Search

Introduction Anti-osteoclast treatment with denosumab or zoledronate is known to effectively reduce the need for radiotherapy to bone and other skeletal-related events (SREs) in patients with metastatic castration-resistant prostate cancer (mCRPC). In this study, we analyze primary versus secondary initiation of bone-targeting agents (BTAs) relative to first palliative bone radiotherapy in patients dying of mCRPC. Methods Provincial administrative databases from Ontario, Canada identified patients with prostate cancer (2007-2018, n  = 98 646) who received continuous androgen deprivation therapy (n  = 29 453), died of prostate cancer (2013-2018, n  = 3864), and received life-prolonging therapy for mCRPC (n  = 1850). Variables were collected looking back 3 years from death. Multivariable analysis explored the relationship between clinical variables and BTAs. Results Of the 58% (1066/1850) patients with mCRPC who received BTA, only 289 (25.4%) started BTA prior to first palliative bone radiotherapy as primary prevention. Eight hundred and forty-eight (74.6%) patients either never received BTA before death (n  = 447) or started BTA only after first bone radiotherapy (n  = 401). More patients received denosumab (n  = 825, 77%) than zoledronic acid (n  = 241, 23%). 51.2% (582/1137) of palliative bone radiotherapy was initiated in the last 12 months of life. Factors associated with the use of BTA included elevated alkaline phosphatase (OR = 1.0, P  = .023), de novo metastases (OR = 1.4, P  = .005), medical oncologist involvement (OR = 2.0, P  = .007), diagnosis 2012-2017 versus 2007-2011 (OR = 0.75, P  = .034), and academic center (OR = 0.061, P  = .007). Conclusion A majority of patients with mCRPC never receive BTAs prior to first SRE, despite universal access and availability of these agents in Ontario. These results highlight an opportunity to improve outcomes by emphasizing early introduction of BTA in patients with mCRPC being started on systemic therapy. [ABSTRACT FROM AUTHOR]

Context: Home visits at the end of life decrease hospitalizations and hospital deaths, which reduces healthcare costs and aligns with most patients' wishes. In addition to family physicians, nurse practitioners (NPs) play a critical role in meeting the rising demand for home and community-based palliative care. However, very few population-level studies have examined practice patterns of NPs delivering home-based end-of-life care and the collaboration between physicians and NPs. Objective: To describe the characteristics and outcomes of patients receiving home-based palliative care provided by physicians and NPs in the last 90 days of life. Study Design and Analysis: Retrospective population-based study with a descriptive analysis of patient characteristics and multivariate logistic regression analyses of end-of- life outcomes controlling for patients' demographics, health, and healthcare use. Setting or Dataset: Healthcare administrative data in Ontario, Canada. Population Studied: Adults 19 years and older who died between January 1, 2018, and December 31, 2019, and received home care in their last 90 days of life (N=103,664). Intervention/Instrument: Receipt of home visits by an NP, physician, or both. Outcome Measures: Receipt of medications for symptoms (e.g., pain, delirium/agitation, and terminal secretion) in the last 3 weeks of life, acute care use in the last 3 weeks of life, and location of death. Results: Over half (56.9%) of the decedents did not receive any visits from an NP or physician; 3.8% received at least 1 visit from an NP (and no physician visits), 34.5% received at least 1 visit from a physician (but no NP visits), and 4.9% received at least 1 visit from each. NP visits were more prevalent among patients living in rural areas. Patients who received at least 1 home visit were less likely to be hospitalized, more likely to have received medications for symptom management, and more likely to experience a community-based death. These associations were strongest when patients received home visits from both NPs and physicians. Results from multivariable regression are forthcoming. Conclusions: The receipt of at least 1 NP or physician home visit at the end of life can significantly reduce acute care use, improve access to symptom management medications, and mitigate hospital-based deaths. Collaboration between NPs and physicians was associated with greater benefits to patients' outcomes., Presenters Amy Ramzy, BHSc, Mary Scott, MSc, Sarina Isenberg, Colleen Webber, Carrie Heer, NP-PHC, MN, Maya Murmann, MSc, HBA, Jennifer Rayner, PhD, Roshanak Mahdavi, Peter Tanuseputro, David Ponka, MD, CCFP, [...]

Introduction: Adherence to best practices for care of hip fracture patients is fundamental to decreasing morbidity and mortality in older adults. This includes timely transfer from the hospital to rehabilitation soon after their surgical care. Hospitals experience challenges in implementing several best practices. We examined the potential barriers associated with timely discharge for patients who underwent a hip fracture surgery in an academic hospital in Ontario, Canada. Methods: We conducted a retrospective cross-sectional review of a local database. We used descriptive statistics to characterize individuals according to the time of discharge after surgery. Multivariable binary logistic regression was used to evaluate factors associated with delayed discharge (>6 days post-surgery). Results: A total of 492 patients who underwent hip fracture surgery between September 2019 and August 2020 were included in the study. The odds of having a delayed discharge occurred when patients had a higher frailty score (odds ratios [OR] 1.19, 95% confidence interval [CI] 1.02;1.38), experienced an episode of delirium (OR 2.54, 95% CI 1.35;4.79), or were non-weightbearing (OR 3.00, 95% CI 1.07;8.43). Patients were less likely to have a delayed discharge when the surgery was on a weekend (OR.50, 95% CI.32;.79) compared to a weekday, patients had a total hip replacement (OR.28, 95% CI.10;.80) or dynamic hip screw fixation (OR.49, 95% CI.25;.98) compared to intramedullary nails, or patients who were discharged to long-term care (OR.05, 95% CI.02;.13), home (OR.26, 95% CI.15;.46), or transferred to another specialty in the hospital (OR.49, 95% CI.29;.84) compared to inpatient rehabilitation. Conclusions: Clinical and organizational factors can operate as potential barriers to timely discharge after hip fracture surgery. Further research is needed to understand how to overcome these barriers and implement strategies to improve best practice for post-surgery hip fracture care. [ABSTRACT FROM AUTHOR]

Background Most individuals prefer to spend their final moments of life outside a hospital setting. This study compares the places of care and death of long-term care (LTC) home residents in Ontario in the last 90 days of life, according to LTC home rurality. Data and methods This retrospective cohort study was conducted using health administrative data from ICES (formerly known as the Institute for Clinical Evaluative Sciences). The study population, which was identified through algorithms, included all Ontario LTC home residents with a dementia diagnosis who died between April 1, 2014, and March 31, 2019. The location of death was categorized as in an acute care hospital, an LTC home, a subacute care facility, or the community. Places of care included emergency department visits and hospitalizations in the last 90 days of life. Statistical tests were used to evaluate differences in location of death and places of care by rurality. Results Of the 65,375 LTC home residents with dementia, 49,432 (75.6%) died in an LTC home. Residents of LTC homes in the most urban areas were less likely to die in an LTC home than those in more rural homes (adjusted relative risk: 0.84; 95% confidence interval: 0.83 to 0.85). A higher proportion of residents of the most urban LTC homes had at least one hospitalization in the last 90 days of life compared with rural residents (23.7% versus 9.9% palliative hospitalizations and 28.3% versus 15.9% non-palliative hospitalizations [p < 0.001]). Interpretation Individuals with dementia residing in urban LTC homes are more likely to receive care in the hospital and to die outside a LTC home than their counterparts living in rural LTC homes. The findings of this work will inform efforts to improve end-of-life care for older adults with dementia living in LTC homes. [ABSTRACT FROM AUTHOR]

Background: The impact of delirium on cognition has not been well‐studied in long‐term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia. Methods: We conducted a population‐based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument‐Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0–6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models. Results: Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval [CI] 1.35–1.99), 1.56 (95% CI 1.34–1.85), 1.57 (95% CI 1.32–1.86) and 1.50 (95% CI 1.25–1.80) after 1–3, 4–6, 7–9, and 10–12 months of follow‐up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79–6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%). Conclusions: Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects. See related editorial by Bellelli et al. in this issue. [ABSTRACT FROM AUTHOR]

Background and Methods: We conducted a population‐based, retrospective cohort study of first‐time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all‐cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. Results: A total of 71,776 AYA had a first‐time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First‐time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69–3.51). Mortality was associated with age 25–29 years (aHR 3.88, 95% CI 2.56–5.86), being male (aHR 1.98, 95% CI 1.49–2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64–6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96–4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27–3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. Conclusion: Incident ED visits due to alcohol in AYA are associated with a high risk of 1‐year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow‐up care in this population. [ABSTRACT FROM AUTHOR]