The use of end-of-life homecare services in Ontario, Canada: Is it associated with using less acute care services in late life

Aim. This research aims to (1) describe the trajectories of how end-of-life nursing and personal support and homemaking (PSH) homecare services are used by patients from homecare admission to death, and (2) investigate whether homecare services use is associated with acute care service use.;Methods. This longitudinal study of end-of-life homecare decedents in Ontario, Canada, linked data from the Homecare Database with other administrative databases, such as hospital records. Decedents were admitted to homecare between April 1, 2005 and December 31, 2006 and dead before March 31, 2007. Decedents were aligned by death date and examined backwards by weeks to initial homecare admission. The trajectories of homecare hours over time were described by a two-step statistical approach that predicted the odds of using any versus no homecare services and the incidence rate ratio of service use among those who used any homecare services. The association between homecare service use and odds of having a hospitalization or emergency room (ER) visit in the last 2 weeks of life, and dying in a hospital were investigated using multilevel logistic regression.;Results. About 84% of this cohort of 11,867 individuals had a cancer diagnosis. Almost 80% of the cohort was over 60 years old, about half were male, and the mean time from homecare admission to death was 14 weeks. Among all patient-weeks, the average nursing hours/week was 3.1 (SD=6.3; IQR=3) and PSH hours/week was 3. 3 (SD=8.5; IQR=2). Among patients receiving any services, the odds ratio of nursing and PSH hours used/week increased slightly (2%; 95% CI: 1.02-1.02; p<0.001) each week closer to death and by an additional 20% (95% CI: 1.20-1.21; p<0.001) and 11% (95% CI: 1.11-1.11; p<0.001) respectively, for each of the last 4 weeks of life compared to use/week at 24 weeks prior to death.;In the last 2 weeks of life, 33% of the cohort had a hospitalization and 17% had an ER visit. 34% of the cohort died in a hospital. Adjusted multilevel logistic regression showed that patients using more than an average of 7 nursing hours/week and 7 PSH hours/week were associated with about 50% (p<0.001) and 30% (p<0.001) lower odds respectively, of having any of the three acute care outcomes. Moreover, the association between increased homecare service use and decreased acute care service use occurred in a dose-response manner, controlling for other covariates.;Conclusion. Nursing and PSH hours/week increase slightly each week closer to death and sharply in the last month of life for end-of-life homecare patients in Ontario. As well, using higher amounts of nursing (>3 hours/week) and PSH (>7 hours/week) services are associated with significantly lower odds of having any of the acute care outcomes. Further research is needed to determine if this association is a causal relationship and whether services currently provided adequately meet patient and family needs.