Palliative Medicine

http://pmj.sagepub.com/

The association between in-patient death, utilization of hospital resources and availability of palliative
home care for cancer patients
Alberto Alonso-Babarro, Jenaro Astray-Mochales, Felicitas Domnguez-Berjn, Ricard Gnova-Maleras, Eduardo Bruera,
Antonio Daz-Mayordomo and Carlos Centeno Cortes
Palliat Med 2013 27: 68 originally published online 4 April 2012
DOI: 10.1177/0269216312442973

The online version of this article can be found at:

http://pmj.sagepub.com/content/27/1/68

Published by:

http://www.sagepublications.com

Additional services and information for Palliative Medicine can be found at:

Email Alerts: http://pmj.sagepub.com/cgi/alerts

Subscriptions: http://pmj.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Dec 21, 2012

OnlineFirst Version of Record - Apr 4, 2012

What is This?

Downloaded from pmj.sagepub.com by guest on July 2, 2013

42973 PMJ27110.1177/0269216312442973Alonso-Babarro et al.Palliative Medicine

PALLIATIVE
Original Article MEDICINE
Palliative Medicine

The association between in-patient

27(1) 6875
The Author(s) 2012
Reprints and permission:
death, utilization of hospital resources sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269216312442973

and availability of palliative home care pmj.sagepub.com

for cancer patients

Alberto Alonso-Babarro Palliative Care Unit, Hospital Universitario La Paz, Spain

Jenaro Astray-Mochales Direccin General de Atencin Primaria, Consejera de Sanidad, Comunidad de Madrid, Spain

Felicitas Domnguez-Berjn Direccin General de Atencin Primaria, Consejera de Sanidad, Comunidad de Madrid, Spain

Ricard Gnova-Maleras Direccin General de Atencin Primaria, Consejera de Sanidad, Comunidad de Madrid, Spain

Eduardo Bruera Department of Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, USA

Antonio Daz-Mayordomo Centro de Salud Tres Cantos, Spain

Carlos Centeno Cortes Equipo de Medicina Paliativa, Clnica Universitaria de Navarra, Spain

Abstract
Background: The impact of palliative home care programs on in-patient admissions and deaths has not been appropriately established.
Aim: The main objectives of this study have been to evaluate the frequency of in-patient hospital deaths and the use of hospital
resources among cancer patients in two areas of the Madrid Region, as well as to assess differences between one area with and one
without a palliative home care team (PHCT) in those variables.
Design and setting: We conducted a population-based study comparing two adjacent metropolitan areas of approximately 200,000
inhabitants each in the Madrid Region, Spain, measuring in-patient deaths, emergency room admissions and in-patient days among
cancer patients who died in 2005. Only one of the two areas had a fully established PHCT.
Results: 524/549 cancer patients (95%) had an identified place of death: 74% died in hospital, 17% at home, 6% in an in-patient hospice
and 3% in a nursing home. The frequency of hospital deaths was significantly lower among patients of the PHCT area (61% versus
77%, p < 0.001), as well as the number of patients using emergency and in-patient services (68% versus 79%, p = 0.004, and 66 versus
76%, p = 0.012, respectively). After adjusting for other factors, the risk of hospital death was lower among patients older than 80 (OR,
95% CI, 0.3, 0.10.5), higher among patients with hematological malignancies (OR 6.1, 2.018.9) and lower among patients of the PHCT
area (OR 0.4, 0.20.6).
Conclusions: Our findings suggest that a PHCT is associated with reduced in-patient deaths and overall hospitalization over the last
two months of life.

Keywords
Place of death, cause of death, death certificate, palliative care, cancer, hospital mortality, home care services, hospital based, age
factors, socioeconomic factors

Introduction frequent in-patient admissions.9,10 In the USA, the structure

and availability of healthcare resources appear to influence
Most patients with advanced cancer prefer to receive care place of death more than the actual preference of patients
and die at home.1,2 However, most patients die in hospital.28 and families.1113 Some studies have suggested that home
During the last months of life, cancer patients undergo care teams decrease the number and duration of in-patient

Corresponding author:
Dr Alberto Alonso-Babarro, Unidad de Cuidados Paliativos, Hospital La Paz, Po Castellana 261, 28046 Madrid, Spain.
Email: albertoalonsob@gmail.com

Downloaded from pmj.sagepub.com by guest on July 2, 2013

Alonso-Babarro et al. 69
admissions and increase the rate of home deaths.1422
However, the number of studies is small, there is quite a
variable level of physician participation and the role of
these home-based programs in reducing the rate of hospital
deaths among cancer patients has not been completely
established.23 Health regions around the world have
attempted to establish palliative care programs as a way of
improving the quality of life of terminally ill patients and
their families and also as a way of reducing utilization of
expensive acute care hospital resources.24,25
The percentage of patients dying in hospital as com-
pared to those dying at home, and the possibility of spend-
ing most of the last weeks of life at home, have been utilized
as quality indicators of palliative care programs.26 Although
there are several limitations, these measures can be used to
evaluate programs over time, as well as to compare the
impact of different programs on care at the end of life.3,6,7,14
22,27,28 The World Health Organization (WHO) and a num-
ber of other international organizations have focused on the
importance of research in factors associated with place of
death in different regions of the world.29
In this population-based study, we sought to investigate
the frequency of in-patient hospital death and the use of
hospital resources (measured as emergency room admis-
sions, in-patient admissions and in-patient days) in two
metropolitan areas of the Madrid Region. We hypothesized
that a palliative home care team (PHCT) established in one
of these areas could influence those variables.
Methods
Study location
The Madrid Region has a population of approximately 6
million, essentially of an urban nature (94%). All residents
of the Region have access to universal healthcare provided
by the National Health System.
In 2006 the Madrid Region activated an integrated pal-
liative care program aimed at providing universal access to
all levels of palliative care services for the community.
Until that year, resource distribution was highly irregular
among the different regional healthcare areas. Six of the
eleven health areas established a PHCT in 1998. Patients
living in an area without a PHCT could not use the PHCT
from the other areas. Each team provided care to 300,000
700,000 inhabitants. The team was composed of two physi-
cians, two nurses, an assistant nurse and an administrative
clerk. The PHCTs conducted regular follow-up of patients
referred by acute care hospitals, medical oncologists or
family physicians when these patients were perceived by
the referring physician as having a progressive incurable
disease and high symptom distress.
We compared two adjacent areas of approximately
200,000 inhabitants each. Area 1 [named Alcobendas-San-
Sebastian de Los Reyes] had access to a PHCT and from
Downloaded from pmj.sagepub.com by guest on July 2, 2013
now on will referred to as the PHCT Area. Area 2 [named
Alcala de Henares] had no access to a PHCT in 2005 and
from now on will be referred to as the Non-PHCT Area.
Both health areas had full access to major university hospitals,
oncology services, family physicians and in-patient
hospice beds.
Average income per capita in the Non-PHCT Area was
similar to the average Spanish income, while in the PHCT
Area, one of the sub-areas [San-Sebastian de Los Reyes]
had approximately 20% above-mean income, and the
other sub-area [Alcobendas] approximately 50% above
the Spanish mean income.30 The PHCT Area also had a
higher availability of acute hospital beds (2.2 versus 1.6
beds per 1000 people).
Study design
We reviewed cancer deaths for 2005 for all adult cancer
patients over 18, in both health regions. The Madrid
Regional Statistics Institute (IECM) provided the individ-
ual data of deceased patients.
This study was approved by the Institutional Review
Board of the Primary Care Program of each of the two
health areas. Appropriate authorization was obtained from
the Madrid Regional Government and the Data Protection
Agency.31
In Spain the death certificate has two components: one
of them is called the Medical Death Certificate (MDC),
which includes the address where the death took place.
The other component is the Statistic Death Bulletin (SDB)
which is used for statistical purposes and includes the
patients main diagnosis and other demographic charac-
teristics. Since 2009, a new document has been imple-
mented, containing both MDC and SDB information in a
single form and including a new place-of-death checklist.
In order to double-check the appropriate place of death,
we cross-linked the information from the MDC regarding
address with the Tanatos Registry kept by funeral directors.
This registry determines the exact address where a body
has been collected for funerary purposes.
In-patient care data were obtained from the register of
the public and private hospitals of the Madrid Region, and
emergency room visit data were obtained from the register
of the major public hospitals available in the health regions.
All the institutions kept electronic activity records. We only
considered the last two months before death [62 days] for
the purpose of this study. We used the PHCT Register to
check the patients who had been followed up by this Team.
Variables
We classified the cause of death according to International
Classification of Diseases (ICD)-10 and, for the purpose of
this study, we used all the codes corresponding to neoplas-
tic diseases. These include, according to anatomic location,
70 Palliative Medicine 27(1)
digestive tract codes, C00C26, C48, C451; respiratory
codes, C30C34, C37C39, C45.0, C45.2; breast code,
C50; genitourinary codes, C51C58, C60C68; hemato-
logical codes, C81C85, C88C96, D46; and other codes,
C40, C41, C43, C44, C49, C69C80, C97, C457C479,
D00D45, D47, D48.
Other variables include demographic characteristics,
such as age, gender, marital status and place of residence.
For the purpose of socioeconomic level we used a depri-
vation index based on residence census information. This
index has been elaborated for small areas (census tracts
with a median of 1000 inhabitants) of the Madrid Region
based on several census (2001) indicators,32 and the areas
have been categorized into quintiles in which the fifth is the
most unfavorable one.
With regard to healthcare utilization, we determined in-
patient hospital care within the last two months before
death, access to a PHCT, number of times the patient was
seen by an emergency room and total number of days the
patient remained admitted during the study period. Visiting
the emergency room did not mean being admitted to the
hospital, so we collect data about both variables.
Data analysis
We analyzed the probability of dying in hospital in accord-
ance with different sociodemographic and clinical varia-
bles and in accordance with the assistance of a PHCT
using bi-variate and multi-variate analysis by logistic
regression. We calculated the odds ratio and 95% confi-
dence interval (CI) using the statistical package for the
social sciences (SPSS V15).
Results
There were a total of 549 adult cancer deaths in the two
areas during 2005. The age-adjusted population mortality
rate according to the Standard European Population was
2.23 cancer deaths per 1000 inhabitants. The rate was the
same in the two areas.
In the vast majority of cases the place of death was
obtained from the MDC and/or the Tanatos Registry. There
were 10 cases of disagreement between Tanatos and the
MDC and, in such cases, the Tanatos-registered place of
death was used as the appropriate location. In 21 cases
where this information was not available, the information
was ultimately available from hospital medical records.
In 25 [4.6%] cases the exact place of death could not be
determined.
Overall, 524 patients were studied for place of death. A
total of 387 (74%) patients died in hospital, 90 (17%) died
at home, 29 (6%) died in an in-patient hospice and 18 (3%)
died in a nursing home.
Table 1 summarizes the differences by place of death
and other sociodemographic and clinical variables in each
Downloaded from pmj.sagepub.com by guest on July 2, 2013
of the two different areas. Hospital death frequency was
significantly lower among patients in the PHCT Area (61%
versus 77%, p < 0.001). The PHCT Area patients used
emergency services and in-patient services less frequently
than those in the Non-PHCT Area (68% versus 79%, p =
0.004, and 66 versus 76%, p = 0.012, respectively).
Table 2 summarizes the probability of hospital death
and differences in both bi-variant and multi-variant anal-
yses. After adjusting for other factors, patients in the
PHCT Area and patients aged over 80 had a significantly
lower risk of hospital death, whereas the risk among
patients with hematological malignancies was signifi-
cantly higher. In the bi-variant analysis, the risk of hospi-
tal deaths was significantly higher among patients with
lower socioeconomic levels. There was no difference by
gender or marital status.
The probability of a hospital death increased in direct
relationship with the number of visits to the emergency
center and/or the in-patient hospital and with the number of
in-patient days. The mean of in-patient days during the last
two months of life among patients who died at home, hav-
ing been admitted at least once, was 7, versus 17 among
patients who died in hospital [p < 0.001].
Table 3 summarizes the differences according to place
of death and hospital utilization between patients followed
up by a PHCT and those who did not receive this kind of
assistance at home (in the PHCT Area and in the Non-
PHCT Area). PHCT patients had a higher percentage of
home deaths compared with the rest of the patients (67.6%
versus 12.5%, OR after adjusting for other factors [95% CI]
23.4, 9.160.0).
Discussion
To our knowledge this is one of the first population-based
studies addressing the association between hospital mortal-
ity and presence of a PHCT in two areas within the same
healthcare system, and one of the first population-based
studies to analyze place of death in Spain. A study has been
published recently about place of death in Andalusia
(Spain) in 2009 using the Death Certificate, but the authors
could only find less than 50% of the patients places of
death.33
Our study found that the frequency of in-patient hospital
deaths and use of hospital resources during the last two
months of life was significantly lower in the PHCT Area.
The risk of a hospital death was significantly lower when
patients had access to a PHCT, after adjusting for other fac-
tors [OR 0.4, 95% 0.20.6]. The two healthcare areas
belong to the urban part of the Madrid Region and they are
part of the same healthcare system. Patients have access to
the same level of family physician coverage, medical
oncology specialists and tertiary hospital in-patient admis-
sions. Clinical and demographic characteristics of patients
in both areas were quite similar. In spite of everything, the
Alonso-Babarro et al. 71

Table 1. Patient clinical and demographic characteristics in the palliative home care team (PHCT) and Non-PHCT Areas.

Non-PHCT Area PHCT Area p

N % N %
TOTAL 323 226
Gender
Female 113 35.0 77 34.1 0.825
Male 210 65.0 149 65.9
Age at death (years)
<65 114 35.3 94 41.6 0.217
6579 126 39.0 73 32.3
80+ 83 25.7 59 26.1
Marital status
Single 29 9.0 16 7.1 0.528
Married 215 66.6 148 65.5
Widowed 65 20.1 55 24.3
Separated or divorced 14 4.3 7 3.1
Socioeconomic status
Quintile 1 (highest) 22 6.8 46 20.4 <0.001
Quintile 2 47 14.6 26 11.6
Quintile 3 54 16.7 73 32.4
Quintile 4 60 18.6 69 30.7
Quintile 5 (lowest) 140 43.3 11 4.9
Cancer type
Gastrointestinal 93 28.8 69 30.5 0.261
Lung 79 24.5 61 27.0
Breast 17 5.3 14 6.2
Genitourinary 50 15.5 19 8.4
Hematological 32 9.9 21 9.3
Others 52 16.1 42 18.6
Place of death
Home 42 13.0 47 20.8 <0.001
Hospital 249 77.1 138 61.1
In-patient hospice 3 0.9 26 11.5
Nursing home 14 4.3 5 2.2
Unknown 15 4.6 10 4.4
Visited the emergency rooma
No 68 21.1 72 31.9 0.004
Yes 255 78.9 154 68.1
Mean number of visits 1.46 1.09 <0.001
Admitted to the hospitala
No 77 23.8 76 33.6 0.012
Yes 246 76.2 150 66.4
Mean number of admissions 1.00 0.87 0.043
Emergency room visits and admissions
No 26 8.0 40 17.7 0.001
Yes 297 92.0 186 82.3
Mean number of visits/admissionsa 2.08 1.72 <0.001
aLast 62 days before death

differences we found between the PHCT and the Non-
PHCT Areas may not necessarily have been due to the pres-
ence of the PHCT, but to other regional differences we did
not measure. However, when comparing both regions for
only those patients who did not make use of the PHCT,
there were no large differences. Therefore, the observed
differences seem to suggest that the PHCT allowed patients
to remain out of the in-patient hospital facilities and to die
more commonly in a non-hospital setting. Our findings
regarding patients followed up by the PHCT are similar to
those reported recently by our group in an observational
cohort study.34 The PHCT seems to be the strongest factor

Downloaded from pmj.sagepub.com by guest on July 2, 2013

72 Palliative Medicine 27(1)

Table 2. Risk of in-patient hospital death according to clinical and demographic characteristics.

N % In-patient Odds ratio 95% CI Adjusted odds 95% CI

hospital deaths ratioa
TOTAL 549 70.5
Gender
Female 190 67.9 1 1
Male 359 71.9 1.2 0.81.8 1.2 0.72.0
Age at death (years)
<65 208 77.9 1 1
6579 199 75.9 0.9 0.61.5 0.8 0.51.3
80+ 142 52.1 0.3 0.20.5 0.3 0.10.5
Marital status
Single 45 77.8 1 1
Married 363 74.7 0.9 0.41.9 0.8 0.31.8
Widowed 120 55.0 0.4 0.20.9 0.7 0.31.8
Separated or divorced 21 71.4 1.0 0.33.6 0.8 0.23.1
Socioeconomic status
Quintile 1 (highest) 68 58.8 1 1
Quintile 2 73 60.3 1.1 0.52.1 0.9 0.41.9
Quintile 3 127 71.7 1.8 0.93.4 1.8 0.93.7
Quintile 4 129 72.9 1.8 1.03.5 1.8 0.93.7
Quintile 5 (lowest) 151 78.1 2.7 1.45.3 1.8 0.83.9
Cancer type
Gastrointestinal 162 66.7 1 1
Lung 140 66.4 1.0 0.61.7 0.7 0.41.3
Breast 31 74.2 1.2 0.52.9 1.1 0.43.0
Genitourinary 69 69.6 1.1 0.62.0 0.9 0.51.9
Hematological 53 90.6 5.0 1.714.7 6.1 2.018.9
Others 94 71.3 1.3 0.72.3 1.2 0.62.2
Palliative home care
Non-PHCT Area 323 77.1 1 1
PHCT Area 226 61.1 0.4 0.30.6 0.4 0.20.6
aAdjusted Odds Ratio (OR) and 95% confidence interval (CI) from a multiple logistic regression model with all variables listed in the table.

PHCT: palliative home care team

to explain differences between the PHCT Area and the
Non-PHCT Area regarding place of death and hospital uti-
lization by cancer patients who died in the study areas. In
Canada, similar findings have been reported when compar-
ing hospital deaths and total in-patient days of the last
admission before and after the inception of a regional pal-
liative care program.35 A study in Belgium strongly relates
place of death with involvement of palliative care ser-
vices.22
A number of studies have attempted to establish the
relationship between home palliative care programs and
in-patient deaths. Grande et al.15 randomized 229 pallia-
tive care patients to hospital-at-home versus standard
care. Patients admitted to hospital-at-home were more
likely to die at home than controls. However, the findings
were limited, since a number of patients allocated to one
of the treatment groups did not receive such treatment.
Jordhy et al.20 conducted a cluster randomized control trial
of a palliative care intervention versus conventional care.
They enrolled 434 patients who had incurable malignant
disease and an expected survival of 29 months. More
patients receiving palliative care were able to die at home,
although time spent at home was not significantly
increased and overall hospital utilization was similar in
both groups. Brumley et al.21 randomized 298 terminally
ill patients to usual care versus in-home palliative care
plus usual care delivered by an interdisciplinary team.
They found that patients randomized to home palliative
care were more likely to die at home and less likely to visit
the emergency department or be admitted to the hospital
than those receiving usual care. The authors suggested
that this resulted in a significant decrease in care cost.
Our findings are consistent with those of the rand-
omized controlled trials. One of the limitations of clinical
trials is the relatively artificial environment created by
eligibility criteria and settings where these studies are con-
ducted. It is encouraging that our population-based study
supports the fact that a relatively simple physician- and

Downloaded from pmj.sagepub.com by guest on July 2, 2013

Alonso-Babarro et al. 73

Table 3. Differences according to place of death and hospital utilization between patients followed up by a palliative home care
team (PHCT) and those who did not receive this kind of assistance at home (in the PHCT Area and in Non-PHCT Area).

Patients in the Patients in the PHCT Patients followed up p value

Non-PHCT Area Area who did not by the PHCT
receive assistance from
the PHCT

N % N % N %
TOTAL 323 100.0 189 100.0 37 100.0
Place of death
Home 42 13.0 22 11.6c 25 67.6c <0.001
Hospital 249 77.1 133 70.4c 5 13.5c
In-patient hospice 3 0.9b 21 11.1b 5 13.6
Nursing home 14 4.3 5 2.6 - -
Unknown 16 4.6 8 4.2 2 5.4
Number of emergency room visitsa
0 68 21.1 56 29.6 16 43.2 0.001
1 105 32.5 70 37.0 13 35.1
2 82 25.4 43 22.8 7 18.9
3+ 68 21.1b 20 10.6b 1 2.7
Number of admissionsa
0 77 23.8 54 28.6c 22 59.5c <0.001
1 180 55.7 98 51.9 12 32.4
2+ 66 20.4 37 19.6 3 8.1
Number of emergency room visits and admissionsa
0 26 8.0 25 13.2c 15 40.5c <0.001
1 71 22.0 47 24.9 6 16.2
2 77 23.8 53 28.0 10 27.0
3+ 149 46.1b 64 33.9b 6 16.2
aLast 62 days before death.
bStatistically significant (p < 0.05) between patients in the Non-PHCT Area and patients in the PHCT Area who did not receive assistance from the
PHCT.
cStatistically significant (p < 0.05) between patients followed up by the PHCT and patients in the PHCT Area who did not receive assistance from the

PHCT.

nurse-based palliative home care intervention is capable of
significantly reducing the number of in-patient deaths.
Since the vast majority of the cost of end-of-life care is
related to in-patient care, our findings could be encourag-
ing as a potential for substantial cost savings. However,
cost savings are predominantly linked with the number of
days of in-patient care during the last months of life, rather
than the actual location of death. More research is required
to better determine if PHCTs are capable of reducing not
only the number of in-patient deaths, but also the overall
duration of in-patient days during the last months of life.
Our findings regarding in-patient admissions and total
number of in-patient days during the last two months of life
are consistent with those of studies conducted in Canada
and Belgium.9,10 These findings emphasize the very large
cost of caring for advanced cancer patients in the last
months of life. Unfortunately, this high cost of acute care
institution admissions does not seem to correlate with
better symptom control and overall family distress, particularly
for those patients who die in hospital.36,37
Our study found that patients with lower socioeconomic
status had a higher risk of an in-patient death. A number of
studies have made similar findings.34,38,39 A Swedish study
observed no significant association between income and in-
patient deaths.40 These findings might reflect the outstand-
ing level of Swedish social services, including intensive
home support and paid leave of absence for relatives. Some
authors suggest that level of social support is one of the
most important factors that influence place of death.4143
These findings could be important for the planning of pal-
liative home care programs. Programs in areas where there
is higher socioeconomic level and social support should be
expected to be able to achieve higher rates of home death.
Programs should pay specific attention to patients with
lower socioeconomic status in order to develop appropriate
policies addressing their needs.
Regarding the remaining demographic variables (includ-
ing age, gender and marital status), only age had significant
association with place of death. People over 80 had the
highest proportion of home deaths. Our findings are similar

Downloaded from pmj.sagepub.com by guest on July 2, 2013

74 Palliative Medicine 27(1)
to those found in Italy, but opposite to other European
countries. This could be a characteristic common to
Mediterranean countries and exemplifies how cultural
differences determine patterns in place of death.13,38
Our findings regarding a significantly higher risk of in-
patient death among patients with hematological malig-
nancy are consistent with those of our group and others
showing a higher in-patient mortality rate, higher num-
bers of intensive care unit (ICU) deaths and later referral
to palliative care teams in patients with hematological
malignancies.3,5,7,8,13,41,44,45 More research is necessary to
better understand the different mechanisms and possible
ways to improve end-of-life care among patients with
hematological malignancies.
Our study has a number of limitations. Firstly, the
absence of a single register of mortality, containing all
the information, could lead to loss of data. However, we
used multiple sources of cross-referencing, including
identity card number, multiple names and surnames,
social security number and date of birth. We believe this
was highly effective, since the place of death was not
identified in less than 5% of patients in our sample.
Secondly, the socioeconomic level was assigned to each
patient based on the socioeconomic level of small resi-
dence areas. However, this methodology has been found
to be valid when there are no individual socioeconomic
data.46 Finally, this study was limited to two specific
urban areas, and there could be confusing and unidenti-
fied factors that explain differences regarding in-patient
deaths. Our results should be considered preliminary and
they need to be reproduced by other studies conducted in
different areas. In fact, as the methodology has proved to
be reliable, we plan to do the study in a larger number of
areas to further evaluate whether differences between
areas are indeed due to the presence of a PHCT. Studies
should also be conducted comparing similar areas before
and after the inception of palliative care programs, in an
effort to determine the clinical and financial impact of
such programs on end-of-life care.
Our findings have practical implications. Improvements
can be achieved in aspects of end of life through public
health policy. Policy strategies should be developed to
facilitate home death.
We conclude that in-patient mortality and use of hospital
resources during the last two months of life were signifi-
cantly lower in an area with a PHCT. Home deaths were
significantly higher among patients over 80 and lower
among those with hematological malignancies.
Acknowledgements
Our thanks are due to Mara Esteban-Vasallo for preparing the
database and for her research assistance. We also thank Luis
Miguel Blanco-Ancos for assistance in the database computer
treatment and Mr Martin Smyth, BA, for his help in correcting the
English and for his editorial contributions.
Downloaded from pmj.sagepub.com by guest on July 2, 2013
Funding
Dr Eduardo Bruera is supported in part by the National Institutes
of Health (Grant numbers RO1NR010162-01A, RO1CA122229-
01 and RO1CA124481-01).
Conflict of interest statement
The authors declare that there is no conflict of interest.
References
1. Higginson IJ and Sen-Gupta GJA. Place of care in advanced
cancer: a qualitative systematic literature review of patient
preferences. J Palliat Med 2000; 3: 287300.
2. Beccaro M, Costantini M, Giorgi Rossi P, et al. Actual and
preferred place of death of cancer patients. Results from the
Italian survey of the dying of cancer (ISDOC). J Epidemiol
Community Health 2006; 60: 412416.
3. Higginson IJ, Astin P and Dolan S. Where do cancer patients
die? Ten-year trends in the place of death of cancer patients
in England. Palliat Med 1998; 12: 353363.
4. Hansen SM, Tolle SW and Martin DP. Factors associated
with lower rates of in-hospital death. J Palliat Med 2002; 5:
677685.
5. Bruera E, Russell N, Sweeney C, et al. Place of death and
its predictors for local patients registered at a comprehensive
cancer center. J Clin Oncol 2002; 20: 21272133.
6. Burge F, Lawson B and Johnston G. Trends in the place of
death of cancer patients, 19921997. Can Med Assoc J 2003;
168: 265270.
7. Hunt R, Bonett A and Roder D. Trends in the terminal care of
cancer patients: South Australia, 19811990. Aust N Z J Med
1993; 23: 245251.
8. Cohen J, Bilsen J, Addington-Hall J, et al. Population-based
study of dying in hospital in six European countries. Palliat
Med 2008; 22: 702710.
9. Huang J, Boyd C, Tyldesley S, et al. Time spent in hospital
in the last six months of life in patients who died of cancer in
Ontario. J Clin Oncol 2002; 20: 15841592.
10. Van den Block L, Deschepper R, Drieskens K, et al.
Hospitalisations at the end of life: using a sentinel surveillance
network to study hospital use and associated patient, disease
and healthcare factors. BMC Health Serv Res 2007; 7: 69.
11. Prichard RS, Fisher ES, Teno JM, et al. Influence of patient
preferences and local health system characteristics on the
place of death. J Am Geriatr Soc 1998; 46: 12421250.
12. Tolle SW, Rosenfeld AG, Tilden VP, et al. Oregons low
in-hospital death rates: What determines where people die
and satisfaction with decisions on place of death? Ann Intern
Med 1999; 130: 681685.
13. Cohen J, Houttekier D, Onwuteaka-Philipsen B, et al. Which
patients with cancer die at home? A study of six European
countries using death certificate data. J Clin Oncol 2010; 28:
22672273.
14. Hughes SL, Ulasevich A, Weaver FM, et al. Impact of home
care on hospital days: a meta analysis. Health Serv Res 1997;
32: 415432.
15. Grande GE, Todd CJ, Barclay SIG, et al. Does hospital at
home for palliative care facilitate death at home? Randomised
controlled trial. Br Med J 1999; 319: 14721475.
Alonso-Babarro et al. 75
16. Hughes SL, Weaver FM, Giobbie-Hurder A, et al.
Effectiveness of team-managed home-based primary
care: a randomized multicenter trial. J Am Med Assoc
2000; 284: 28772885.
17. Costantini M, Higginson IJ, Boni L, et al. Effect of a pallia-
tive home care team on hospital admissions among patients
with advanced cancer. Palliat Med 2003; 17: 315321.
18. Miccinesi G, Grocetti E, Morino P, et al. Palliative home
care reduces time spent in hospital wards: a population-based
study in the Tuscany Region, Italy. Canc Causes Contr 2003;
14: 971977.
19. Ahlner-Elmqvist M, Jordhoy MS, Jannert M, et al. Place of
death: hospital-based advanced home care versus conven-
tional care. A prospective study in palliative cancer care.
Palliat Med 2004; 18: 585593.
20. Jordhoy MS, Fayers P, Saltnes T, et al. A palliative-care
intervention and death at home: a cluster randomised trial.
Lancet 2000; 356: 888893.
21. Brumley R, Enguidanos S, Jamison P, et al. Increased sat-
isfaction with care and lower costs: results of a randomized
trial of in-home palliative care. J Am Geriatr Soc 2007; 55:
9931000.
22. Houttekier D, Cohen J, Van den Block L, et al. Involvement
of palliative care services strongly predicts place of death in
Belgium. J Palliat Med 2010; 13: 14611468.
23. Zimmermann C, Riechelmann R, Krzyzanowska M, et al.
Effectiveness of specialized palliative care: a systematic
review. J Am Med Assoc 2008; 299: 16981709.
24. Davies E and Higginson IJ (eds). Palliative care the
solid facts. Copenhagen: WHO Regional Office for
Europe, 2004.
25. Recommendation Rec (2003) 24 of the Committee of Minis-
ters to member status on the organization of palliative care.
Adopted by the Committee of Ministers on 12 November
2003 at the 860th meeting of the Ministers Deputies. Council
of Europe. Stockholm, 2004.
26. Higginson IJ. Clinical and organizational audit in pallia-
tive medicine. In: Doyle D, Hanks G, Cherny N, et al. (eds)
Oxford textbook of palliative medicine. New York: Oxford
University Press, 2004, pp.190191.
27. Serra-Prat M, Gallo P and Picaza JM. Home palliative care
as a cost-saving alternative: evidence from Catalonia. Palliat
Med 2001; 15: 271278.
28. Bruera E, Neumann CM, Gagnon B, et al. The impact of a
regional palliative care program on the cost of palliative care
delivery. J Palliat Med 2000; 3: 181186.
29. Mpinga EK, Pennec S, Gomes B, et al. First international
symposium on places of death: an agenda for the 21st century.
J Palliat Care 2006; 22: 293296.
30. Instituto de Estadstica de la Comunidad de Madrid. Avail-
able at: http://www.madrid.org/iestadis/ (accessed March
2012).
Downloaded from pmj.sagepub.com by guest on July 2, 2013
31. Regional Data Protection Authority, Madrid. Available at:
http://www.madrid.org/cs/Satellite?pagename=APDCM/
Page/homeAPDCM. (accessed March 2012).
32. Domnguez-Berjn MF, Borrell C, Cano-Serral G, et al.
Construccin de un ndice de privacin a partir de datos cen-
sales en grandes ciudades (Proyecto MEDEA). Gac Sanit
2008; 22: 179187.
33. Ruiz-Ramos M, Javier Garca-Len F and Mndez-Martnez
C. Place of death in Andalusia: influence of age, gender and
cause of death. Rev Clin Esp 2011; 211: 127132.
34. Alonso-Babarro A, Bruera E, Varela-Cerdeira M, et al. Can
this patient be discharged home? Factors associated with at-
home death among patients with cancer. J Clin Oncol 2011;
29: 11591167.
35. Bruera E, Neumann CM, Gagnon B, et al. Edmonton
Regional Palliative Care Program: impact on patterns of ter-
minal cancer care. Can Med Assoc J 1999; 161: 290293.
36. Earle CC, Park ER, Lai B, et al. Identifying potential indicators
of the quality of end-of-life cancer care from administrative
data. J Clin Oncol 2003; 21: 11331138.
37. Zhang B, Wright AA, Huskamp HA, et al. Health care costs
in the last week of life: associations with end-of-life conversa-
tions. Arch Intern Med 2009; 169: 480488.
38. Gomes B and Higginson IJ. Factors influencing death at
home in terminally ill patients with cancer: systematic review.
Br Med J 2006; 332: 515521.
39. Higginson IJ, Jarman B, Astin P, et al. Do social factors
affect where patients die: an analysis of 10 years of cancer
deaths in England. J Publ Health Med 1999; 21: 2228.
40. Hanratty B, Burstrom B, Walander A, et al. Hospital deaths
in Sweden: are individual socioeconomic factors relevant?
J Pain Symptom Manage 2007; 33: 317323.
41. Costantini M, Balzi D, Garronec E, et al. Geographical vari-
ations of place of death among Italian communities suggest
an inappropriate hospital use in the terminal phase of cancer
disease. Publ Health 2000; 114: 1520.
42. Sims A, Radford J, Doran K, et al. Social class variation in
place of cancer death. Palliat Med 1997; 11: 369373.
43. Kessler D, Peters TJ, Lee L, et al. Social class and access
to specialist palliative care services. Palliat Med 2005; 19:
105110.
44. Costantini M, Camoirano E, Madeddu L, et al. Palliative
home care and place of death among cancer patients: a pop-
ulation-based study. Palliat Med 1993; 7: 323331.
45. Cardenas-Turanzas M, Carrillo MT, Tovaln-Ahumada H, et
al. Factors associated with place of death of cancer patients
in the Mexico City Metropolitan area. Support Care Cancer
2007; 15: 243249.
46. Domnguez-Berjn F, Borrell C, Rodrguez-Sanz M, et al.
The usefulness of area-based socioeconomic measures to
monitor social inequalities in health in Southern Europe.
Eur J Publ Health 2005; 16: 5461.