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October - 2017

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Association Between Immigrant Status and End-of-Life Care in Ontario, Canada

C.J Yarnell, L Fu, D Manuel, P Tanuseputro, T Stukel, R Pinto D Scales, A Laupacis, R Fowler JAMA, 2017, online first Oct 17

Comment

This population based cohort study examines the end-of-life care for recent immigrant patients in Ontario, Canada, and compares it to long-standing resident patients. 

What did they do?

  • Identified  967013 people who died in Ontario between April 1 2004 and March 31 2015. Patients were categorised as recent immigrants if Canadian citizenship/residency was granted between 1985 and 2015, and subgroups created according to duration. All other patients were defined as long term. 
  • By linking multiple healthcare databases they collected data on patient characteristics and outcomes, with the primary outcome place of death. 

What did they find?

  • 5% of decedents were recent immigrants, with diverse global origins
  • median age at death was 75-80 years, with IHD, dementia and lung cancer most common cause for both groups
  • A higher proportion of recent immigrant decedents died in intensive care (15.6% vs 10.0%; diff, 5.6%; 95% CI, 5.2%-5.9%). This increase persisted after adjusting for differences in age, sex, income, geography, and cause of death (adjusted RR of dying in intensive care comparing recent immigrant with long-standing resident decedents: 1.30; 95% CI, 1.27-1.32)
  • In their last 6 months of life, recent immigrant decedents experienced more (even after adjusting for confounders);
    • ICU admissions (24.9% vs 19.2%; diff, 5.7%; 95% CI, 5.3%-6.1%)
    • hospital admissions (72.1% vs 68.2%; diff, 3.9%; 95% CI, 3.5%-4.3%)
    • mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%)
    • dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%)
    • percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI,2.3%-2.8%)
    • tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%) 
  • The RR of death in ICU for recent immigrant vs long-standing resident  was highest if older than 80 years, female, and lower comorbidity index.  
  • There was substantial variation in end-of-life care according to region of birth and time since immigration. The RR of dying in ICU ranged from;
    • N and W Europe 0.84 (95% CI, 0.74-0.95) 
    • W and Central Asia 1.78 (95% CI, 1.66-1.92) 
    • Africa 1.84 (95% CI, 1.70-2.00) 
    • SE Asia 1.96 (95% CI, 1.89-2.05) 
  • Differences were associated with time in Canada, with an RR of dying in ICU of 1.42 (95% CI, 1.36-1.48) among those who immigrated 21 to 30 years before death and an RR of 2.03 (95% CI, 1.80-2.29) seen in those who immigrated fewer than 2 years before death. 

What does it mean?

  • There is previous evidence that suggests immigrants face cultural and logistical challenges in end-of-life care due to decreased health literacy, language ability, different modes of family-based decision-making and filial responsibility, decreased access to care due to insufficient financial and social resources, and different end of-life care preferences. 
  • This study shows a different pattern of end-of-life care in recent immigrants, with a more medicalised death, exists. This was more prominent in recent immigrant, varied with region of birth, and was not due to socioeconomic status, cause of death etc.
  • It doesn’t tell us why it happens, if it is good or bad, and what we should do about it. As the authors point out, it does suggest we need to understand the issue better.

 

Abstract

Importance  People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.

Objective  To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.

Design, Setting, and Participants  This population-based cohort study (April 1, 2004, to March 31, 2015) included 967?013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.

Exposures  All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.

Main Outcomes and Measures  Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.

Results  Among 967?013 decedents of whom 47?514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.

Conclusions and Relevance  Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

October


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