Monday, June 25, 2007

Geographic variations in EOL care; Early palliative integration into lung cancer; Dying homeless

Medical Care has an interesting article about geographic variations in end of life care. It looks at the phenomenon of wide geographic disparities in end of life spending (last 6 months of life - apparently $8300 in Grand Junction, CO & >$21,000 in McAllen, TX) in Medicare beneficiaries and tries to see if these differences can be explained by patient preferences. The researchers essentially compared end of life preference survey results with regional variations in end of life spending (adjusted to age, sex, and race). The survey proposed to the subjects (all Medicare beneficiaries) a hypothetical terminal illness situation in which they were likely to live less than a year & looked at things like desired location of terminal care/death; whether people would want to be vented if it would extend their life by only a week or a month; if they'd want drugs for comfort even if it meant their lives might be shorter, etc. ~2500 people were surveyed (this was a disappointing but typical response rate of 65%); average age 76; 85% white. Of note: 87% of these subjects would not want ventilation for a week of life gained; 77% wouldn't want it even for a month of life gained. Anyway, when they divided patients up by quintiles of EOL spending & controlled for age, race, and other demographic information there were no differences. That is - the EOL preferences of those in the highest EOL spending regions were the same as those in the lowest spending regions. This of course raises the question of why there is such a disparity in spending and local medical culture is certainly one possibility & is certainly the possibility I'd be most interested in hearing more about (the obvious follow-up study is to mail surveys to physicians about end of life care practices and see if they vary by regional spending). That said, and one of the more annoying things about this study, is that it is well recognized that medical/Medicare spending in general has wide regional variations and it's certainly possible that these differences are explained by those larger/regional forces and not local medical culture. This is unaddressed by the study.

A recent Journal of Clinical Oncology has a couple notable articles. First and briefly was one finding that depressive symptoms are a poor prognostic sign in patients with newly diagnosed hepatobiliary cancer.

Second and less briefly was a study describing a project to integrate palliative care into the care of advanced non-small cell lung cancer patients from the time of diagnosis. The project, which took place at Dana-Farber, involved patients newly diagnosed with Stage IIIb or IV NSCLCa and good performance statuses (presumably all patients with this diagnosis were approached for the study although this is unclear). This paper presents the "phase II" feasibility part of the project: their goal was for the palliative care team to meet with the patients monthly from the time of diagnosis and for at least 6 months & they defined their (feasibility) success as an at least 50% patient 'compliance' rate with the monthly PC visits - basically asking is this even do-able?.

Findings: median survival was 9 months, 1-year survival was 36%, symptoms were very common, and 'compliance' with palliative care visits/symptom assessments was good (overall 86%). The authors note they are now doing a randomized trial comparing early/integrated palliative care with usual care in these patients which will presumably look at symptom improvement, patient & physician acceptability, etc. This is an exciting project & I'm looking forward to the coming results (& hoping they're positive!). The mantra has long been that palliative care should be integrated into cancer care early on, long before the terminal phase. This is easier said than done of course, and there are lots of barriers to doing this (including legitimate questions about whether this really benefits patients - does an entire population 'at risk' benefit from seeing specialized palliative care or are we best "reserved" for the tougher cases and how would you define those tougher cases and make sure they get to palliative care etc. etc.). The only way of knowing for sure is of course studying it, and then you won't know for sure anyway, but it's something - and if it does show a benefit to patients (or health systems in reduced utilization/costs) then it helps us politically in expanding our presence, for instance, in the cancer clinic.

Journal of General Internal Medicine recently had a couple of articles about end of life care & the chronically homeless. They are both based on qualitative research done with homeless people in Minnesota . The first is about homeless persons' attitudes towards death & dying and the second is about end of life concerns/preferences (both available in free full-text). My favorite quote:

'For some participants advance care planning meant discussion with significant others and/or appointment of a proxy; however, the most cited forms of advance care planning included written documentation of wishes or contact information, personal identification, or written directive or other advance care planning document. One participant voiced a typical strategy to dictate circumstances of his death: "In my wallet, I have a card with my sister's name and a phone number. Do I want to be buried in Minnesota? Hell no!"'

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