit (ICU) care, cardiopulmonary resuscitation (CPR), intubation, and mechanical ventilation in the last month of life. The quality of EOL cancer care in Taiwan varied significantly by physician specialty. Cancer decedents cared for by medical oncologists were more likely to receive chemotherapy and prolonged hospitalization but less likely to have multiple ER visits, ICU care, or undergo CPR, intubation, or mechanical ventilation in the last month of life than patients of other physician specialists.

A population-based study on the prevalence and determinants of cardiopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, 2001–2006

Background The success rate of cardiopulmonary resuscitation (CPR) for cancer patients following in-hospital cardiac arrest has remained poor over the last 3 decades, but little is known about determinants of undergoing CPR for these patients at the end of life. Objective To determine the prevalence of CPR for Taiwanese cancer patients in the last month of life and the association between their undergoing CPR and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels. Methods This retrospective cohort study examined administrative data for a cohort of 204,850 cancer decedents in 2001–2006. Results Rates of CPR decreased substantially over the study period, from 13.18% to 8.63%, and the adjusted odds ratio of undergoing CPR decreased significantly by a factor of 0.93 for each successive year. Taiwanese cancer patients were predisposed to undergo CPR in their last month of life if they were male, young, and unmarried (except for widowhood); had high comorbidity; had certain cancers (hematological malignancies, head and neck, esophageal, and prostate cancers); had a localized or newly diagnosed (within 1–2 months of death) cancer; had a non-oncologist as their primary physician; and received care at a non-teaching hospital. Conclusion One-tenth of Taiwanese cancer patients underwent CPR in the last month of life, and the rates of CPR decreased substantially from 2001 to 2006. The propensity for CPR was influenced by patient demographics, disease characteristics, physician specialty, and teaching status of the patient's primary hospital.

3013 Performance of medical oncologists on end-of-life care for Taiwanese cancer decedents, 2001–2006

3013 Performance of medical oncologists on end-of-life care for Taiwanese cancer decedents, 2001–2006

Determinants of Aggressive End-of-Life Care for Taiwanese Cancer Decedents, 2001 to 2006

To assess the association between aggressiveness of end-of-life (EOL) care and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and availability of health care resources at the hospital and regional levels in Taiwan for a cohort of 210,976 cancer decedents in 2001 to 2006. This retrospective cohort study examined administrative data. Aggressiveness of EOL care was examined by a composite measure adapted from Earle et al. Scores range from 0 to 6, with higher scores indicating more aggressive EOL care. The mean composite score for aggressiveness of EOL care was 2.04 (mean) +/- 1.26 (standard deviation), increasing from 1.96 +/- 1.26 in 2001 to 2.10 +/- 1.26 in 2006. Each successive year of death significantly increased the composite score. Cancer decedents received more aggressive EOL care if they were male, younger, single, had a higher level of comorbidity, had more malignant and extensive diseases or hematologic malignancies, were cared for by oncologists, and received care in a hospital with a greater density of beds. Controlling for patient demographics and cormorbidity burden, EOL care in Taiwan was more aggressive for patients with cancer with highly malignant and extensive diseases, for patients with oncologists as primary care providers, or in hospitals with abundant health care resources. Health policies should aim to ensure that all patients receive treatments that best meet their individual needs and interests and that resources are devoted to care that produces the greatest health benefits.

Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000–2006

BackgroundQuality of end-of-life care received by cancer patients has never been explored in an entire Asian country for all ages and cancer groups. Patients and methodsRetrospective cohort study to examine trends in quality of end-of-life care among a cohort of 242530 Taiwanese cancer patients who died in 2000–2006. ResultsIn the last month of life, cancer care tended to become increasingly aggressive as shown by (i) intensive use of chemotherapy (15.45%–17.28%), (ii) frequent emergency room visits (15.69%–20.99%) and >14-day hospital stays (41.48%–46.20%), (iii) admissions to intensive care units (10.04%–12.41%), and (iv) hospital deaths (59.11%–65.40%). Use of cardiopulmonary resuscitation (13.09%–8.41%), intubation (26.01%–21.07%), and mechanical ventilation (27.46%–27.05%) decreased, whereas use of hospice services increased considerably (7.34%–16.83%). Among those receiving hospice services, rates of referrals to hospice services in the last 3 days of life decreased from 17.88% to 17.13% but remained steady after adjusting for selected covariates. ConclusionsThe quality of end-of-life care for Taiwanese cancer decedents was substantially inferior to that previously reported and to that recommended as benchmarks for not providing overly aggressive care near the end of life.