Using Time Spent at Home to Measure End-of-Life Care Quality

Jaime Rosenberg

There are several demographic features of patients with hematologic malignancies that affect their likelihood of dying at home, suggesting a crucial role for access to caregiver support, according to an abstract presented at the 59th Annual Meeting of the American Society of Hematology in Atlanta, Georgia.

“Despite advances in the management of patients with hematologic malignancies, a significant proportion of patients will still die of their disease,” the study authors wrote.

Existing quality indicators at the end of life (EOL) focus on whether patients receive aggressive interventions such as chemotherapy during the last days of life. However, many patients and caregivers have put emphasis on the importance of time spent at home as a quality measure for EOL care.

Using a population-based health system administration database from Ontario, Canada, the authors identified 6792 adult patients who died of a hematologic malignancy between January 2005 and December 2013. The primary outcome of “days at home” in a patient’s last 6 months of life was defined as 180 days minus the number of days in an acute care facility.

The authors also accounted for patient variables, such as comorbidities identified by a mortality risk score, and system level variables, such as palliative care consultation prior to the last 6 months of life, that predicted the number of days at home and determined trends over time.
The patients' median age was 72 at the time of death, and 58% of the patients were male. The median number of days at home during the last 6 months of life was 156 days; 81% of the patients spent more than 120 days at home.

Patients who were older spent more time at home than younger patients, and women spent less time at home than men. A possible explanation for this is that women typically live longer than men, and when women get sick, their spouses have often already died or can’t provide care because they are too frail, said lead author Matthew Cheung, MD, MS, FRCP, associate scientist, Sunnybrook Health Sciences Center in an interview with The American Journal of Managed Care®.

In addition, Cheung said, patients getting at least 2 or more transfusions were spending much less time at home than those who did not require transfusions, which could signal being unable to access transfusions while at home or that the patients are sicker. or the  patients are sicker.

Patients who received palliative care consultation prior to the last 6 months of life were more likely to spend time at home than patients who had not been seen by a palliative care specialist (OR 1.34; CI, 1.20-1.49; P<0.0001). Meanwhile, patients with more comorbidities were less likely to spend time at home (OR 0.96; CI, 0.96-0.97; P<0.0001).

“We see that there may be a few targetable patient characteristics that can be identified to help us better help patients spend time at home,” said Cheung. “Patients with comorbidities, women, and patients who are younger spend less time at home, so we can target these patients.”

The meeting takes place from December 9-12, 2017.
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