Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.
Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA.
JCO Oncol Pract. 2020 Dec;16(12):e1543-e1552. doi: 10.1200/OP.20.00217. Epub 2020 Aug 17.
Aggressive care at the end of life (EOL) can lead to unnecessary suffering and health care costs for patients with cancer. Despite geographic proximity and cultural similarities, we hypothesize that EOL care is more intense in the United States multipayer system versus the Canadian single-payer system. We compared health care utilization at EOL among patients with cancer in Alberta, Canada, with those in Washington state in the United States.
Adult patients with American Joint Committee on Cancer stage II to IV solid tumors who died between 2014 and 2016 in Alberta and between 2015 and 2017 in Washington were identified from regional population-based cancer registries linked to treatment and hospitalization records (Alberta) and health claims from major regional insurance plans (Washington). The proportion of patients receiving chemotherapy and having multiple emergency department (ED) visits, or intensive care unit (ICU) admissions in the last 30, 60, and 90 days of life (DOL) in Alberta and Washington were determined and compared using two-sample -test and multivariable logistic regression (α = .006 after Bonferroni correction).
Of patients, 11,177 in Alberta and 12,807 in Washington were included. Patients were similar in age (median, 71 72 year), with more patients in Washington with no comorbidities. More patients in Washington were treated with chemotherapy (12.6% 6.6%; adjusted OR [aOR], 2.74), had multiple ED visits (16.2% 12.1%; aOR, 1.40), and ICU admissions (23.7% 3.9%; aOR, 14.27) in the last 30 DOL. Utilization was also higher in Washington in the last 60 and 90 DOL and among those with stage IV disease and those age 65 years and older.
Utilization of chemotherapy, ED visits, and ICU admissions near EOL was higher in Washington versus Alberta. Future studies to characterize drivers of aggressive EOL care may help improve cancer care for patients in the United States and Canada.
生命末期（EOL）的积极治疗可能会给癌症患者带来不必要的痛苦和医疗费用。尽管地理位置相近，文化相似，但我们假设在美国的多付款人系统中，EOL 护理比加拿大的单一付款人系统更密集。我们比较了加拿大艾伯塔省和美国华盛顿州癌症患者在 EOL 期间的医疗保健利用情况。
从与治疗和住院记录相关联的区域人群癌症登记处（艾伯塔省）以及主要区域保险计划的健康索赔（华盛顿）中，确定了 2014 年至 2016 年期间在艾伯塔省和 2015 年至 2017 年期间在华盛顿州死亡的美国癌症联合委员会（AJCC）分期 II 至 IV 期实体肿瘤的成年患者。在艾伯塔省和华盛顿州，确定并比较了在生命最后 30、60 和 90 天内接受化疗和多次急诊就诊或重症监护病房（ICU）入院的患者比例，使用两样本 t 检验和多变量逻辑回归（经 Bonferroni 校正后为 α =.006）。
在艾伯塔省有 11177 例患者，在华盛顿州有 12807 例患者。患者的年龄相似（中位数，71 岁），华盛顿州的患者无合并症的比例更高。华盛顿州接受化疗的患者比例更高（12.6% 比 6.6%；调整后的比值比[aOR]，2.74），在生命最后 30 天内急诊就诊次数更多（16.2% 比 12.1%；aOR，1.40），入住 ICU 次数更多（23.7% 比 3.9%；aOR，14.27）。在生命的最后 60 天和 90 天，以及在 IV 期疾病和 65 岁及以上的患者中，华盛顿州的使用率也更高。
与艾伯塔省相比，华盛顿州在生命末期接受化疗、急诊就诊和 ICU 入院的患者比例更高。未来的研究以描述积极的 EOL 护理的驱动因素，可能有助于改善美国和加拿大癌症患者的护理。
