Trends and Social Barriers for Inpatient Palliative Care in Patients With Metastatic Bladder Cancer Receiving Critical Care Therapies

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Background: Use of inpatient palliative care (IPC) in the treatment of advanced cancer represents a well-established guideline recommendation. A recent analysis showed that patients with genitourinary cancer benefit from IPC at the second lowest rate among 4 examined primary cancers, namely lung, breast, colorectal, and genitourinary. Based on this observation, temporal trends and predictors of IPC use were examined in patients with metastatic urothelial carcinoma of the bladder (mUCB) receiving critical care therapies (CCTs). Patients and Methods: Patients with mUCB receiving CCTs were identified within the Nationwide Inpatient Sample database (2004–2015). IPC use rates were evaluated in estimated annual percentage change (EAPC) analyses. Multivariable logistic regression models with adjustment for clustering at the hospital level were used. Results: Of 1,944 patients with mUCB receiving CCTs, 191 (9.8%) received IPC. From 2004 through 2015, IPC use increased from 0.7% to 25.0%, respectively (EAPC, +23.9%; P<.001). In analyses stratified according to regions, the highest increase in IPC use was recorded in the Northeast (EAPC, +44.0%), followed by the West (EAPC, +26.8%), South (EAPC, +22.9%), and Midwest (EAPC, +15.5%). Moreover, the lowest rate of IPC adoption in 2015 was recorded in the Midwest (14.3%). In multivariable logistic regression models, teaching status (odds ratio [OR], 1.97; P<.001), more recent diagnosis (2010–2015; OR, 3.89; P<.001), and presence of liver metastases (OR, 1.77; P=.02) were associated with higher IPC rates. Conversely, Hispanic race (OR, 0.42; P=.03) and being hospitalized in the Northeast (OR, 0.36; P=.01) were associated with lower rate of IPC adoption. Finally, patients with a primary admission diagnosis that consisted of infection (OR, 2.05; P=.002), cardiovascular disorders (OR, 2.10; P=.03), or pulmonary disorders (OR, 2.81; P=.005) were more likely to receive IPC. Conclusions: The rate of IPC use in patients with mUCB receiving CCTs sharply increased between 2004 and 2015. The presence of liver metastases, infections, or cardiopulmonary disorders as admission diagnoses represented independent predictors of higher IPC use. Conversely, Hispanic race, nonteaching hospital status, and hospitalization in the Midwest were identified as independent predictors of lower IPC use and represent targets for efforts to improve IPC delivery in patients with mUCB receiving CCT.

Submitted November 2, 2018; accepted for publication May 15, 2019.Author contributions: Study concept and design: Mazzone, Knipper, Karakiewicz. Data curation: Mistretta, Palumbo. Formal analysis: Mazzone, Mistretta, Tian. Methodology: Mazzone, Tian, Gallina, Tilki. Project administration: Tian, Montorsi, Karakiewicz. Software: Tian. Supervision: Shariat, Montorsi, Saad, Karakiewicz. Visualization: Mazzone, Knipper, Tian. Writing of original draft: Mazzone, Karakiewicz. Manuscript review and editing: Montorsi, Briganti.Disclosures: The authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.Correspondence: Elio Mazzone, MD, Division of Experimental Oncology, Unit of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy. E-mail: eliomazzone@gmail.com
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