Care at the End of Life among People Living With HIV in Ontario

Transcription

1 Care at the End of Life among People Living With HIV in Ontario OHTN Endgame 2016 Claire Kendall Bruyère Research Institute, University of Ottawa Mathieu Chalifoux, Doug Manuel, Robert Reinhard, Gregory Robinson, Jean Bacon, Sean Rourke, Ron Rosenes, Peter Tanuseputro

2 Presenter disclosure I have no relationships with commercial interests to disclose.

3 The results of success The population of people living with HIV is aging and becoming more medically complex Mortality from non-hiv-related events exceeds that of AIDS-defining conditions We know little about the end-of-life experience among people with HIV

4 Objectives To describe the places of care experienced by people with HIV at the end of life To quantify the costs of this care To compare these findings to the experience of people without HIV

5 How we conducted the study Institute for Clinical Evaluative Sciences We used a retrospective populationbased observational design to capture all deaths in Ontario from 1 April March 2013 We applied a validated case ascertainment algorithm to identify decedents with HIV

6 We looked at the these outcomes Services received in the last 90 days of life Places of care Location of death Receipt of palliative services Receipt of home care Health care costs by sector

7 We modeled the association between HIV status and days in hospital Multivariable logistic regression analyses Adjusted for patient characteristics: age, sex, neighborhood income quintile, rurality, immigration status, comorbidity Adjusted for health care characteristics: primary care model, receipt of home care services (palliative, non-palliative, none), receipt of ART

8 Decedents with HIV and without HIV differed significantly Decedents with HIV were more likely to be: Male Live in lowest income, urban neighborhoods Emigrated from HIV endemic country Higher comorbidity Received care in older, non-capitation non-team based primary care models Died significantly younger: mean age of death 56.1 years vs 76.6 years

9 Places of care in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Places of Care number of days Acute Care <.01 Complex continuing care Rehabilitation Emergency Department <.01 Total hospital use (from places of care listed above) <.01 Home Care <.01 Location of Death (n, %) Hospital 137,083 (53.6) 361 (65.4) <.01

10 Places of care in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Places of Care number of days Acute Care <.01 Complex continuing care Rehabilitation Emergency Department <.01 Total hospital use (from places of care listed above) <.01 Home Care <.01 Location of Death (n, %) Hospital (53.6) 361 (65.4) <.01

11 Places of care in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Places of Care number of days Acute Care <.01 Complex continuing care Rehabilitation Emergency Department <.01 Total hospital use (from places of care listed above) <.01 Home Care <.01 Location of Death (n, %) Hospital (53.6) 361 (65.4) <.01

12 Palliative care services in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Palliative Hospitalizations (n, %) Yes (34.9) 219 (38.4) 0.08 Home Care Services (n, %) None (38.4) 233 (42.2) 0.17 Non Palliative (42.9) 227 (41.1) Palliative (18.7) 92 (16.7) Physician Home Visits (n, %) None (79.2) 465 (84.2) 0.04 Yes non Palliative specialist involvement (12.6) 46 (8.3) Yes at least one visit from Palliative specialist (8.2) 41 (7.4)

13 Palliative care services in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Palliative Hospitalizations (n, %) No (66.0) 351 (61.6) 0.08 Yes (34.9) 219 (38.4) Home Care Services (n, %) None (38.4) 233 (42.2) 0.17 Non Palliative (42.9) 227 (41.1) Palliative (18.7) 92 (16.7) Physician Home Visits (n, %) None (79.2) 465 (84.2) 0.04 Yes non Palliative specialist involvement (12.6) 46 (8.3) Yes at least one visit from Palliative specialist (8.2) 41 (7.4)

14 Palliative care services in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Palliative Hospitalizations (n, %) No (66.0) 351 (61.6) 0.08 Yes (34.9) 219 (38.4) Home Care Services (n, %) None (38.4) 233 (42.2) 0.17 Non Palliative (42.9) 227 (41.1) Palliative (18.7) 92 (16.7) Physician Home Visits (n, %) None (79.2) 465 (84.2) 0.04 Yes non Palliative specialist involvement (12.6) 46 (8.3) Yes at least one visit from Palliative specialist (8.2) 41 (7.4)

15 Palliative care services in last 90 days of life No HIV (n=264,184) HIV (n=570) p value Palliative Hospitalizations (n, %) No (66.0) 351 (61.6) 0.08 Yes (34.9) 219 (38.4) Home Care Services (n, %) None (38.4) 233 (42.2) 0.17 Non Palliative (42.9) 227 (41.1) Palliative (18.7) 92 (16.7) Physician Home Visits (n, %) None (79.2) 465 (84.2) 0.04 Yes non Palliative specialist involvement (12.6) 46 (8.3) Yes at least one visit from Palliative specialist (8.2) 41 (7.4)

16 Model outcomes Living with HIV was significantly associated with a greater number of days spent in hospital (p<0.0001) Among people with HIV, more days in hospital was associated with: Higher comorbidity Having non-palliative home visits Not receiving ODB

17 Costs of care in last year of life No HIV HIV Health Care Users (n) Mean $ Per User Health Care Users (n) Mean $ Per User Total Cost Continuing Care Sectors Long-Term Care Complex Continuing Care Home Care Rehabilitation Acute Care Sectors Inpatient without ICU Inpatient with 1+ ICU Emergency Department Outpatient Care Sectors Outpatient Clinics Physician Billings Non-physician Billings (OHIP) Laboratory (OHIP) Drugs/Devices no ART Drugs/Devices with 1+ ART

18 Costs of care in last year of life No HIV HIV Health Care Users (n) Mean $ Per User Health Care Users (n) Mean $ Per User Total Cost Continuing Care Sectors Long-Term Care Complex Continuing Care Home Care Rehabilitation Acute Care Sectors Inpatient without ICU Inpatient with 1+ ICU Emergency Department Outpatient Care Sectors Outpatient Clinics Physician Billings Non-physician Billings (OHIP) Laboratory (OHIP) Drugs/Devices no ART Drugs/Devices with 1+ ART

19 As always, there are limitations Poor control of HIV itself leads to increased acute care use (and costs), but we do not know immune status of patients in our study Unmeasured health and social determinants ART in hospital may contribute to acute care costs Does not account for out of pocket, insurancerelated, or indirect costs 19

20 Key messages for policy and practice Mean age of death remain 20 years younger among decedents with HIV, who are also more marginalized and with lower income Most people prefer to die at home, but the end of life is dominated by acute care with 8 additional days in hospital in last 90 days of life Lower use of palliative care and long term care facilities

21 Key messages for policy and practice Despite having lower quality end-of life health care, costs are 50% greater ($27,000 per person), higher than for people with cancer or congestive heart failure Need to integrate end-of-life services with attention to mental health, chronic pain management and polypharmacy, social isolation, stigmatization, economic hardship, and housing stability

22 Acknowledgements Mathieu Chalifoux, Doug Manuel, Robert Reinhard, Gregory Robinson, Jean Bacon, Sean Rourke, Ron Rosenes, Peter Tanuseputro

23 Care at the End of Life among People Living With HIV in Ontario OHTN Endgame 2016 Claire Kendall Bruyère Research Institute, University of Ottawa Mathieu Chalifoux, Doug Manuel, Robert Reinhard, Gregory Robinson, Jean Bacon, Sean Rourke, Ron Rosenes, Peter Tanuseputro