Use of Unscheduled Care by People who Die from Cancer

Abstract

Background: People who die from cancer (cancer decedents) frequently attend unscheduled care; little is known about what factors influence these presentations. Most research focuses on Accident & Emergency (A&E) and does not consider GP Out-of-hours (GPOOH) services.

Aim:  Describe demographic, clinical, temporal and prescribing factors that are associated with unscheduled care use by cancer decedents in their last year of life.Design and SettingRetrospective cohort study of all 2,443 cancer decedents in Tayside, Scotland. Clinical, demographic, cancer registry and prescribing datasets were linked to routinely collected clinical data using the Community Health Index number.

Method: Anonymised linked data were analysed in SafeHaven. Analysis was descriptive, with binary logistic regression and GEE Analysis used to examine adjusted associations for demographic and clinical factors in patient-level and attendance-level analyses respectively, and Poisson regression used to test associations between prescribing and unscheduled care use.

Results: 77.9% of cancer decedents attended unscheduled care in the year before death. Most only attended GPOOH (n=1,070;56.2%), with the rest attending A&E only (n=204, 10.7%), or both (n=630, 33.1%). Age, gender, deprivation and cancer type were not significantly associated unscheduled care attendance. People living rurally were less likely to attend unscheduled care (AOR=0.64(0.50 to 0.82)). Pain was the commonest clinical reason for presenting (GPOOH:10.5%, A&E:28.8%). 21% of people dying from cancer were frequent (≥5 attendances/year) users and accounted for over half (57.7%) of unscheduled care attendances. Many attendances occurred in the last week (19.7%), four weeks (36.7%) and twelve weeks (60.3%) of life. Prescribing of palliative care medications increased towards the end of life. Eight in ten cancer decedents were prescribed opioids; however, only two-thirds were co-prescribed laxatives or anti-emetics, and only one in ten were prescribed breakthrough medication. Cancer decedents who attended unscheduled care received more prescriptions per person in all drug categories, compared to those who did not attend unscheduled care. Frequent and very frequent attenders received more than double the number of prescriptions per person for every drug category, compared to non-attenders. Multiple demographic factors, cancer type, and timing of diagnosis, influenced whether or not cancer decedents were prescribed particular drugs or drug categories in their last year of life.

Conclusion: Unscheduled care attendance by cancer decedents was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and other palliative care symptoms. Most cancer decedents seen in unscheduled care were close to their date of death. Prescribing in the last year of life was associated with demographic, cancer type and temporal factors, and was associated with type and frequency of unscheduled care use.

Date of Award	2021
Original language	English
Awarding Institution	University of Dundee
Sponsors	Chief Scientist Office
Supervisor	Blair Smith (Supervisor), Deans Buchanan (Supervisor), Peter Donnan (Supervisor) & Bruce Guthrie (Supervisor)