1. 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

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

3. 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)

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

5. Rapidly Ageing Population
Source: Department of Statistics Singapore, 2014

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

7. 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

8. 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

9. Palliative Care in Singapore

10. 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

11. 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

12. 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

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

14. 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)

15. 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)

16. 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)

17. 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
<0.001
1.09
Mean age in years (SD)
72.76 (13.05)
68.63 (13.37)
1.01
Mean of log-transformed LOS in services (SD)
1.54 (0.66)
1.60 (0.60)
0.94
0.88
Mean number of episodes of hospitalisation (SD)
0.58 (1.32)
1.18 (1.73)
0.83
0.81
Mean number of doctor visits (SD)
1.32 (1.14)
0.89 (0.94)
1.16
1.05
0.003
Mean number of nurse visits (SD)
3.68 (2.42)
2.65 (2.18)
1.08
1.06

18. 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
0.005
0.97
0.092
Mean distance from hospital, kilometre (SD)
11.02 (5.67)
10.80 (5.75)
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
0.98
0.548
Not related
42 (31.1)
93 (68.9)
0.54
0.84
0.546
None
9 (34.6)
17 (65.4)
0.61
0.063
1.13
0.907
Diagnosis, n (%)
Non-cancer
445 (68.5)
205 (31.5)
Cancer
7,676 (54.1)
6,518 (55.9)
0.79
0.93
0.042

19. 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
1.54
0.026
Institution
3 (5.2)
55 (94.8)
0.18
0.003
0.11
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
1.03
0.334
>50%
2,736 (54.9)
2,251 (55.1)
1.07
0.99
0.861

20. 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

21. 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)

22. 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

23. 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.

24. 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.

25. 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.

26. 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.