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Objectives: End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions., Design: Retrospective cohort study using administrative data., Setting/participants: Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death., Methods: Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions., Results: Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04)., Conclusions and Implications: Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Objectives: Long-term care (LTC) homes provide personal and medical care 24/7 to individuals unable to live at home due to illness or disability and are often the final place of care and death for their residents. Therefore, LTC homes are tasked with providing quality end-of-life care, often requiring injectable symptom management medications to relieve distressing symptoms (eg, pain). In this study, we aimed to understand the enablers and barriers to prescribing and administering end-of-life symptom management medications in LTC homes., Design: Qualitative study., Setting and Participants: From February 2021 to December 2022, we conducted virtual semi-structured interviews with health care providers (physicians and nurses) who worked in Ontario LTC homes and family caregivers of residents who died in LTC., Methods: We analyzed interview transcripts using thematic analysis., Results: We identified 4 themes related to factors that may impact the prescribing and administering of medications for end-of-life symptom management: (1) identifying the end-of-life period and symptoms, (2) communication among health care providers and between health care providers and family caregivers, (3) health care provider competency with end-of-life medications, and (4) resources for LTC staff to support medication prescribing and administrating., Conclusions and Implications: In LTC, there are distinct challenges in the prescribing and administrating of end-of-life symptom management medications. Our findings can be used to inform interventions aimed at improving end-of-life care for LTC residents. However, these interventions require buy-in and investment from the provincial government and the LTC sector., Competing Interests: Disclosures The authors declare no conflicts of interest., (Copyright © 2024 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic., Design: Retrospective cohort study using routinely collected health administrative data in Ontario, Canada., Setting and Participants: We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021)., Methods: For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles., Results: We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%)., Conclusions and Implications: LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Medications are often needed to manage distressing end-of-life symptoms (eg, pain, agitation)., Objectives: In this study, we describe the variation in prescribing rates of symptom relief medications at the end of life among long-term care (LTC) decedents. We evaluate the extent these medications are prescribed in LTC homes and whether prescribing rates of end-of-life symptom management can be used as an indicator of quality end-of-life care., Design: Retrospective cohort study using administrative health data., Setting and Participants: LTC decedents in all 626 publicly funded LTC homes in Ontario, Canada, between January 1, 2017, and March 17, 2020., Methods: For each LTC home, we measured the percent of decedents who received 1+ prescription(s) for a subcutaneous end-of-life symptom management medication ("end-of-life medication") in their last 14 days of life. We then ranked LTC homes into quintiles based on prescribing rates., Results: We identified 55,916 LTC residents who died in LTC. On average, two-thirds of decedents (64.7%) in LTC homes were prescribed at least 1 subcutaneous end-of-life medication in the last 2 weeks of life. Opioids were the most common prescribed medication (overall average prescribing rate of 62.7%). LTC homes in the lowest prescribing quintile had a mean of 37.3% of decedents prescribed an end-of-life medication, and the highest quintile mean was 82.5%. In addition, across these quintiles, the lowest prescribing quintile had a high average (30.3%) of LTC residents transferred out of LTC in the 14 days compared with the highest prescribing quintile (12.7%)., Conclusions and Implications: Across Ontario's LTC homes, there are large differences in prescribing rates for subcutaneous end-of-life symptom relief medications. Although future work may elucidate why the variability exists, this study provides evidence that administrative data can provide valuable insight into the systemic delivery of end-of-life care., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death., Methods: A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada., Results: Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home., Conclusions: In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience., (© 2022 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: The mix of care provided by family physicians, specialists and palliative care physicians can vary by the illnesses leading to death, which may result in disruptions of continuity of care at the end of life. We measured continuity of outpatient physician care in the last year of life across differing causes of death and assessed factors associated with higher continuity., Methods: We conducted a retrospective descriptive study of adults who died in Ontario between 2013 and 2018, using linked provincial health administrative data. We calculated 3 measures of continuity (usual provider, Bice-Boxerman and sequential continuity), which range from 0 to 1, from outpatient physician visits over the last year of life for terminal illness, organ failure, frailty, sudden death and other causes of death. We used multivariable logistic regression models to evaluate associations between characteristics and a continuity score of 0.5 or greater., Results: Among the 417 628 decedents, we found that mean usual provider, Bice-Boxerman and sequential continuity indices were 0.37, 0.30 and 0.37, respectively, with continuity being the lowest for those with terminal illness (0.27, 0.23 and 0.33, respectively). Higher number of comorbidities, higher neighbourhood income quintile and all non-sudden death categories were associated with lower continuity., Interpretation: We found that continuity of physician care in the last year of life was low, especially in those with cancer. Further research is needed to validate measures of continuity against end-of-life health care outcomes., Competing Interests: Competing interests: Peter Tanuseputro is supported by a PSI Graham Farquharson Knowledge Translation Fellowship. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Introduction: To provide equitable cancer care at the end of life, it is essential to first understand the evidence underpinning the existence of unequal cancer outcomes. Study design, measurement and analytical decisions made by researchers are a function of their social systems, academic training, values and biases, which influence both the findings and interpretation of whether inequalities or inequities exist. Methodological choices can lead to results with different implications for research and policy priorities, including where supplementary programmes and services are offered and for whom. The objective of this scoping review is to provide an overview of the methods, including study design, measures and statistical approaches, used in quantitative and qualitative observational studies of health equity in end-of-life cancer care, and to consider how these methods align with recommended approaches for studying health equity questions., Methods and Analysis: This scoping review follows Arksey and O'Malley's expanded framework for scoping reviews. We will systematically search Medline, Embase, CINAHL and PsycINFO electronic databases for quantitative and qualitative studies that examined equity stratifiers in relation to end-of-life cancer care and/or outcomes published in English or French between 2010 and 2021. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. Data from included full-text articles will be extracted into a data form that will be developed and piloted by the research team. Extracted information will be summarised quantitatively and qualitatively., Ethics and Dissemination: No ethics approval is required for this scoping review. Results will be disseminated to researchers examining questions of health equity in cancer care through scientific publication and presentation at relevant conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.

Context: Most people spend the majority of their last year of life at home or in a home-like setting, receiving outpatient healthcare. Increasing numbers of physicians and teams, including palliative care providers, may become involved in care in addition to a usual provider such as a family physician. Continuity of care (CoC) near the end of life, although considered a marker of quality of care, may be interrupted despite the provision of high-quality care. Objective: To describe continuity of outpatient physician care in the last 12 months of life and determine patient and illness-related factors associated with high continuity. Study Design: Retrospective cohort study. Datasets: Linked population-based health administrative databases for Ontario, Canada, held at ICES. Population: Decedents aged 19 years or older, who died between January 1, 2013, and December 31, 2017. Outcome Measures: Continuity of care scores for the last 12 months of life, using the Usual Provider continuity (UPC), Bice-Boxerman continuity (CoC), and Sequential Continuity (SECON) indices. Multivariate models were used to determine factors associated with higher continuity scores (>= 0.75). Results: Decedents (n=322,445) were on average 76.3 years of age, 47.8% were female, and 13.2% resided in rural regions. Decedents had a mean of 16.2 outpatient physician encounters in the last year of life, from a mean of 3.8 different physician specialties. Mean continuity indices' scores (1 being perfect) were low: UPC= 0.36, CoC= 0.31, and SECON= 0.37. Proportions of decedents with high continuity were: UPC= 12.6%, CoC= 9.6%, and SECON= 12.9%. Decedents who experienced a terminal illness (i.e., cancer) end-of-life trajectory were least likely to experience high UPC (OR= 0.32; 95% CI= 0.30, 0.34). Having six or more comorbidities (OR= 0.65; 95% CI= 0.63, 0.66), and being in the highest quintile of outpatient physician encounters (i.e., >22 visits) (OR= 0.28; 95% CI= 0.27, 0.29) were also negatively associated with high UPC. Results were similar for other indices. Conclusions: Decedents experience low continuity of outpatient physician care in the last year of life, especially those with cancer, comorbidities, and frequent physician visits. Modifications to existing indices may be needed to serve as end-of-life care quality indicators., Competing Interests: Authors report none., (2021 Annals of Family Medicine, Inc.)

Background: Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking., Aim: The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use., Settings and Participants: We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died., Results: Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use., Conclusions: Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.

Background: For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories., Methods: We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory., Results: Decedents ( n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians., Interpretation: Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care., Competing Interests: Competing interests: James Downar reports consulting fees from CMA Joule and honoraria from Boehringer Ingelheim (Canada), outside the submitted work. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Context: Care transitions at the end of life are associated with reduced quality of life and negative health outcomes, yet up to half of patients in developed countries experience a transition within the last month of life. A variety of these transitions have been described as "burdensome" in the literature; however, there is currently no consensus on the definition of a burdensome transition., Objectives: The purpose of this review was to identify current definitions of "burdensome transitions" and develop a framework for classifying transitions as "burdensome" at the end of life., Methods: A search was conducted in databases including Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, CINAHL, and PsychINFO for articles published in English between January 1, 2000 and September 28, 2019., Results: A total of 37 articles met inclusion criteria for this scoping review. Definitions of burdensome transitions were characterized by the following features: transition setting trajectory, number of transitions, temporal relationship to end of life, or quality of transitions., Conclusion: Definitions of burdensome transitions varied based on time before death, setting of cohorts, and study population. These definitions can be helpful in identifying and subsequently preventing unnecessary transitions at the end of life., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes., Aim: To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death., Design: Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death., Setting/participants: All adults aged 18-105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017., Results: Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%-59%), acute hospitalization (64%-69%) or ICU admission (7%-17%), as well as community death (36%-40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4-9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9-2.0)., Conclusion: The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.

Background: Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients' receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs., Methods: Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital., Results: There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement)., Conclusions: Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Background: Limited research has characterized team-based models of home palliative care and the outcomes of patients supported by these care teams., Case Presentation: A retrospective case series describing care and outcomes of patients managed by the London Home Palliative Care Team between May 1, 2017 and April 1, 2019., Case Management: The London Home Palliative Care (LHPC) Team care model is based upon 3 pillars: 1) physician visit availability 2) active patient-centered care with strong physician in-home presence and 3) optimal administrative organization., Case Outcomes: In the 18 month study period, 354 patients received care from the London Home Palliative Care Team. Most significantly, 88.4% ( n = 313) died in the community or at a designated palliative care unit after prearranged direct transfer; no comparable provincial data is available. 21.2% ( n = 75) patients visited an emergency department and 24.6% ( n = 87) were admitted to hospital at least once in their final 30 days of life. 280 (79.1%) died in the community. These values are better than comparable provincial estimates of 62.7%, 61.7%, and 24.0%, respectively., Conclusion: The London Home Palliative Care (LHPC) Team model appears to favorably impact community death rate, ER visits and unplanned hospital admissions, as compared to accepted provincial data. Studies to determine if this model is reproducible could support palliative care teams achieving similar results.

Background: A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada., Methods: We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12-2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC)., Results: We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs., Conclusions: High users - persistent and non-persistent - are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

Background: There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care., Aim: To determine (1) the feasibility of integrating 'LIFEView', a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using 'LIFEView' videos., Design: A mixed-methods pre-post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life., Setting/participants: Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants., Results: Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System-revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using 'LIFEView', perceptions of the technology, reminiscence, 'LIFEView' as an adaptable technology and ongoing or future use., Conclusion: A future adequately powered study to investigate the impacts of 'LIFEView' on patient well-being and quality of life appears to be feasible.

Context: The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home., Objectives: To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients., Methods: This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s)., Results: The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P < 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death., Conclusion: Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)