Days Spent at Home in the Last 6 Months of Life. a Potential Patient-Determined Quality Indicator for Patients with Hematologic Malignancies at the End of Life

Despite advances in the management of patients with hematologic malignancies, a significant proportion of patients will still die of their disease. Current quality indicators at the end of life (EOL) focus on whether patients receive aggressive interventions, including chemotherapy in the last days of life. However, frail patients and caregivers themselves have recently highlighted that "time spent at home" represents the most important measure of EOL quality care (Groff et al., NEJM 2016). This potential patient-determined quality indicator has not been previously studied in patients with hematologic malignancies.

We used population-based health system administrative databases from Ontario, Canada. We identified a cohort of all adult patients who died of a hematologic malignancy from January 2005 to December 2013 within the Ontario Cancer Registry. The primary outcome of "days at home" in the last 6 months of life was defined as: 180 days minus the number of days in an acute care facility (inpatient, emergency department, and same day surgery stays), an inpatient rehabilitation facility, skilled nursing facility, or chronic care facility. We further identified patient variables (including comorbidities identified by a mortality risk score by Austin and van Walraven, Med Care 2011) and system level variables (including palliative care consultation prior to the last 6 months of life) that predicted for number of days at home and identified trends over time. We used a logistic regression model to identify relevant predictors of time spent at home beyond the median.

During the relevant time-period, 6792 patients with hematologic malignancies died in Ontario. Median age was 72 (IQR 62-80) at the time of cancer death and 58% of patients were male. Median comorbidity score, measured by the mortality risk score, was moderate-to-high at 27 (IQR 20-34), 15% of patients were rural-based, and 27% had received palliative care consultation prior to the last 6 months of life. The median number of days at home in the last 6 months of life was 166 days; 81% of patients spent more than 120 days at home over the last 6 months of life. Increased age (per five year increase OR 1.14; CI 1.12-1.17; p<0.0001), male gender (OR 1.30; CI 1.17-1.44; p<0.0001), and an extended time period from diagnosis until death (per 5 year increase OR 1.02; CI 1.01-1.03; p=0.0021) were independent predictors of spending more than the median number of days at home. Patients who had received palliative care consultation prior to the 6 months were also more likely to spend time at home compared to those who had not been seen by palliative care (OR 1.34; CI 1.20-1.49; p<0.0001). In contrast, patients with more comorbidities according to the mortality risk score were less likely to spend time at home (OR 0.96; CI 0.96-0.97; p<0.0001). There was evidence of geographic/regional variation in ability to die at home (p<0.0001). Rural status (p=0.26) and year of death (trend analysis p=0.50) were not associated with the outcome of days at home in the last 6 months of life.

In a large population of patients who die from hematologic malignancies, >80% of patients spend >120 days at home in the last 6 months of life. Certain demographic features of patients more likely to die at home suggest an important role for access to caregiver support (i.e. spousal/family support). Importantly, earlier access to palliative care may increase the likelihood that patients can die at home, representing a modifiable/actionable factor for physicians to consider to improve the quality of care in patients who are nearing the end of life.