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- Title
Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19.
- Authors
Iqbal, Javaid; Moineddin, Rahim; Fowler, Robert A.; Krzyzanowska, Monika K.; Booth, Christopher M.; Downar, James; Lau, Jenny; Le, Lisa W.; Rodin, Gary; Seow, Hsien; Tanuseputro, Peter; Earle, Craig C.; Quinn, Kieran L.; Hannon, Breffni; Zimmermann, Camilla
- Abstract
Key Points: Question: Was the COVID-19 pandemic associated with increased socioeconomic disparities in the use of specialized palliative care (SPC) and deaths at home among patients with cancer? Findings: In this cohort study of 173 915 adult patients who died with cancer, the COVID-19 pandemic was associated with a significant immediate increase in home deaths but a decrease in delivery of SPC at the end of life. For patients with low socioeconomic status, the increase in home deaths was smaller and only observed among patients who did not receive SPC. Meaning: These findings suggest that the COVID-19 pandemic amplified end-of-life care disparities associated with socioeconomic status; future interventions are needed to ensure equitable, consistent access to SPC. This cohort study evaluated the association of the COVID-19 pandemic with delivery of specialized palliative care and death at home for patients with cancer by socioeconomic status. Importance: The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes. Objective: To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes. Design, Setting, and Participants: In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre–COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023. Exposure: COVID-19–related hospital restrictions starting March 16, 2020. Main Outcomes and Measures: Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic. Results: Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre–COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, −6.3% to –4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, −1.0% to 3.5%]). Conclusions and Relevance: These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.
- Subjects
HOME environment; CANCER patient psychology; CONFIDENCE intervals; HOME care services; REGRESSION analysis; MEDICAL care; SOCIOECONOMIC factors; COMPARATIVE studies; TIME series analysis; DESCRIPTIVE statistics; SOCIAL classes; SOCIOECONOMIC disparities in health; RESEARCH funding; TUMORS; COVID-19 pandemic; PALLIATIVE treatment; LONGITUDINAL method; OVERALL survival
- Publication
JAMA Network Open, 2024, Vol 7, Issue 2, pe240503
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.0503