CIHI Survey: Dying of Cancer in Canada's Acute Care Facilities
The Changing Face of HealthcareOver the past 10 years, the Canadian healthcare system has undergone substantial change in how care is organized and delivered. Some of these changes may have an impact on community and home-based care. Examples include:
- More spending on home care. Spending on care provided in
the home by healthcare workers or through health programs supported
by governments at the provincial or community level has increased
substantially. Between 1988/1989 and 2000/2001 total provincial
home-care spending increased by over 469%. At the beginning of this
period, home care accounted for 1.6% of total provincial health
spending. By 2000/2001, it had risen to 5.0% of the total (Canadian
Institute for Health Information 2003).
- Increased ambulatory care. There has been a shift away
from in-hospital care toward increased day surgery and outpatient
care. At the same time, there has been a decrease in the number of
approved inpatient beds in the system - from approximately 170,000
in 1994/1995 to 115,000 in Canada in 2001/2002.
- Increases in total health spending. Since the mid-1990s, overall spending on healthcare has increased. As of 2004, health spending is estimated to be over $130 billion dollars.
Dying of Cancer in HospitalAccording to the National Cancer Registry, the number of people with breast, prostate, colorectal and lung cancer and the number of those who die from them has increased over the past few years, from 31,300 deaths in 1995 to an estimated 34,600 deaths in 2002. The percentage of cancer patients who die in hospital varies by the type of cancer involved. For example, based on 2002 estimates, about one-third of people diagnosed with breast cancer die in hospital; for lung cancer, it is over 55%.
The decline in the proportion of cancer deaths that occur in hospital is apparent in all regions of the country. However, regional in-hospital death rates related to specific cancers vary. For example, Quebec's rates of in-hospital breast cancer deaths have been higher than those of other Canadian jurisdictions over the past few years. In 1995, over 60% of people diagnosed with breast cancer in Quebec died in hospital, whereas, in Ontario, the percentage is just over 38%. By 2001, both rates had declined substantially, but Quebec's rate of in-hospital deaths remained higher than any other jurisdiction in Canada. Regional differences may reflect differences in the distribution of palliative care both in and outside of acute care facilities.
The Need for Palliative CareMost palliative care in Canada is provided to patients who have been diagnosed with cancer (Health Canada 2004). As a result, in-hospital death rates for cancer patients have been used as an indicator of the need for community/palliative care (e.g., Johnston et al. 1998; Townsend et al. 1990). That said, not everyone who is diagnosed with cancer would opt to receive end-of-life care at home. Recent reports (Health Canada 2004; Subcommittee … Science and Technology 2000) have suggested several factors that might influence inhospital death rates:
- cultural and spiritual beliefs and practices of individuals,
families and communities.
- availability of integrated, multidisciplinary palliative care
- ability (both emotional and financial) of family members to
provide care - and the supports/assistance they receive to do
- financial considerations - While care, supplies (such as pain
pumps and oxygen) and drugs are generally provided without cost to
the patient in acute hospital settings, this is not always true in
other parts of the health system, such as continuing care, hospices
or homecare. These financial factors may drive some people to seek
admission to hospital.
- educational supports and reimbursements strategies for primary healthcare providers, particularly family doctors, to assist with care.
While we have more information about cancer deaths than in the past, many questions remain. For example, how many people receive appropriate end-of-life care in hospital and at home? How satisfied are patients and their families with endof- life care? Who provides this care, inside and outside the hospital, and how is this changing? Are home-based deaths meeting patient needs, or are reductions in inpatient bed availability exerting pressure on families to care for dying patients at home? What would be the impact of mandatory palliative care curriculum in medical schools at the undergraduate and postgraduate level? Mandatory curriculum is only offered at 13% of undergraduate programs and 31% of post graduate training (Health Canada 2004).
Answers to these and many other questions may help inform those making decisions about how end-of-life care is supported in Canada. The Canadian Institute for Health Information is embarking on a study of end-of-life healthcare utilization in the four western provinces. Results from this study may help begin the process of answering these questions.
About the Author(s)
Kira Leeb, MA, Manager, Health Services Research, has managed the production of CIHI's annual report on the health of Canada's healthcare system and has led the production of more focused reports or research on Canada's healthcare system.
Naomi Kasman, MSc, is a senior analyst. She has previously done population health and health services research as the Epidemiologist at the Central East Health Information Partnership and as a Research Associate at the Arthritis Community Research and Evaluation Unit.
Kathleen Morris, MBA, conducts special projects for CIHI. Recent assignments have included coordination of CIHI activities regarding the measurement and reporting of wait times for health services, development of a long range analytic plan and an assessment of how CIHI data and reports are used by decision-makers.
Ramirez. 2005. "Depression and Anxiety with Early Breast Cancer: Five Year Observational Cohort Study." British Medical Journal 330: 702-06.
Canadian Institute for Health Information (CIHI). 2002. Health Care in Canada 2002. Ottawa: Author.
Canadian Institute for Health Information (CIHI). 2003. Monitoring the Feasibility of Reporting Home Care Estimates in National Health Expenditures. Ottawa: Author.
Flory, J., Y. Young-Xu, I. Gurol, N. Levinsky, A. Ash and E. Emanuel. 2004. "Place of Death: U.S. Trends since 1980." Health Affairs 23(3): 194-200.
Health Canada. 2004. Progress Report on Cancer Control in Canada. Centre for Chronic Disease Prevention and Control. Population and Public Health Branch. Ottawa: Author.
Johnston, G.M., L. Gibbons, F.I. Burge, I. Cummings, R.A. Dewar and I.G. Levy. 1998. "Identifying Potential Need for Cancer Palliation in Nova Scotia." Canadian Medical Association Journal 158(13): 1691-98.
Subcommittee of the Standing Senate Committee on Social Affairs, Science and Technology. 2000. Quality End-of-Life Care: The Right of Every Canadian. Ottawa: Author.
Townsend, J., A.O. Frank, D. Fermont, S. Dyer, O. Karran, A. Walgrove and M. Piper. 1990. "Terminal Cancer Care and Patients' Preference for Place of Death: A Prospective Study." British Medical Journal 301(6749): 415-17.
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