Dr YeeSong Lee, BMBS(UK), MPH(Singapore) 21st June 2017 Clinical and socio-demographic predictors of home hospice patients dying at home: A retrospective analysis of Hospice Care Association’s database in Singapore Dr YeeSong Lee, BMBS(UK), MPH(Singapore) 21st June 2017

Outlines Background Objectives of study Methodology Results Discussion Limitation/Strength Conclusion

Singapore Population: 5,781,728 (2016) Chinese 74.3%, Malay 13.4%, Indian 9.1% (includes Sri Lankan), other 3.2% (2016) Urban population: 100% of total population (2015) Singapore — GDP per capita: $87,082, 4th in the world (Source: IMF)

Challenges in Singapore’s Palliative Care Sector Rapidly ageing population Increase in prevalence of non-communicable diseases Low awareness of palliative care Finance/Manpower

Rapidly Ageing Population Source: Department of Statistics Singapore, 2014

Increase in prevalence of non-communicable diseases Source: Ministry of Health, Singapore

Lack of Public Awareness Death attitude survey: only 50% of those surveyed are aware of palliative care Taboo on discussing death related subject Source: Lien Foundation Death Survey 2013

Finance/Manpower High cost of care/High out-of-pocket payment (3M care model: Medisave, Medishield, Medifund) Sustainability of funding (hospices are mainly run by NGOs) Lack of manpower in public palliative care/hospice care sector

Palliative Care in Singapore

Objectives To examine the independent factors associated with home hospice patient dying at home: Demographic (gender, age, socio-economic status) of home hospice patients and place of death; Caregiver profile and living arrangement Proximity to primary hospital and place of death Health services utilization while on home hospice services

Methodology Retrospective database analysis of Hospice Care Association (HCA) database Permission granted by the Hospice Care Association (HCA) Research protocol was approved by National University of Singapore (NUS) IRB Inclusion criteria All home hospice patients admitted under HCA care from 1 Jan 2004 to 31 Dec 2013 Patients with life-limiting illness and degenerative disease

Statistical Analysis Patient characteristics were described in frequencies for categorical variables, while continuous variables were reported in mean and standard deviation. Bivariate and multivariate analyses were conducted using Cox Proportional Hazards modelling with time as a constant to study the relationship between the independent variables and place of death. Risk ratios were reported using robust standard errors. Presence of co-linearity between independent variables in the final model was tested by examining variance inflation factors. The conventional P<0.05 was used as the cut-off for statistical significance All statistical analyses were performed using SPSS version 22 and STATA 13

Hospice Care Association (HCA) in Singapore HCA is the largest local home hospice provider in Singapore Services offered by Hospice Care Association (HCA) in Singapore Medical and nursing services Caregiver support/training Family support Psychological and spiritual support Bereavement services

Results Total number of decedents included in the analysis: 19,721 Variables N (%) Place of death At home 10,858 (55.0) Hospital 8,335 (42.3) In-patient hospice 397 (2.0) Nursing home 131 (0.7) Gender Male 10,090 (51.2) Female 9,629 (48.8)

Results Variables N (%) Age in years (Mean, SD) 71.00 (13.34) Diagnosis Non-cancer 650 (4.4) Cancer 14,194 (95.6) Log-transformed length of stay in service, days (Mean, SD) 1.57 (0.63) Number of hospitalisation episodes(Mean, SD) 0.85 (1.55) Number of doctor visits (Mean, SD) 1.12 (1.08) Number of nurse visits (Mean, SD) 3.22 (2.37) Number of medical social worker visits (Mean, SD) 0.08 (0.45) Distance from hospital, kilometre (Mean, SD) 10.9 (5.71)

Results Variables N (%) Caregiver status Spouse 12,412 (65.8) Non-spouse relative 6,279 (33.3) Not related 135 (0.7) None 26 (0.1) Living arrangement Alone 87 (1.7) At home with caregivers 5,034 (97.2) Institution 58 (1.1) Mean-tested subsidy level 0% 7,967 (45.5) >0% to 50% 4,549 (26.0) >50% 4,987 (28.5)

Bivariate and multivariate analyses   Place of Death Unadjusted Model Adjusted Model Variables Home Non-home Crude RR 95% CI P-value Adjusted RR Gender, n (%) Male 5,252 (52.1) 4,838 (47.9) 1.00 Female 5,605 (58.2) 4,024 (41.8) 1.12 1.09 - 1.15 <0.001 1.09 1.04 - 1.15 Mean age in years (SD) 72.76 (13.05) 68.63 (13.37) 1.01 1.01 - 1.01 1.00 - 1.01 Mean of log-transformed LOS in services (SD) 1.54 (0.66) 1.60 (0.60) 0.94 0.92 - 0.96 0.88 0.82 - 0.94 Mean number of episodes of hospitalisation (SD) 0.58 (1.32) 1.18 (1.73) 0.83 0.81 - 0.85 0.81 0.75 - 0.86 Mean number of doctor visits (SD) 1.32 (1.14) 0.89 (0.94) 1.16 1.15 - 1.17 1.05 1.01 - 1.08 0.003 Mean number of nurse visits (SD) 3.68 (2.42) 2.65 (2.18) 1.08 1.08 - 1.09 1.06 1.04 - 1.08

Bivariate and multivariate analyses   Place of Death Unadjusted Model Adjusted Model Variables Home Non-home Crude RR 95% CI P-value Adjusted RR Mean number of medical social worker visits (SD) 0.07 (0.42) 0.09 (0.48) 0.95 0.92 - 0.99 0.005 0.97 0.93 - 1.01 0.092 Mean distance from hospital, kilometre (SD) 11.02 (5.67) 10.80 (5.75) 1.00 1.00 - 1.00 0.009 0.866 Caregiver status, n (%) Spouse 7,902 (60) 5,320 (40) <0.001 0.870 Non-spouse 3,220 (51.3) 3,059 (48.7) 0.90 0.87 - 0.92 0.98 0.93 - 1.04 0.548 Not related 42 (31.1) 93 (68.9) 0.54 0.42 - 0.70 0.84 0.48 - 1.47 0.546 None 9 (34.6) 17 (65.4) 0.61 0.36 - 1.03 0.063 1.13 0.15 - 8.66 0.907 Diagnosis, n (%) Non-cancer 445 (68.5) 205 (31.5) Cancer 7,676 (54.1) 6,518 (55.9) 0.79 0.75 - 0.83 0.93 0.86 - 1.00 0.042

Bivariate and multivariate analyses   Place of Death Unadjusted Model Adjusted Model Variables Home Non-home Crude RR 95% CI P-value Adjusted RR Living arrangement, n (%) Alone 25 (28.7) 62 (71.3) 1.00 <0.001 Home with caregiver 3,089 (61.4) 1,945 (38.6) 2.14 1.53 - 2.98 1.54 1.05 - 2.26 0.026 Institution 3 (5.2) 55 (94.8) 0.18 0.06 - 0.57 0.003 0.11 0.03 - 0.45 0.002 Mean-tested subsidy level, n (%) 0% 4,078 (51.2) 3,889 (48.8) 0.503 >0% to 50% 2,779 (61.1) 1,770 (48.9) 1.19 1.16 - 1.23 1.03 0.97 - 1.10 0.334 >50% 2,736 (54.9) 2,251 (55.1) 1.07 1.04 - 1.11 0.99 0.94 - 1.05 0.861

Discussions Demographics Female and old age Cancer diagnosis Discrepancy with studies that do not support these findings are likely due to patient characteristics, healthcare system and/or cultural factors. Cancer diagnosis Smaller sample size of non-cancer patients in our study (4.4%) compared to 95.6% being cancer patients. Selection bias by the referring doctor, i.e., only non-cancer patients who were deemed to be fit to be cared for at home were referred to HCA

Discussions Healthcare utilization Length of stay in home hospice service Terminal discharges Number of hospitalizations Caregivers’ ability and coping skills Change in patients preference Healthcare professionals Doctors and nurses visits increase chance of dying at home Medical social worker visits associated with lower chance of home death (not statistically significant in multivariate analysis)

Discussions Living arrangement and caregiver status Living arrangement Living with caregiver is more like to die a home Proximity matters Caregiver status Significant determinant of place of death for home hospice patients in bivariate analysis but not in the logistic regression Asian values Foreign domestic workers

Discussions Mean testing A proxy for determining the socio-economic status It was found to be statistically significant in bivariate analysis but not in the multivariate analysis Bivariate analysis showed that: Middle-income group was more likely to die at home compared to lowest and highest socio-economic status group.

Limitations Retrospective study and information available is limited to that what was collected. Unable to study potentially important determinants of home death, such as patient/caregiver preference, prognostic awareness, level of caregiver support, insurance coverage, and intensity of home hospice visits. Data used were spanning for 10 years and the environment/health system might have changed significantly throughout the years.

Strengths Large sample size, 19,723. Hospice care association (HCA) is the largest home hospice service provider in Singapore and serves all the regions in the city state. First study in Singapore that examined the effect of caregiver status, living arrangement, mean testing and clinician visit on the place of death of home hospice patient.

Conclusions Provide insights into home hospice care in an urban, multicultural and Asia country. Importance of: Empowerment of family members/caregivers Assessment of risk (demographic, socio-economic status, living arrangement) Future prospective study is recommended to look into: Attitudes and emotions of patient and caregivers Reason for not passing on at home Effect of community support such as friends, religion organization etc.