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Effectiveness of palliative home-care services in reducing hospital admissions and determinants of
hospitalization for terminally ill patients followed up by a palliative home-care team: A retrospective
cohort study
Mirko Riolfi, Alessandra Buja, Chiara Zanardo, Chiara Francesca Marangon, Pietro Manno and Vincenzo Baldo
Palliat Med 2014 28: 403 originally published online 23 December 2013
DOI: 10.1177/0269216313517283
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research-article2013
PMJ0010.1177/0269216313517283Palliative MedicineRiolfi et al.
Original Article
Effectiveness of palliative home-care
services in reducing hospital admissions
and determinants of hospitalization for
terminally ill patients followed up by a
palliative home-care team:
A retrospective cohort study
Palliative Medicine
2014, Vol. 28(5) 403­–411
© The Author(s) 2013
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269216313517283
pmj.sagepub.com
Mirko Riolfi1, Alessandra Buja2, Chiara Zanardo2, Chiara
Francesca Marangon1, Pietro Manno1 and Vincenzo Baldo2
Abstract
Background: It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative
home-care services.
Aim: The aim of this study was to assess the effectiveness of appropriate palliative home-care services in
reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being
hospitalized.
Design: Retrospective cohort study.
Setting/participants: We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (NorthEast Italy), as dying of cancer in 2011.
Results: Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team.
Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more
likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their
life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and
hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium)
were predictive of hospitalization.
Conclusions: Our study confirms the effectiveness of palliative home care in enabling patients to spend the final
period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital
resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular
carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for
these diseases.
Keywords
Health services research, home-care service, epidemiology, palliative medicine, comparative effectiveness research
1Palliative
Care Team, Distretto Socio Sanitario Azienda ULSS 5 Ovest
Vicentino, Arzignano, Italy
2Department of Molecular Medicine, Laboratory of Public Health
and Population Studies, Institute of Hygiene, University of Padova,
Padova, Italy
Corresponding author:
Alessandra Buja, Department of Molecular Medicine, Laboratory of
Public Health and Population Studies, Institute of Hygiene, University of
Padova, Via Loredan, 18, 35128 Padova, Italy.
Email: [email protected]
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Palliative Medicine 28(5)
What is already known about the topic?
•• The World Health Organization (WHO) recommends that all countries adopt a national palliative care policy for providing
home-based care.
•• The majority of terminally ill patients would prefer to stay and die at home.
•• Providing palliative care at home enables patients to spend the final period of their lives in their own homes.
What this paper adds?
•• This study confirmed that terminally ill cancer patients, who were recruited and consent to being cared for by a palliative
home-care team (PHCT) at home, are more likely to die at home, and to have fewer hospitalizations and shorter hospital
stays in the last 2 months of their lives.
•• The study found that patients in the care of a PHCT who had certain types of neoplastic disease, for example, hematological
cancers and hepatocellular carcinoma, were more likely to be hospitalized.
•• The study indicated that certain symptoms, for example, dyspnea, pain, and delirium, were predictive of patients in the care
of a PHCT being hospitalized.
Implications for practice, theory, or policy
•• The services of a PHCT might reduce the consumption of hospital resources.
•• This study revealed the need to reconsider the pathways of care for hematological cancers and hepatocellular carcinoma in
terminally ill patients.
Background
Nowadays, cancer has become one of the leading causes of
death worldwide. Franks et al.1 estimated that 25% of people in the terminal phase of cancer in the United Kingdom
will require inpatient palliative care, and 65% will benefit
from home-based palliative care. The World Health
Organization (WHO) recommends that all countries adopt
a national palliative care policy as a human right, providing different resources and settings, including home-based
care.2 Providing palliative care at home preserves the dignity of terminally ill patients and allows them to spend the
final period of their lives in their own homes, together with
relatives who can offer them a more empathetic support.
Quality of life is closely related to the chance to stay close
to loved ones, to reduce the loneliness typical of all forms
of hospitalization. The literature consistently demonstrates
that the majority of terminally ill patients would prefer to
stay and die at home,3,4 but unfortunately, most patients are
unable to do so.5 In a prospective review and questionnaire
study, Brogaard et al.6 recently showed that most patients
declaring a preference concerning where they might
receive care and wanted to be cared for (66%–84%) and to
die (64%–71%) at home, but only half of them had their
wish fulfilled. There also emerges from the literature a significant association between such patients’ wishes being
fulfilled and contact with a palliative care team.6
Concerning the efficiency of palliative care services,
other studies have demonstrated that changing the focus of
care-providing policy from the hospital to the home
reduces health-care costs by reducing hospital admissions
and the length of hospital stays.7 Costantini et al.8 found
the difference in the length of stay particularly evident in
the last 6 months before death. Alonso-Babarro et al.9
found that, when an appropriate palliative home-care team
(PHCT) was available, there were fewer deaths in hospital
and a drop in the overall hospitalization rates for patients
in the last 2 months of their life.
Numerous studies from around the world were
reviewed by Gomes and Higginson,10 who analyzed the
factors (relating to the illness, individual characteristics,
the health-care input and social support) affecting the
place where terminally ill cancer patients die: there was
consistent evidence of the influence of several factors on
the place of death, and six of these factors were strongly
associated with death at home, that is, patients’ functional
status, their preferences, the availability of home care and
its intensity, living with relatives, and extended family
support.
Aim
The aim of this study was to assess the impact of appropriate home-based palliative care in reducing hospitalizations, and also to identify factors predicting the chances of
patients in the care of a PHCT at home having to be hospitalized or dying at home.
Methods
Context
The Italian National Health Service (NHS) is funded
mainly through taxes and provides universal access to
health services. Primary care lies at the core of the NHS.
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405
Riolfi et al.
General practitioners (GPs) act as gatekeepers to the health
system. In each of the 21 regions of Italy, Local Health
Authorities (LHAs) are responsible for the delivery of primary care provided by GPs to a geographically designated
population. Traditionally, GPs have worked in solo practices. However, in the last 10 years, in an effort to increase
coordination of care, the Italian NHS has introduced substantial reforms seeking to encourage collaborative
arrangements among GPs and with other kind of physicians or other health-care personnel. In Italy, there is a law
(L.38 15/04/2010)11 that ratifies the right of terminally ill
patients to be treated and to die at home in the care of a
team of GP, specialists, and nurses.
The LHA No. 5 in Veneto Region (serving a population
of 179,783) set up a PHCT in 2011. The team of this LHA
consists of 2 palliative care physicians and 30 nonspecialist nurses, who cooperate with GPs. GPs have to
guarantee their on-call availability, and they do not always
recommend activating home care for their patients, either
because of the burden of this kind of care or because they
do not recognize the terminal phase of illness. The intensity of care depends on the patient’s condition: at least one
specialist medical examination a week is guaranteed for
all terminally ill patients being cared for at home, and this
specialist medical examination is conducted daily in the
last days of life. Nurses are called in to deal with any need
for medication or infusion therapies. The services of a palliative care physician or nurse are assured from Monday
to Friday (8.00 a.m. to 20.00 p.m.). On Saturdays and
Sundays, there is a nurse on call (8.00 a.m. to 20.00 p.m.).
During the night and weekends, patients, caregivers, and
colleagues can always contact a palliative care physician
by phone. The features defining a terminally ill patient
were as follows: the absence of life-prolonging cancer
treatment, ruled out by an oncologist; a predicted life
expectancy of no more than 3 months; and patients’ and/
or their family members’ explicit consent to treatment at
home.
Patients and materials
This was a retrospective cohort study enrolling all 402
patients who died with cancer as the first cause of death
in 2011 in the area served by the LHA No. 5 in the Veneto
Region of north-east Italy. During the first semester of
2012, the study collected information from administrative databases such as the ISTAT (Italian Statistics
Institute) death registry and hospital discharge records,
and from the palliative care team’s data. The ISTAT death
registry also records the place of death and patients’
demographic data. For each case identified, details of the
patient’s hospital admissions (number and length of stay)
in the last 2 months of life were obtained from the hospital discharge records. The data recorded by the PHCT on
the palliative care provided for patients at home
concerned the presence of symptoms (“yes” or “no”),
including pain, dysphagia, asthenia, dyspnea, cognitive
impairment, wheezing, delirium; the Karnofsky
Performance Status score; the patients’ awareness of their
condition (dummy “disease and incurability,” “only of
the diagnosis,” or “none”); the period of time spent in the
care of the PHCT; the number of days when at least one
health professional provided care at home; the PHCT service rate (i.e. the sum of the days spent at home in the
PHCT’s care/number of days on which at least one health
professional provided care at home); the need for therapeutic benzodiazepine sedation (“yes” or “no”); and the
need for opioid therapy (“yes” or “no”). Approval for the
study was obtained from the Ethical Committee of the
Vicenza Provincial Authorities.
Statistical methods
All categories of tumors were considered separately in our
descriptive analysis, but for the purposes of the inference
analysis, any cancers with fewer than 20 cases were
grouped into a category defined as “others.” Data were
summarized as means with standard deviations for continuous variables, and as numbers (percentages) of
patients for categorical variables. The χ2 was used to identify any significant differences in the frequency distribution of categorical variables by group, and student’s t-test
was used to assess differences in means by group.
Adjusted odds ratios (ORs) with 95% confidence intervals were calculated with a logistic regression model with
death at home as the dependent variable, and being taken
into the PHCT’s care as the independent variable (yes or
no). The other covariates included in the model were as
follows: age, sex, and type of cancer (a dummy variable
with lung cancer as the reference category). A linear
regression analysis was also performed with length of
hospital stay as the dependent variable and being taken
into the PHCT’s care as the independent variable (yes or
no). The other covariates included in the model were the
same as those listed above. A Poisson regression analysis
was also performed with the number of hospital admissions as the dependent variable and being taken into the
PHCT’s care as the independent variable (yes or no). The
other covariates included in the models were the same as
those listed above.
A logistic regression model was used to identify predictors of death at home among the patients taken into care by
the PHCT, using death at home as the dependent variable,
and the following independent variables: age, sex, symptoms (pain, dysphagia, asthenia, dyspnea, cognitive impairment, wheezing, delirium), the patients’ awareness of their
condition (“disease and incurability,” “only of the diagnosis,” or “none”), period in the care of the PHCT, therapeutic
sedation (yes or no), Karnofsky Performance Status, and
type of cancer (with lung cancer as the reference category),
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Palliative Medicine 28(5)
Table 1. Bivariate analysis of the sample’s characteristics and outcomes by type of care group.
Sex
Age
Cancer
Place of death
Time spent in hospital in last
2 months of life
Number of hospitalizations in
last 2 months of life
Male, % (n)
Mean age (±SD)
Lung, % (n)
Colorectal, % (n)
Pancreas, % (n)
Breast, % (n)
HCC, % (n)
Prostate, % (n)
Hematological, % (n)
Unknown, % (n)
Others, % (n)
Hospital, % (n)
Home, % (n)
Nursing home, % (n)
Country hospital,
% (n)
Mean days (±SD)
Total sample
(N = 402)
Not given palliative
care (n = 242)
Given palliative
care (n = 160)
p value
58.5% (235)
73.9 (±11.9)
22.1% (89)
11.7% (47)
7.2% (29)
5.2% (21)
6.5% (26)
5.0 % (20)
9.5 % (38)
1.8% (7)
31.1% (125)
53.5% (215)
26.1% (105)
10.7% (43)
9.7% (39)
57.4% (139)
75.1 (±11.9)
19.8% (48)
12.4% (30)
4.6% (11)
5.8% (14)
6.2% (15)
4.1% (10)
13.2% (32)
2.1% (5)
31.8% (77)
73.6% (178)
7.9% (19)
12.4% (30)
6.2% (15)
60.0% (96)
72.1 (±11.9)
25.6% (41)
10.6% (17)
11.2% (18)
4.4% (7)
6.9% (11)
6.2% (10)
3.8% (6)
1.3% (2)
30.0% (48)
23.1% (37)
53.8% (86)
8.1% (13)
15.0% (24)
0.610
0.012
0.017
13.4 (±17.6)
19.6 (±18.9)
4.4 (±10.4)
<0.001
0.9 (±0.99)
1.3 (±1.0)
0.4 (±0.7)
<0.001
Mean (±SD)
<0.001
HCC: heaptocellular carcinoma; SD: standard deviation.
that is, colorectal, pancreas, breast, hepatocellular carcinoma (HCC), stomach, prostate, hematological, genitourinary, and “others.”
A linear regression model was used to find predictors of
the number of days spent in hospital by patients in the care of
the PHCT, considering hospitalization as the dependent variable and the independent variables listed in the previous
paragraph. Finally, a Poisson regression model was used to
identify predictors of the number of hospital stays for patients
in the care of the PHCT, with hospitalization as the dependent variable and the above-listed independent variables.
Results
The patients were a mean 73.9 years of age, and the leading
cause of cancer-related death was lung cancer for males
(28.9% of all cancer-related deaths), and lung and breast
cancers for females (12.6% and 12.0%, respectively). In
our cohort, 26.1% of the patients died at home, and 53.5%
in hospital; 39.9% of the whole cohort had been in the care
of the PHCT. The characteristics of the sample by healthcare setting are shown in Table 1. Patients enrolled for the
palliative care program were slightly younger (73.9 vs 75.1
years), more likely to die at home (53.8% vs 7.9%), and had
fewer hospital stays (0.4 vs 1.3 admissions) and shorter
stays (4.4 vs 19.6 days) in their last 2 months of life than
patients who were not taken into the PHCT’s care.
Table 2 shows the differences in the mean number of
hospital admissions, lengths of hospital stay, and probability
of dying at home by type of cancer and health-care setting,
indicating that terminally ill patients with pulmonary, colorectal, pancreatic, and hematological cancers in the care of
the PHCT had fewer admissions and spent fewer days in
hospital than patients with the same diseases who were not
in the care of the PHCT. These patients also had a higher
chance of dying at home, as did breast cancer and HCC
patients in the care of the PHCT.
Table 3 shows the results of the three regression models: irrespective of age, gender, or type of cancer, patients
who were in the care of the PHCT had higher odds (OR =
14.3) of dying at home than those who were not. The palliative care program was also associated with a reduction
for hospital admissions and for days in hospital stays.
Considering only the patients in the care of the PHCT
(Table 4), delirium and pain predicted a higher number of
days spent in hospital, while therapeutic sedation (administered to 28% of patients in the care of the PHCT) coincided with a higher probability of dying at home. Symptoms
such as weakness, pain, and dyspnea, together with HCC
and hematological tumors, were predictors of more hospital admissions.
Discussion
This study confirmed that terminally ill cancer patients who
were recruited by their GPs and consent to being cared for
by a PHCT at home are more likely to die at home, and to
have fewer hospitalizations and shorter hospital stays in the
last 2 months of their lives. In addition, this is one of the
first cohort studies to address the predictors of days spent in
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Riolfi et al.
Table 2. Bivariate analysis of outcomes for each type of cancer by type of care group.
Total sample
Mean days in hospital in last 2 months of life
Lung: days (±SD)
9.9 (±13.8)
Colorectal: days (±SD)
14.3 (±17.5)
Pancreas: days (±SD)
8.2 (±13.6)
Breast: days (±SD)
10.4 (±13.5)
HCC: days (±SD)
13.6 (±17.0)
Prostate: days (±SD)
9.9 (±16.9)
Hematological: days (±SD)
22.8 (±20.6)
Unknown: days (±SD)
14 (±15.4)
Others: days (±SD)
15.0 (±19.9)
Mean number of hospitalizations in last 2 months of life
Lung: number (±SD)
0.9 (±0.9)
Colorectal: number (±SD)
0.8 (±0.9)
Pancreas: number (±SD)
0.7 (±0.8)
Breast: number (±SD)
0.6 (±0.7)
HCC: number (±SD)
1.2 (±1.3)
Prostate: number (±SD)
0.8 (±1.2)
Hematological: number (±SD)
1.4 (±1.0)
Unknown: number (±SD)
0.9 (±0.9)
Others: number (±SD)
0.9 (±1.0)
Death at home
Lung, % (n)
22.1% (89)
Colorectal, % (n)
11.7% (47)
Pancreas, % (n)
7.2% (29)
Breast, % (n)
5.2% (21)
HCC, % (n)
6.5% (26)
Prostate, % (n)
5.0 % (20)
Hematological, % (n)
9.5 % (38)
Unknown, % (n)
1.8% (7)
Others, % (n)
31.1% (125)
Not given
palliative care
Given
palliative care
p value
15.8 (±14.1)
21.2 (±18.7)
16.9 (±17.6)
13.6 (±14.9)
17.1 (±15.7)
16.6 (±21.5)
26.1 (±20.7)
19.6 (±14.7)
21.1 (±21.6)
3.4 (±10.1)
2.9 (±5.5)
2.8 (±6.4)
4 (±7.7)
8.8 (±18.3)
3.2 (±6.5)
5.8 (±8.2)
0 (±0)
5.6 (±12.2)
<0.001
<0.001
0.004
0.129
0.228
0.075
0.025
0.135
<0.001
1.5 (±0.9)
1.1 (±0.8)
1.3 (±0.8)
0.8 (±0.7)
1.5 (±1.2)
1.1 (±1.5)
1.5 (±1.0)
1.2 (±0.8)
1.3 (±1.0)
0.3 (±0.6)
0.3 (±0.6)
0.3 (±0.6)
0.3 (±0.5)
0.8 (±1.3)
0.5 (±0.7)
0.7 (±0.8)
0 (±0)
0.4 (±0.7)
<0.001
<0.001
0.001
0.107
0.202
0.273
0.049
0.113
<0.001
14.3% (7)
10.0% (3)
0.0% (0)
0.0% (0)
0.0% (0)
30.0% (3)
3.1% (1)
20.0% (1)
6.5% (5)
60.0% (24)
58.8% (10)
55.6% (10)
42.9% (3)
41.7% (5)
40.0% (4)
66.7% (4)
0.0% (0)
52.1% (25)
<0.001
<0.001
0.002
0.008
0.007
0.639
<0.001
0.495
<0.001
HCC: heaptocellular carcinoma; SD: standard deviation.
hospital or number of hospital admissions in the last 2
months of life for patients in the care of a PHCT.
This study found a strong association between the
involvement of palliative care services and the place of
death, and would suggest that palliative home-care enables
patients to spend the final days of their lives at home, a
condition strongly related to the feasibility of preserving
their relationship with loved ones. A Belgian study demonstrated the effectiveness of palliative care in reducing hospital deaths, showing that people were more likely to die in
their usual place of residence if multidisciplinary PHCTs
were involved.12 In Spain, a population-based study
reported similar findings, suggesting that a PHCT can
reduce inpatient deaths.13 In Norway too, a randomized
controlled trial on palliative versus conventional care
showed that palliative care enabled more patients to die at
home, although the amount of time spent at home was not
significantly longer, and the overall use of the hospital
remained much the same.14 Our study seems to confirm the
effectiveness of PHCT services in reducing the use of
hospital resources, showing that the availability of a PHCT
reduced patients’ hospital admissions and days spent in
hospital in the last 2 months of life. Our findings are consistent with other studies conducted in Spain and
Belgium,15 and strongly support the conviction that using
palliative care services can help to contain the costs of providing health care as well as improving patients’ and their
families’ quality of life. An English study exploring the
cost of end-of-life care suggested that reducing the use of
acute care facilities and expanding community-based care
could release resources and better serve peoples’ preferences.16 This is an important issue because, although the
focus of palliative care is the patients’ and their families’
quality of life, increasing attention should also have to be
paid to the potential positive economic impact of palliative
care services. End-of-life care in hospital is identified as
by far the greatest cost, accounting on average for 33.2%
of the total cost per patient,14 and despite this high cost of
admissions for acute care, many studies have shown that
end-of-life care in hospital is inappropriate for patients and
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408
Palliative Medicine 28(5)
Table 3. Stepwise regression analyses on the total sample of terminally-ill patients. Dependent variables: death at home (logistic
regression), days spent in hospital (linear regression), hospital admissions (Poisson regression). Independent variables: being taken
into care by a PHCT. Covariates: age, sex, and type of tumor.
Death at home
OR
Age (y)
Sex (male)
Taken into care
Colorectal
Pancreas
Breast
HCC
Prostate
Hematological
Others
1.01
1.25
14.30
0.79
0.56
0.27
0.33
0.91
0.54
0.58
Lower IC 95%
0.99
0.69
7.90
0.31
0.20
0.06
0.10
0.27
0.16
0.28
Upper IC 95%
1.03
2.26
25.86
2.00
1.57
1.23
1.10
3.03
1.81
1.20
p
0.353
0.465
0.000
0.621
0.270
0.090
0.071
0.880
0.315
0.145
Number of hospital admissions
β
Age (y)
Sex (male)
Taken into care
Colorectal
Pancreas
Breast
HCC
Prostate
Hematological
Unknown
Others
−0.01
−0.07
−1.11
−0.11
−0.06
−0.47
0.26
−0.06
0.18
−0.08
−0.03
Lower IC 95%
−0.02
−0.30
−1.38
−0.51
−0.56
−1.08
−0.15
−0.60
−0.18
−0.92
−0.32
Upper IC 95%
−0.00
0.16
−0.84
0.28
0.44
0.14
0.68
0.49
0.54
0.76
0.26
p
0.007
0.560
0.000
0.561
0.816
0.131
0.216
0.837
0.328
0.851
0.852
Days spent in hospital
Age (y)
Sex (male)
Taken into care
Colorectal
Pancreas
Breast
HCC
Prostate
Hematological
Unknown
Others
β
Lower IC 95%
Upper IC 95%
p
−0.23
1.18
−15.06
3.68
0.57
−2.71
3.12
1.22
7.50
2.36
3.52
−0.37
−2.31
−18.36
−2.08
−6.19
−10.75
−3.84
−6.54
1.19
−9.98
−0.93
−0.09
4.67
−11.75
9.44
7.33
5.34
10.09
8.97
13.80
14.70
7.97
0.001
0.507
0.000
0.210
0.868
0.509
0.379
0.758
0.020
0.707
0.120
Bold values indicate statistically significant association (p <0.05) between the variable and the outcome.
PHCT: palliative home-care team; HCC: heaptocellular carcinoma; CI: confidence interval; OR: odds ratio.
their families, with inadequate symptom control, a higher
likelihood of receiving unwarranted medication and a
worse quality of death.17,18 The lack of an end-of-life care
pathway in hospital and the “aggressive” care of patients
are also associated with a greater difficulty for caregivers
to adjust, more bereavement problems, and a higher risk of
caregivers developing psychiatric conditions.19
Our findings need to be confirmed, however, because—
although our cohort of patients was very homogeneous
(served by the same Local Health Unit, accessing the same
primary care system, referring to the same medical
oncology specialist and hospital), and all the patients were
presumably eligible for palliative home care (they all died of
cancer within 2 months)—our analyses compared patients
who did or did not join the PHCT program without adjusting for their characteristics, for example, symptoms or
socio-economic status. If such characteristics are associated
with exposure (GPs recruitment of patients and patients’
consent to palliative home care) and outcome (hospitalization), then our results may be biased. In an effort to at least
partially remedy this limitation, our analyses were adjusted
by type of cancer to enable the analysis of the case mix.
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Table 4. Regression analyses on terminally-ill patients given palliative home care. Dependent variables: death at home (logistic
regression); days spent in hospital (linear regression); number of hospital stays (Poisson regression). Independent variables for three
models were: symptoms (pain, dysphasia, asthenia, dyspnea, cognitive impairment, wheezing, delirium), sex, age, type of tumor
(reference category: lung cancer), i.e. colorectal, pancreas, breast, HCC, stomach, prostate, hematological, genitourinary, and
‘others’, awareness of illness (reference: awareness of disease and of incurability), Karnofsky performance status, time on palliative
care, and use of therapeutic sedation and use of strong opioids. The table only shows the variables found associated with the
outcome with a p value below 0.10.
Days spent in hospital
β
Lower CI 95%
Upper CI 95%
p
Age
Delirium
Pain
Time on palliative care
Therapeutic sedation
−0.20
8.25
4.10
0.09
−3.67
−0.35
4.29
0.48
0.04
−7.66
−0.52
12.21
7.73
0.14
0.33
0.009
< 0.001
0.027
0.001
0.072
β
Lower CI 95%
Upper CI 95%
p
−0.02
0.03
0.98
0.74
0.73
1.23
1.74
−0.05
0.01
0.25
0.14
−0.12
0.21
0.33
OR
Lower CI 95%
Number of admissions
Age
Karnofsky
Dyspnea
Pain
Weakness
HCC tumor
Hematological tumor
0.00
0.06
1.72
1.34
1.57
2.25
3.15
0.053
0.016
0.009
0.016
0.093
0.018
0.016
Death at home
Age
None awareness of condition
Weakness
Dysphagia
Wheezing
Therapeutic sedation
1.04
0.36
0.34
0.31
2.43
2.74
1.00
0.13
0.11
0.12
0.97
1.00
Upper CI 95%
1.08
0.98
0.97
0.83
6.11
7.48
p
0.038
0.045
0.043
0.021
0.058
0.050
PHCT: palliative home-care team; HCC: heaptocellular carcinoma; CI: confidence interval; OR: odds ratio.
Considering only the patients taken into care by the
PHCT, we tried to identify clinical predictors of hospital
admissions, the number of days spent in hospital, and
death at home. Factors determining where patients die
seem to be social as much as medical, but in the present
study, we focused only on the medical issues. Gomes et
al.4 reviewed the data from 58 studies involving more than
1.5 million patients in 13 countries, finding 17 factors
capable of influencing the place of death. The factors most
strongly associated with death at home were the social
environment, the health services available, and, on weaker
evidence, solid tumors. Patients with more than one illness
and with non-solid tumors were more likely to die in hospital.4 Our findings are consistent with those in the Gomes
report: hematological cancers were positively associated
with more hospital admissions. Such patients might be
more likely to be hospitalized for multiple therapies, even
in the advanced stages of their disease; as their disease
evolves, they also usually respond well to treatment, and
when they reach the terminal phase, they may be unprepared and unwilling to accept the withdrawal of any further treatments, especially in the absence of a clear
explanation for this and good communications with
specialists.
We also found certain symptoms associated with hospital admission rates, that can be very challenging for
patients and/or caregivers, prompting requests for hospitalization. For instance, we found dyspnea associated with
more frequent hospital admissions, and states of delirium
correlated with more days spent in hospital. Dyspnea and
delirium are multidimensional symptoms and can cause
severe physical, social, emotional, and functional distress
in patients and their caregivers. Toward the end of life,
there is a tendency for dyspnea and delirium to become
more prevalent and more severe.20–23 When an acute attack
occurs, caregivers may call in the emergency services,
often resulting in patients being admitted to hospital (particularly during the night and at weekends, when the palliative care specialist can only be consulted by phone). Our
findings are consistent with those reported by the Home
Care Italy Group in 2012, that is, that the most common
reasons for calling an emergency medical service for
patients with advanced cancer being cared for at home
were dyspnea, delirium, pain and loss of consciousness.24
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Palliative Medicine 28(5)
As for medication, we found that administering palliative sedation as part of end-of-life home care can increase
the probability to dying home. Sedation is a medical intervention designed to control refractory symptoms in
patients with terminal cancer and, in this setting, it is considered part of a continuum of palliative care.25 Adequate
symptom control by means of its appropriate prescription
and administration, honestly sharing the methods and purposes of this procedure with the patient’s relatives, makes
palliative sedation a feasible treatment option in selected
patients. Our findings show that palliative sedation (not
hastening the end) would help to improve symptom control for patients cared for at home and willing or wishing to
die there. Controlling a patient’s suffering in the last days
of life also relieves relatives’ distress, and prompts fewer
requests for hospitalization.
Conclusion
•• Although they need to be confirmed, our findings
indicate that palliative home care enables more
terminally ill consenting patients, who were
recruited by their GPs, to spend their last days at
home with relatives; PHCTs would permit for
these patients to reduce the consumption of hospital resources for the terminally ill, enabling their
more appropriate use.
•• Evidence that some diseases (e.g. hematological
cancers and HCC) are more likely to require patients’
hospitalization might suggest the need to reconsider
the pathways of care for such conditions.
•• Evidence that some symptoms of sudden onset, like
dyspnea and delirium, are more predictive of hospitalization probably means that a strategy is needed
to train out-of-hours physicians on the appropriate
management of these symptoms.
•• Finally, our findings support the use of sedation as a
therapeutic tool in the care of the terminally ill at
home to control patients’ symptoms and alleviate
relatives’ distress.
Declaration of conflicting interests
The authors have no conflicts of interest to declare.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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