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

ABSTRACTObjectivesTo compare the referral-to-death duration among palliative cancer and non-cancer patients and to determine its influencing factors in a Malaysian community hospice.MethodsThis 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.ResultsOf 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).ConclusionShorter 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 MESSAGESWhat is already known on this topic⍰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⍰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.⍰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⍰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.⍰At a policy level, plans to develop interventions to allow timely integration of community palliative care should target specific groups of patients.