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An analysis of access to end-of-life care for adults dying of cancer in Nova Scotia

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Title: An analysis of access to end-of-life care for adults dying of cancer in Nova Scotia


1
An analysis of access to end-of-life care for
adults dying of cancer in Nova Scotia
  • Meaghan OBrien
  • June 6, 2006

2
Outline
  • Purpose
  • Databases
  • Study subjects
  • Concentration 1 Culture in research
  • Concentration 2 EOL data quality
  • Concentration 3 Trends in the place of death
    of cancer patients
  • Strengths and limitations
  • The future

3
Purpose
  • Identify variables associated with place of
    cancer deaths in NS to help assess level of
    equality in access to EOL/PC services

4
Databases
Cape Breton PC Program Database
Capital Health PC Program Database
NS Vital Statistics
NS Cancer Centre OPIS
Study Subjects
NS Cancer Registry
1996 and 2001 Census Data
Statistics Canada Postal Code Conversion File
5
Study Subjects
All NS residents who died of cancer according to
death certificates, 1994-2003 (n 25,127)
Excluding
Those 19 years of age or younger (n 63)
Those whose cancer diagnosis was not known prior
to death, i.e. death certificate only cases (n
930)
Those who died out of province (n 150)
Those with missing place of death information (n
1097)
22,886 final study subjects 6,151 died out of
hospital 16,735 died in hospital
6
Concentration 1 A sociological critique of
ecological measures of culture
  • No universally accepted definition of culture
  • Leads to difficulties in research
  • Cultural safety issues also arise
  • Potential method for developing ecological
    cultural variables presented

7
Ecological cultural variable creation
Subjects postal code of usual residence at time
of death or most recent residential postal code
from OPIS
Cut-points for EA/DAs developed for each
cultural variable (ex. 10, 50)
Census EA/DA
Subjects assigned cultural labels based on
the cultural description developed for their
EA/DA
8
Likelihood of out-of-hospital death
Increased Decreased Not significant
gt10 Immigrant gt 10 unemployed gt50 Aboriginal
gt10 Mixed Black gt 50 not high school graduates gt 10 religion other than Catholic, Protestant or none
Median household income upper quintile gt10 Non-black Visible minority
gt10 Non-official language
gt10 French
gt50 single occupant dwellings
From multivariate logistic regression analysis
with year of death, sex, age and tumour group
also in the model to control for potential
confounding
9
  • Strengths
  • Information in existence
  • Available nation-wide
  • Weaknesses
  • Conceptually narrow definition
  • Undercount in census
  • Describes communities of residence not
    individuals
  • Cultural safety and acceptance of method could be
    a problem

10
Concentration 2 - Assessment and improvement of
end-of-life and palliative care datasets
  • Increasing interest in EOL/PC, meaning increasing
    of EOL/PC datasets
  • Quality data is essential
  • Little published to guide data quality
    improvement in EOL/PC dataset development

11
Concentration 2
From literature and NS EOL dataset development, 9
data quality concepts described with examples
  • Data acceptance
  • Subject completeness
  • Service completeness
  • Data field completeness
  • Coding constancy
  • Data field accuracy
  • Validity
  • Reporting constancy
  • Timeliness

12
Concentration 3 Trends in the place of death
of cancer patients in Nova Scotia, 1994-2003
  • Based on Burge F, Lawson B, Johnston G. (2003)
    Trends in the Place of Death of Cancer Patients.
    CMAJ
  • Dependent variable - place of death
  • In hospital (includes deaths in acute care
    hospital beds, transitional care beds and nursing
    home beds in a nursing home that occupies the
    same location as a hospital)
  • Out of hospital

13
Variables
ENVIRONMENT POPULATION
HEALTH
OUTCOMES
CHARACTERISTICS
BEHAVIOUR
  • Health care
  • system
  • Distance to
  • cancer care
  • External
  • environment
  • Year of death
  • Predisposing
  • characteristics
  • - Demographics
  • Age
  • Sex
  • -Social structure
  • -Health beliefs
  • Ecological
  • cultural
  • variables
  • Enabling
  • resources
  • Personal
  • Nursing home
  • resident
  • Community
  • Income
  • Region of
  • province
  • Need
  • Tumour
  • group
  • Time from
  • diagnosis
  • to death
  • Time from
  • initial
  • registration
  • in a PCP
  • to death
  • Personal health
  • practices
  • Use of health
  • services
  • Medical
  • oncology
  • Palliative
  • radiation
  • Palliative care
  • program
  • Location of
  • death
  • Consumer
  • satisfaction

14
Definitions
  • Nursing home residence place of death or place
    of usual residence at time of death matches the
    name of a nursing home on an extended list of
    nursing homes in NS
  • Systemic therapy receipt of chemotherapy in
    last 12 months of life
  • Palliative radiation - definition based Johnston
    et al. (2001) given a palliative intent code by
    treating radiation oncologist or if lt10
    fractions were administered in last 9 months of
    life

15
Method of analysis
  • Statistical software (SAS)
  • Univariate and multivariate logistic regression
    analysis used to identify odds of dying out of
    hospital over time
  • Most parsimonious model of out-of-hospital death
    developed using multivariate logistic regression
    analyses  

16
Predictors of out-of-hospital death
  • Population characteristics
  • Predisposing characteristics
  • - Demographics
  • Female (OR1.3, CI 1.2-1.3, vs male)
  • 75-84 yrs (OR1.5, CI 1.3-1.9, vs 20-44 yrs)
  • 85 years (OR2.4, CI 2.0-2.9, vs 20-44 yrs)
  • - Social structure and health beliefs
  • Immigrant cmty (OR1.2, CI 1.1-1.3)
  • Enabling Resources
  • - Personal
  • Nursing home residence (OR12.3, CI 9.3-16.2)
  • - Community
  • Upper quintile MHI (OR1.2, CI 1.1-1.3, vs lowest
    quintile)

17
Predictors of out-of-hospital death
  • Population characteristics
  • Need
  • Survival
  • 61-120 days (OR2.2, CI 1.9-2.4, vs lt60 days)
  • 121 days (OR2.6, CI 2.4-2.8, vs lt 60 days)
  • Tumour group
  • Breast (OR1.2, CI 1.03-1.3 vs lung)
  • Colorectal (OR1.2, CI 1.1-1.4, vs lung)
  • Prostate (OR1.1, CI 1.00-1.3, vs lung)
  • CB PCP
  • 17-45 days in program (OR1.4, CI 1.01-1.9 vs
    lt16 days)
  • 46-124 days in program (OR1.4, CI 1.03-2.0 vs
    lt16 days
  • 125 days in program (OR1.7, CI 1.2-2.3 vs lt16
    days)
  • CH PCP
  • 17-45 days in program (OR2.0, CI 1.6-2.5 vs lt16
    days)
  • 46-124 days in program (OR2.3, CI 1.8-2.9 vs
    lt16 days)
  • 125 days in program (OR2.1, CI 1.7-2.7 vs lt16
    days)

18
Predictors of out-of-hospital death
  • Health Behaviour
  • Use of health services
  • Referral to
  • CB PCP (OR1.5, CI 1.2-1.8)
  • CH PCP (OR1.1, CI 1.0-1.2)

Systemic therapy, Aboriginal and French were not
significant in univariate analysis.
19
Predictors of out-of-hospital death
  • Population characteristics
  • Predisposing characteristics
  • - Social structure and health beliefs
  • Non-official language cmty (OR0.8, CI 0.7-1.00)
  • Enabling Resources
  • - Community
  • Cape Breton County (OR0.7, CI 0.6-0.7, vs
    Halifax County)
  • All other NS counties (OR0.7, CI 0.7-0.8, vs
    Halifax County)
  • Health behaviour
  • Use of health services
  • Palliative radiation (OR0.9, CI 0.8-0.9)

20
  • Variables significant in univariate but not
    multivariate analysis

Variable Crude OR and CI Correlated with
Year of death 1996 1.2 (1.0-1.3) 1998 1.2 (1.0-1.4) 2003 1.1 (0.9-1.2)
Rural or urban residence 0.8 (0.8-0.9) Region, income and distance to cancer center
Distance to cancer center 21-100km 0.8 (0.8-0.9) 101km 0.8 (0.7-0.8) Region
Mixed Black 1.1 (1.0-1.3)
Visible minority other than Black 1.4 (1.1-1.6) Immigrant
Religion other than Catholic, Protestant or none 1.4 (1.0-1.9) Immigrant
Majority not high school graduates 0.8 (0.8-0.9) Income and immigrant
Majority single occupant dwellings 1.2 (1.0-1.3) Sensitivity analysis
High unemployment 0.8 (0.7-0.9) Income
21
Strengths
  • Creation of several new variables
  • Nursing home residence
  • Systemic therapy
  • Palliative radiation
  • Addition of CB PCP database
  • Co-operation with researchers in other provinces
  • Increased attention to cultural safety
  • Creation of detailed data quality and study
    methods
  • Data and results reviewed by stakeholders
  • Results presented to peers at 4 conferences

22
Limitations
  • Data limited to what was available from existing
    databases
  • Absence of preferred place of death data
  • Lack of data on intensity of hospital use at EOL
    and type of hospital unit (PC, ICU, ..)
  • Only deals with inequality, not inequity

23
The future
  • Co-operation amongst researchers, database
    administrators and stakeholders
  • Linkage to
  • Hospital separations database
  • Physician claims
  • Home care data
  • Drug data
  • Other PCP databases
  • Addition of other variables
  • Begin to assess whether inequities exist

24
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