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Quality and Costs of End-of-Life Cancer Care: The Effect of Homecare Nursing in Three Provinces
Providing homecare nursing to cancer patients in the last months of life can potentially improve the quality and reduce the cost of end-of-life (EOL) care. Previous work in Ontario found a strong association between increased homecare nursing use and decreased risk of hospitalization in the last two weeks of life. The objectives of this study were to investigate whether the same relationship between homecare nursing and hospitalization exists across three Canadian provinces (British Columbia, Ontario and Nova Scotia) for cancer patients in the last 6 months of life, and to extend the analysis to measure the relationship between homecare nursing and hospitalization costs.
Data sources and analysis
Each province identified a cohort of cancer decedents, with death dates between 2004 and 2009, from their respective cancer registries. The outcomes of interest, hospital admission rate and hospitalization cost, were defined using the CIHI Discharge Abstract Database. The exposure of interest, homecare nursing rate, was defined by each province separately using their available homecare nursing data. In BC, the BC Cancer Agency and the BC Ministry of Health approved access to and use of the data facilitated by Population Data BC.
The association between homecare nursing rate in a given week and hospitalization rate in the subsequent week was analyzed using Poisson regression under a generalized estimating equations approach, adjusting for age, sex, cancer site, comorbidity, neighborhood income, community size, and palliative indication. Preliminary cost analysis is currently underway.
Strengths and caveats associated with data analysis process
The primary challenge that the study team encountered was the difference in homecare nursing program structure, and consequently data structure, in the three provinces. However, despite differences in how each province’s homecare nursing rate was defined, the observed associations were similar, strengthening the generalizability of results. Receiving nursing with palliative intent in the last six months of life significantly reduced the risk of hospitalization, while in the last month of life, increased homecare nursing, regardless of indication, decreased hospitalization.
Impact to health policy and implications for related research
To improve end-of-life cancer care, policymakers should consider prioritizing palliative homecare nursing services to manage symptoms in the last months of life, and support policies to provide easier access to more homecare nursing during the last month of life as the complexity and burden of symptoms increases.