Skip to main content

Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery

Journal of Gastrointestinal Surgery volume 23, pages 153–162 (2019)Cite this article

Abstract

Background

The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery.

Methods

The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC.

Results

Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease.

Conclusions

In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. Washington, DC: National Academies Press; 2015.

    Google Scholar 

  2. World Health Organization. Global atlas of palliative care at the end of life. 2014. http://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf. Accessed April 20th, 2018.

  3. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733–742.

    Article  CAS  PubMed  Google Scholar 

  4. Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Services Research. 2010;45(2):565–576.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Dans M, Smith T, Back A, et al. NCCN guidelines insights: palliative care, version 2.2017. J Natl Compr Canc Netw 2017;15:989–997

    Article  PubMed  Google Scholar 

  6. Braun LT, Grady KL, Kutner JS, et al. Palliative care and cardiovascular disease and stroke: a policy statement from the American Heart Association/American Stroke Association. Circ 2016;134:e198-e225

    Article  Google Scholar 

  7. Lilley EJ, Cooper Z, Schwartze M, Mosenthal AC. Palliative care in surgery: defining the research priorities. Ann Surg 2018;267(1):66–72.

  8. Suwanabol PA, Kanters AE, Reichstein AC, et al. Characterizing the role of U.S. surgeons in the provision of palliative care: a systematic review and mixed-methods meta-synthesis. J Pain Symp Man 2018;55(4):1196–1215.

    Article  Google Scholar 

  9. Olmsted CL, Johnson AM, Kaboli P, Cullen J, Vaughan-Sarrazin MS. Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration. JAMA Surg. 2014;149(11):1169–1175.

    Article  PubMed  Google Scholar 

  10. American Academy of Hospice and Palliative Medicine. Number of Certified hospice and palliative medicine physicians by cosponsoring specialty board. http://aahpm.org/hpm/number-certified. Accessed on April 21, 2018.

  11. Task Force on Surgical Palliative care; Committee on Ethics. Statement of principles of palliative care. Bull Am Coll Surg 2005;90:34–5.

    Google Scholar 

  12. Dunn GP. Surgery, palliative care, and the American College of Surgeons. Ann Pall Med 2015;4(1):5–9

    Google Scholar 

  13. Dunn GP, Martensen R, Weissman D. Surgical palliative care: a resident’s guide. American College of Surgeons/Cunniff-Dixon Foundation: Chicago, IL/Essex, CT, 2009

    Google Scholar 

  14. Mustafa R, Lisa O, Leigh N, et al. Prospective evaluation of surgical palliative care immersion training for general surgery residents. Am J Surg 2017;214(2):378–383.

    Article  Google Scholar 

  15. Ernst KF, Hall DE, Schmid KK, Seever G, Lavedan P, Lynch TG, Johanning JM. Surgical palliative care consultations over time in relationship to systemwide frailty screening. JAMA Surg. 2014;149(11):1121–1126

    Article  PubMed  PubMed Central  Google Scholar 

  16. Washington J, Al-Kindi SG, Oliveira GH, Robinson MR. Inpatient palliative care utilization in elderly patients admitted with heart failure in the United States. J Cardiac Failure 2017;23(8):S118

    Article  Google Scholar 

  17. Tarvinder S, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative care for hospitalized patients with stroke: results from the 2010 to 2012 national inpatient sample. Stroke 2017;48:2534–2540

    Article  Google Scholar 

  18. Patel AA, Walling AM, Ricks-Oddie J, May FP, Saab S, Wenger N. Palliative care and health care utilization for patients with end-stage liver disease at the end of life. Clin Gastroent Hep 2017;15(10):1612–1619

    Article  Google Scholar 

  19. Chong K, Silver SA, Long J, et al. Infrequent provision of palliative care to patients with dialysis-requiring AKI. Clin J Am Soc Neph 2017 CJASN ePress

  20. Hammad AY, Robbins JR, Turaga KK, Christians KK, Gamblin TC, Johnston FM. Palliative interventions for hepatocellular carcinoma patients: analysis of the National Cancer Database. Ann Palliat Med 2017;6(1):26–35.

    Article  PubMed  Google Scholar 

  21. Krell RW, Regenbogen SE, Wong SL. Variation in hospital treatment patterns for metastatic colorectal cancer. Cancer. 2015;121(11):1755–1761. https://doi.org/10.1002/cncr.29253.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kulaylat AS, Rivet EB, Hollenbeak CS, Stewart DB. Palliative therapy for stage IV rectal adenocarcinoma: how frequently is it used? J Surg Res. 2017;218:1–8.

    Article  PubMed  Google Scholar 

  23. Kulaylat AS, Mirkin KA, Hollenbeak CS, Wong J. Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: a U.S. population-based study. J Gastrointest Oncol 2017;8(4):710–720.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hossein M, Kang CY, Chen A, et al. Predictive factors of in-hospital mortality in colon and rectal surgery. JACS. 2012;215(2):255–261.

    Google Scholar 

  25. Anderson JH, Hole D, McArdle CS. Elective versus emergency surgery for patients with colorectal cancer. Br J Surg. 1992;79:706–709.

    Article  CAS  PubMed  Google Scholar 

  26. Bayar B, Yilmaz KB, Akinci M, et al. An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients. Ulus Cerrahi Deg. 2016;32:11–17.

    Google Scholar 

  27. Neuman, H. B., O'Connor, E. S., Weiss, J. , LoConte, N. K., Greenblatt, D. Y., Greenberg, C. C. and Smith, M. A. (2013), Surgical treatment of colon cancer in patients aged 80 years and older. Cancer, 119: 639–647.

    Article  PubMed  Google Scholar 

  28. Wong SK, Jalaludin BB, Berthelsen AS, et al. Tumor pathology and long-term survival in emergency colorectal cancer. Dis Colon rectum. 2008;51(2):223–230.

    Article  PubMed  Google Scholar 

  29. Hossein M, Kang CY, Chaudhry O, et al. Predictive factors of early bowel obstruction in colon and rectal surgery: data from the nationwide inpatient sample, 2006–2008. JACS. 2012;214(5):831–837.

    Google Scholar 

  30. Ming-gao G, Jian-zhong D, Yu W, et al. Colorectal cancer treatment in octogenarians: elective or emergency surgery? World J Surg Onc. 2014;12(386):1–6

    Google Scholar 

  31. Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER cancer statistics review, 1975-2015, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2015/, based on November 2017 SEER data submission, posted to the SEER web site, 2018. Accessed May 1st, 2018.

  32. HCUP Databases. Healthcare Cost and Utilization Project (HCUP). 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed April 30, 2018.

  33. HCUP CCS. Healthcare Cost and Utilization Project (HCUP). 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed April 30, 2018.

  34. 2015 ICD-9 CM for physicians, volumes 1 & 2. American Medical Association. 2015 Saunders, an imprint of Elsevier Inc, pp 980.

  35. Feder SL, Redeker NS, Sangchoon J, et al. Validation of the ICD-9 diagnostic code for palliative care in patients hospitalized with heart failure within the Veterans Health Administration. Am J Hosp & Pall Med. 2017;1-7. https://doi.org/10.1177/1049909117747519.

  36. Horton JR, Morrison RS, Capezuti E, Hill J, Lee EJ, Kelley AS. Impact of inpatient palliative care on treatment intensity for patients with serious illness. Journal of Palliative Medicine. 2016;19(9):936–942.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Obermeyer Z, Makar M, Abujaber S, et al. Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA 2014;312(18):1888–1896

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Cheung MC, Earle CC, Rangrej J, et al. Impact of aggressive management and palliative care on cancer costs in the final month of life. Cancer 2015;121(18):3307–3315

    Article  PubMed  PubMed Central  Google Scholar 

  39. HCUP NIS Trend Weights. Healthcare Cost and Utilization Project (HCUP). 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/db/nation/nis/trendwghts.jsp. Accessed on May 3rd, 2018.

  40. Galante JM, Bowles TL, Khatri VP, Schneider PD, Goodnight JE, Bold RJ. Experience and attitudes of surgeons toward palliation in cancer. Arch Surg. 2005;140(9):873–880

    Article  PubMed  Google Scholar 

  41. Cauley CE, Block SD, Koritsanszky LA, et al. Surgeons' perspectives on avoiding nonbeneficial treatments in seriously ill older patients with surgical emergencies: a qualitative study. J Palliat Med 2016;19(5):529–537.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Gidwani R, Joyce N, Kinosian B, et al. Gap between recommendations and practice of palliative care and hospice in cancer patients. J Palliat Med. 2016;19(9):957–963

    Article  PubMed  Google Scholar 

  43. Mor V, Joyce NR, Coté DL, et al. The rise of concurrent care for veterans with advanced cancer at the end of life. Cancer. 2016;122(5):782–90.

    Article  PubMed  Google Scholar 

  44. Roeland EJ, Triplett DP, Matsuno RK, et al. Patterns of palliative care consultation among elderly patients with cancer. J Natl Compr Canc Netw. 2016;14:439–445.

    Article  CAS  PubMed  Google Scholar 

  45. Dumanovsky T, Augustin R, Rogers M, et al. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med. 2016;19(1)8–15.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Morrison SR, Meier DE. America’s care of serious illness: 2015 state-by-state report card on access to palliative care in our Nation’s Hospitals. Available at: https://registry.capc.org/wp-content/uploads/2016/01/2015-State-by-state-Report-Card.pdf. Accessed May 6, 2018.

  47. Hawley P. Barriers to access to palliative care. Palliat Care. 2017;10:1–6.

    CAS  Google Scholar 

  48. Cain CL, Surbone A, Elk R, Kagawa-Singer M. Culture and palliative care: preferences, communication, meaning, and mutual decision making. J Pain & Symp Man. 2018;55(5):1408–1419.

    Article  Google Scholar 

  49. Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci. 2011;1(2)154–156.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences?: a study of the US Medicare population. Med Care. 2007; 45(5):386–93.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Matlock DD, Peterson PN, Sirovich BE, et al. Regional variations in palliative care: do cardiologists follow guidelines? J Palliat Med. 2010;13(11):1315–1319.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This publication was made possible by CTSA Grant Numbers TL1 TR001864 and UL1 TR001863 from the National Center for Advancing Translational Science (NCATS), components of the National Institutes of Health (NIH), NIH roadmap for Medical Research, and by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number T35DK104689. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. We also acknowledge the Center to Advance Palliative Care and the National Palliative Care Research Center for generously permitting use of an original illustration from the “2015 State-by-State Report Card” (Fig. 2).

Author information

Affiliations

  1. Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA

    Danielle R. Heller, Raymond A. Jean, Alexander S. Chiu & Vadim Kurbatov

  2. National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA

    Raymond A. Jean & Shelli I. Feder

  3. US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA

    Shelli I. Feder

  4. Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA

    Charles Cha & Sajid A. Khan

Authors
  1. Danielle R. Heller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Raymond A. Jean
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alexander S. Chiu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shelli I. Feder
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Vadim Kurbatov
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Charles Cha
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sajid A. Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

As per International Committee of Medical Journal Editors guidelines, each listed author made substantial contributions to the manuscript. DR Heller, RA Jean, and SA Khan conceived of and designed this study. Data analysis and interpretation, as well as manuscript drafting and approval, was performed meaningfully by all listed authors. All authors accept responsibility for the accuracy and integrity of this work.

Corresponding author

Correspondence to Sajid A. Khan.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Heller, D.R., Jean, R.A., Chiu, A.S. et al. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 23, 153–162 (2019). https://doi.org/10.1007/s11605-018-3929-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-018-3929-0

Keywords

  • Palliative care
  • Colorectal neoplasms
  • Geriatrics
  • Emergency treatment