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CMAJ Open. 2019 Apr 26;7(2):E306-E315. doi: 10.9778/cmajo.20180097. Print 2019 Apr-Jun.

Trends in site of death and health care utilization at the end of life: a population-based cohort study.

Author information

1
Departments of Critical Care Medicine (Hill, Scales, Rubenfeld, Wunsch, Dev, Fowler) and of Medicine (Gandhi, Berry), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Hill); ICES (Stukel, Fu, Scales); Institute of Health Policy, Management and Evaluation (Stukel, Fowler), Interdepartmental Division of Critical Care (Scales, Rubenfeld, Wunsch, Dev, Fowler), Faculty of Medicine (Laupacis), Department of Anesthesia (Wunsch), Department of Medicine (Sinha, Gandhi, La Delfa), Division of Palliative Medicine, Department of Medicine (Zimmermann), and Division of Palliative Care, Department of Family Medicine, Faculty of Medicine (Myers), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis) and Department of Palliative Care (La Delfa), St. Michael's Hospital, Toronto, Ont.; Departments of Medicine and Critical Care (Downar), Division of Palliative Care, University of Ottawa, Ottawa, Ont.; Divisions of Geriatric Medicine and Neurology (Rockwood), Department of Medicine, Dalhousie University, Halifax, NS; Department of Critical Care Medicine (Heyland), Queen's University, Kingston Ont.; Department of Medicine (Sinha) and Division of Palliative Care (Myers), Sinai Health System; Department of Medicine (Sinha), Division of Palliative Care, Department of Supportive Care (Zimmermann), and Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre (Ross), University Health Network, Toronto, Ont.; School of Population and Public Health (Kozak), University of British Columbia; Department of Family and Community Medicine (Kozak), Providence Health Care, Vancouver, BC Andrea.Hill@sunnybrook.ca.
2
Departments of Critical Care Medicine (Hill, Scales, Rubenfeld, Wunsch, Dev, Fowler) and of Medicine (Gandhi, Berry), Sunnybrook Health Sciences Centre; Sunnybrook Research Institute (Hill); ICES (Stukel, Fu, Scales); Institute of Health Policy, Management and Evaluation (Stukel, Fowler), Interdepartmental Division of Critical Care (Scales, Rubenfeld, Wunsch, Dev, Fowler), Faculty of Medicine (Laupacis), Department of Anesthesia (Wunsch), Department of Medicine (Sinha, Gandhi, La Delfa), Division of Palliative Medicine, Department of Medicine (Zimmermann), and Division of Palliative Care, Department of Family Medicine, Faculty of Medicine (Myers), University of Toronto; Li Ka Shing Knowledge Institute (Laupacis) and Department of Palliative Care (La Delfa), St. Michael's Hospital, Toronto, Ont.; Departments of Medicine and Critical Care (Downar), Division of Palliative Care, University of Ottawa, Ottawa, Ont.; Divisions of Geriatric Medicine and Neurology (Rockwood), Department of Medicine, Dalhousie University, Halifax, NS; Department of Critical Care Medicine (Heyland), Queen's University, Kingston Ont.; Department of Medicine (Sinha) and Division of Palliative Care (Myers), Sinai Health System; Department of Medicine (Sinha), Division of Palliative Care, Department of Supportive Care (Zimmermann), and Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre (Ross), University Health Network, Toronto, Ont.; School of Population and Public Health (Kozak), University of British Columbia; Department of Family and Community Medicine (Kozak), Providence Health Care, Vancouver, BC.

Abstract

BACKGROUND:

High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital.

METHODS:

We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care.

RESULTS:

In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, p < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, p < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care.

INTERPRETATION:

Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.

Conflict of interest statement

Competing interests: James Downar has received speaker’s fees from Boehringer-Ingelheim (Canada) and Novartis, as well as personal fees from the Ontario College of Family Physicians for participation on a steering committee for end-of-life care. Kenneth Rockwood is the founder and chief scientific officer of DGI Clinical, which works with various pharmaceutical companies to develop individualized outcome measurement and advanced data analytics. DGI Clinical is supported by the NRC’s Industrial Research Assistance Program. Dr. Rockwood has asserted copyright in the Clinical Frailty Scale (through Dalhousie University’s Industry Liaison Office), which is available free for use in education, research and not-for-profit health care. He has also received personal fees from various pharmaceutical companies for activities unrelated to this study. No other competing interests were declared.

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