Hospital care utilization trends in patients with COPD and lung cancer in the 6 months prior to death

Background: Hospital care utilization has been described as a key measurable indicator of care quality in patients with terminal respiratory diseases. Knowledge about patterns in service utilization for patients with advanced Chronic Obstructive Pulmonary Disease (COPD), however, is fairly limited. The goal of this study was to investigate health care utilization patterns in the last six months of life among patients who died with COPD compared with those who died of lung cancer, and also to examine variations in health care among individuals living with COPD between sex, age, comorbidity, and temporal trends. Methods: We conducted a retrospective study using administrative health data in the province of Saskatchewan to identify indicators associated with greater hospital care utilization between 1997 and 2006. Those with either COPD or lung cancer as the underlying cause of death (UCOD) were included in this study. Characteristics examined in this study included socio-demographics, comorbidity, location of death, and use of institutional services. Multiple logistic regression was the primary method of analysis. Results: Between 1997 and 2006, 7,114 persons covered by Saskatchewan Health were identified as having COPD (N=2,332) or lung cancer as the UCOD (N=4,782). Approximately 60% were males with an average age of 74.2 years (S.D. =10.1 years). Half of the decedents were rural dwellers (47.0%), and were married or common law (51.6%). The majority had multiple comorbid conditions (60.3%), died in hospitals (73.5%), and had never received services from long-term supportive care institutions (74.3%). Compared with those who died from lung cancer, people dying from COPD were less likely to be admitted to hospitals (OR=0.71, 95%CI: 0.64-0.80 in the last six months of life; OR=0.81, 95%CI: 0.70- 0.93 in the last month of life) and had shorter LOS for each admission (OR=0.78, 95%CI: 0.70-0.87 in the six months of life; OR=0.67, 95%CI: 0.60-0.75 in the last month of life). However, persons with COPD were more likely to be managed in an intensive care settings (5.3% of COPD subjects vs. 1.7% of lung cancer subjects in the last six months of life; 4.3% of COPD subjects vs. 0.06% of lung cancer subjects in the last month of life) and had higher numbers of transfers between long-term care facilities (7.7% of COPD subjects vs. 3.2% of lung cancer subjects). Between 1997 and 2006, there was no significant change in the hospital utilization among patients who died of COPD or those who died of lung cancer. Conclusions: Marked differences in terms of hospital service utilization in the last six months of life were observed between subjects dying with COPD and lung cancer. Our study results support previous work indicating that the nature of care management at the end of life for people who died of advanced COPD is different from those who died from lung cancer, which was reflected by reduced likelihood of hospital service usage, more ICU admissions, and frequent transfers between supportive care facilities. There is no significant change observed regarding the patterns of hospitalization over 10-year study period. We would suggest collecting more information on services managed in other care settings, such as emergency departments, out-patient settings, and clinics, etc. This would allow an in-depth examination regarding what types of institutional services influenced the usage of in-patient care. In addition, education of all health care professionals on the complex needs of patients living with respiratory illnesses is required