Why do people with terminal cancer use unscheduled care?

Problem

Patients with cancer often experience complex pain and symptom control issues that can cause them to presentation to unscheduled care via GP Out-Of-Hours (GPOOH) or Accident and Emergency (A&E). Unscheduled care is unplanned, is often distressing and disruptive for older people, and is poorly integrated with ongoing care.

Approach

This research aims to understand the patterns of unscheduled care attendance and outcomes for patients with cancer in their last 12 months of life, and to examine associations with demographic, temporal, and clinical factors. This analysis is a retrospective cohort study of NHS Tayside residents who died from cancer between 01/01/2012-30/06/2015. Patients were identified posthumously using General Register Office ‘Cause of Death’ Data. Routinely collected clinical data from all unscheduled care during their last year of life was collected using Community Health Index (CHI) number searches. Clinical data was linked to demographic and prescribing datasets using patient CHIs. The CHI is a unique patient identification number used in all clinical encounters.

Findings

The overwhelming majority (82%) of patients dying from cancer used unscheduled care in their last year of life. Of 3,093 patients in the cohort, 2,235 (72.3%) used GP-OOH and 1,168 (37.7%) used A&E in the year before death, resulting in 9,712 unscheduled care contacts. Patients attending GPOOH were more likely to present multiple times than those presenting to A&E. Patient gender was significantly associated with type of unscheduled care use with women being more likely to use GPOOH and men being more likely to use A&E (p=0.007), but was not significantly associated with likelihood of using vs. not using unscheduled care (p=0.014). Patient age was significantly associated with use of unscheduled care. Cancer type was significantly associated with lifelihood of attending unscheduled care. Lung cancer was the commonest cancer in the population (19.7%), followed by haematological malignancies (10%), and bowel cancer (9.9%). Rurality was significantly associated both with likelihood of using unscheduled care, and with the type of unscheduled care accessed; the more rural the patients’ location the more likely they were to use GPOOH over A&E services (p=0.001). Conversely, deprivation was not sicnificantly associated with access to, frequency of use or type of unscheduled care accessed. Patient’s GP practice was associated with whether or not patients attended unscheduled care, but was not associated with patients’ frequency of unscheduled care contacts, particularly in the end of life.

Consequences

Multiple patient and practice level factors influence whether, what type and how often patients with terminal cancer use unscheduled care in their last year of life. Understanding how and why people dying from cancer use unscheduled care is vital to determining what interventions could reduce unnecessary attendance at unscheduled care and improve outcomes of attendances, leading to improved service provision for these vulnerable individuals.