Days at home at end-of-life: a quality measure for cancer care

Looking at the numbers of days a person facing cancer spends at home in the last six months of life can be an indicator of quality cancer care. A new study exploring how Ontario is doing with respect to this indicator was published this week in Journal of Oncology Practice.

A team from Sunnybrook designed the study and used administrative data from between 2005 and 2013 to examine the number of days spent in the hospital versus at home in the last six months of life for those with cancer.

The study found that patients with cancer in Ontario spent a median of 164 days at home in their last six months of life, which corresponded to 91 per cent of their time.

The hospitalizations included emergency room visits and in-patient stays.

While some of the hospital visits are necessary, the study shines a light on an opportunity to improve the patient experience, says medical oncologist and study co-author Dr. Simron Singh.

“Days spent at home is a patient-driven quality indicator,” he said. “Most people would prefer to spend their time at home. It reminds us, as clinicians, to consider how cancer affects our patients’ lives. If you are spending multiple days a month in the emergency room, that is going to harm your quality of life.”

Of 72,987 patients who died of cancer in Ontario during the study dates, the median number of days spent at home in the last 6 months of life was 164 (interquartile range, 144 to 175 days) of a possible 180 days. The strongest predictors of more time at home were male sex (+2.87 days relative to female sex) and receipt of palliative care before the last 6 months of life (+2.38 days).

“People tend to think of palliative care as only for the those who are imminently dying. But access to palliative care resources early on in the cancer experience gives people a chance to think about their own journey — What’s important to me? What are my goals of care? How do I want to spend my days? How can my symptoms be managed?” Dr. Singh said. “It’s not a one-time conversation; it happens over time and evolves. By accessing a palliative care team and having palliative care discussions early, patients may be able to better manage symptoms and side effects, and avoid visits to the emergency room.”

While the opportunity for days at home is more patient-centred, the study authors do note that everyone cannot be painted with the same brush.

“‘Home’ isn’t the same for everyone – not everyone has the support system to be at home in a safe way and those people understandably feel more safe and comfortable in the hospital. So, we don’t want to say no one should be in hospital: there are absolutely appropriate admissions,” said Dr. Matthew Cheung, hematologist and co-author. “But how best we can meet the needs of patients who want to avoid hospitalization? It is best for most patients, and it is better for the system.”