Duration of referral-to-death and its influencing factors among cancer and non-cancer patients: perspective from a community palliative care setting in Malaysia
Authors: Yip Yan Yee , Hwong Wen Yea , McCarthy Sylvia Ann , Hassan Chin Aidah Abdul , Woon Yuan Liang 
Published: August 2022

Objectives

To compare the referral-to-death duration among palliative cancer and non-cancer patients and to determine its influencing factors in a Malaysian community hospice.

Methods

This retrospective cohort study included decedents referred to palliative care in a community hospice between January 2017 to December 2019. Referral-to-death is the interval between first referral date to date of death. Besides descriptive analyses, negative binomial regression analyses were conducted to identify factors associated with referral-to-death duration among both groups.

Results

Of 4346 patients referred, 86.7% (n=3766) and 13.3% (n=580) had primary diagnoses of cancer and non-cancer respectively. Median referral-to-death was 32 days (IQR:12-81) among cancer patients and 19 days (IQR:7-78) among non-cancer patients. The shortest referral-to-death duration among cancer patients were for liver cancer (Median:22 days,IQR:8-58.5). Non-cancer patients with dementia, heart failure and multisystem failure had the shortest referral-to-death duration at 14 days. Among cancer patients, longer referral-to-death duration was associated with women compared to men (IRR:1.26,95%CI:1.16-1.36) and patients aged 80 to 94 years old compared to below 50 years old (IRR:1.19,95%CI:1.02-1.38). Cancer patients with analgesics prescribed before palliative care had 29% fewer palliative care days compared to those with no analgesics prescribed before referral. Non-cancer patients aged 50 to 64 years old had shorter referral-to-death duration compared to below 50 years old (IRR:0.51,95%CI:0.28-0.91).

Conclusion

Shorter referral-to-death duration among non-cancer patients indicated possible access inequities with delayed palliative care integration. Factors influencing referral-to-death duration should be accounted for in developing targeted approaches to ensure timely and equitable access to all patients requiring palliative care.

KEY MESSAGES

What is already known on this topic

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Addressing the need for timely integration of palliative care in low- and middle-income countries (LMIC) is a priority, considering its increasing burden of non-communicable diseases with limited data available in this region.

What this study adds

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Findings from our study have shown an underrepresentation of non-cancer patients amongst community palliative care referrals with a shorter referral-to-death duration among these patients as compared to cancer patients.

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Age, sex, and use of analgesia prior to referrals were factors significantly associated with referral-to-death duration among cancer patients whereas for non-cancer patients, older aged patients had a shorter referral-to-death duration..

How this study might affect research, practice or policy

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The underrepresentation of non-cancer referrals for palliative care indicates the need to determine reasons for the disparity in referrals between cancer and non-cancer patients in clinical practice and to evaluate feasible and effective approaches to narrow this gap in settings similar to that of ours.

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At a policy level, plans to develop interventions to allow timely integration of community palliative care should target specific groups of patients.