Abstract
Background: The prediction of at-home deaths has become an important topic in rural areas of Japan with an advanced aging society. However, there are no well-established predictors to explain how these factors influence intention. This study aims to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan. Methods: This is a nationwide cross-sectional survey. A self-administered questionnaire was sent to 493 rural clinics in Japan. The main outcome was the realization of at-home deaths for cancer patients. Results: Among the 264 clinics (54%) that responded to the survey, there were 194 clinics with the realization of at-home death. The use of a clinical pathway (adjusted odds ratio 4.19; 95% confidence interval 1.57–11.19) and the provision of organized palliative care (adjusted odds ratio 19.16; 95% confidence interval 7.56–48.52) were associated with the prediction of at-home death, irrespective of island geography or the number of doctors and nurses. Conclusions: Having a clinical pathway and systematizing palliative care could be important to determine the possibility of at-home deaths for cancer patients in rural clinics in Japan.
Keywords: critical path, home care, interdisciplinary collaboration, neoplasms, palliative care
1. Introduction
Cancer is the leading cause of death worldwide [1]. The Japanese government approved the Cancer Control Act in 2007 and has launched a Basic Plan in the Promote Cancer Control in order to achieve equal cancer treatment and palliative care throughout the country [2]. Despite the increasing number of at-home death as the population ages [3], a minority of deaths take place at home in the real-world [4,5]. As a general trend, palliative care instruction, the presence of clinical pathways, and the provision of at-home palliative care services can increase the chance of at-home death for cancer patients [6,7,8,9,10,11,12,13].
With the advanced aging of the population, the realization of at-home death has become an urgent issue, and the Cancer Control Act [2] has also been applied to rural areas, which are an advanced aging society, in Japan. However, rural areas are underserved both in terms of human resources and medical facilities, and it can be difficult for individuals to access cancer-specialized facilities [14]. As the number of hospitals is limited, clinics have roles in cancer treatment and palliative care in rural areas. Were the factors related to at-home death for cancer patients in rural areas similar to the above-mentioned general trends [6,7,8,9,10,11,12,13] in relation to the realization of at-home death for cancer patients? Since this remains unknown, the aim of the present study was to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan.
2. Materials and Methods
This nationwide cross-sectional survey was conducted using a self-administered questionnaire in 2013. The survey investigated 493 rural clinics in Japan, and the questionnaires were delivered by mail. The clinics were constructed under Japanese law in rural areas, including remote islands, where the population is declining and transportation is inconvenient [15,16]. The clinics were selected randomly considering the whole balance of survey places (i.e., avoidance of sampling from specific places). The questionnaire included the following data: the number of doctors and nurses, the use of a clinical pathway, the provision of organized palliative care, and their experience of at-home death (Appendix A). The main outcome of the present study was the realization of at-home death. The responding clinic’s name was anonymized on the questionnaire form. This study was approved by the Institutional Ethics Committee.
The difference between groups was examined by chi-square test for categorical variables or the Mann–Whitney U-test for continuous variables. A multiple logistic regression model, adjusted with all examined factors, was used to identify the impact of factors on the outcome. P-values of < 0.05 were considered to indicate statistical significance.
3. Results
Of the 493 rural clinics, 264 (54%) clinics completed the survey. A total of 194 clinics (73%) reported experiencing at-home death in cancer patients. The characteristics of rural clinics with and without the realization of at-home death are listed (Table 1). Rural clinics with the realization of at-home death had more use of a clinical pathway (p < 0.01) and more provision of organized palliative care (p < 0.01) in comparison to clinics without the realization of at-home death.
Table 1.
The characteristics of the rural clinics studied.
| Factors | Realization of At-Home Death (n = 194) |
Non-Realization of At-Home Death (n = 70) |
p |
|---|---|---|---|
| Island geography | 27 (28.7%) | 9 (12.9%) | 0.83 |
| Multiple doctors | 34 (17.5%) | 13 (18.6%) | 0.85 |
| Number of nurses | 3 (2–4) | 3 (2–5) | 0.91 |
| Use of clinical pathway | 59 (30.4%) | 6 (8.6%) | <0.01 |
| Organized palliative care | 121 (62.4%) | 6 (8.6%) | <0.01 |
Data are presented as the number (percentage) or median (interquartile range). p-values were determined by chi-squared test or Mann–Whitney U-test.
Table 2 show the odds ratio (OR) for the realization of at-home death, as analyzed by a logistic regression model. The use of a clinical pathway (adjusted OR 4.19; 95% confidence interval 1.57–11.19; p < 0.01) and the provision of organized palliative care (adjusted OR 19.16; 95% confidence interval 7.56–48.52; p < 0.01) were positively associated with the realization of at-home death, irrespective of island geography or the number of doctors and nurses.
Table 2.
Factors associated with the realization of at-home death.
| Factors | Crude OR (95% CI) | p | Adjusted OR (95% CI) | p |
|---|---|---|---|---|
| Island geography | 1.10 (0.49–2.46) | 0.08 | 1.27 (0.51–3.16) | 0.61 |
| Multiple doctors | 0.93 (0.46–1.89) | 0.85 | 0.55 (0.19–1.58) | 0.27 |
| Number of nurses | 0.99 (0.92–1.08) | 0.91 | 0.97 (0.86–1.09) | 0.56 |
| Use of clinical pathway | 4.66 (1.91–11.40) | <0.01 | 4.19 (1.57–11.19) | <0.01 |
| Organized palliative care | 17.7 (7.29–42.87) | <0.01 | 19.16 (7.56–48.5) | <0.01 |
OR, odds ratio; CI, confidence interval. p-value were determined by a logistic regression analysis; the adjusted OR was calculated with adjustment for all examined factors.
4. Discussion
The present study demonstrated that a clinical pathway and organized palliative care showed a positive independent association with the realization of at-home death for cancer patients in rural clinics of Japan. The findings from this nationwide survey would be useful information for promoting cancer practice in rural areas in Japan.
In the present survey, island geography or the number of doctors and nurses were the insignificant factors in the realization of at-home death. The results might be unexpected because it is typically thought to be difficult to create clinical pathways or receive special instruction in small rural clinics or islands. However, due to the various factors influencing at-home death (e.g., participation in home care by caregivers and family members, the arrangement of community-based informal services), it may cover geographic disadvantages and shortfalls in medical staff within rural areas.
The use of a clinical pathway has been shown to be a general trend in the realization of at-home death [7,11]. This was supported by the results in the present study on rural clinics. The present survey did not detail the contents of the clinical pathways in each clinic; however, since it occasionally seems difficult for the small clinics to create clinical pathways by themselves, some rural clinics could be involved in the clinical pathway of related surrounding hospitals. Involving rural clinics in clinical pathways, which provides access to nearby hospitals with more experience in cancer treatment and palliative care, can be a strategy for the realization of at-home death in rural areas.
Furthermore, systematically organized palliative care has been shown to be a general trend in the realization of at-home death [6,8,9,10,12,13]. This was also supported by the results of the present study in rural clinics. The organization of palliative care includes education or training in care and the existence of interdisciplinary collaboration. Knowledge and skills in palliative care (i.e., the management of pain with opioids and other symptoms related to cancer) is reported to be important for rural physicians to perform palliative care [6,8,9,10,12,13]. This would be similarly important for rural nurses [12]. Using recent technology to overcome the remoteness (i.e., e-learning based on information and communication technology) of rural clinics can be an important strategy for facilitating at-home death [17]. In addition, the usefulness of interdisciplinary work on palliative care has been well established [18,19,20]. Even while there are few human resources, the formation of such a collaborative team would be necessary for rural clinics.
The current study had the advantage of being the first of its kind, and was conducted nationwide with notable findings. Despite this, the present study was associated with some limitations. First, this was not an exhaustive survey, and the response rate was limited. Second, the survey used a self-administered questionnaire. Furthermore, although the organization of palliative care might differ to some degree between the clinics, such a perception was not detailed in the questionnaire. Third, this was a cross-sectional design, which could not determine causality. Fourth, it was performed in 2013, even though the actual status of home care in rural areas might not have changed in recent years. Further studies must be undertaken to address these limitations.
5. Conclusions
Having a clinical pathway and systematizing palliative care could be important for the realization of at-home death for cancer patients in rural clinics in Japan. Further studies are warranted.
Appendix A
The questionnaire survey concerned the following items:
How would you describe the location ofyour facility? -i.e., island, others.
How many doctors are there in your facility?
How many nurses are there in your facility?
Does your facility use any clinical pathway for cancer care? -Yes or No.
Does your facility provide organized palliative care? -Yes or No.
Was at-home death realized in your facility in the present situation? -Yes or No (the realization was not acceptable and/or the hospital admission was recommended).
Author Contributions
Conceptualization, K.K. (Kenichi Komatsu) and K.K. (Kazuhiko Kotani); methodology, J.W., H.T. and K.K. (Kazuhiko Kotani); software, J.W.; validation, J.W., H.T. and K.K. (Kazuhiko Kotani); formal analysis, J.W.; investigation, H.T. and K.K. (Kenichi Komatsu); data curation, J.W. and K.K. (Kenichi Komatsu); writing—original draft preparation, J.W.; writing—review and editing, H.T., K.K. (Kenichi Komatsu), H.Y. and K.K. (Kazuhiko Kotani); visualization, J.W.; supervision, H.Y. and K.K. (Kazuhiko Kotani); project administration, K.K. (Kazuhiko Kotani); funding acquisition, H.Y. All authors have read and agreed to the published version of the manuscript.
Funding
This research was partly supported by a grant from the Professional Training Plan in Cancer Medicine and Health Labor Sciences Research (Iryo-Ippan; 2013).
Institutional Review Board Statement
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Review Board of Jichi Medical University (No. 21-015).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data presented in this study are available on reasonable request and via the ethics committee judgement from the corresponding author.
Conflicts of Interest
The authors declare no conflict of interest in association with the present study.
Footnotes
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Bray F., Ferlay J., Soerjomataram I., Siegel R.L., Torre L.A., Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 2018;68:394–424. doi: 10.3322/caac.21492. [DOI] [PubMed] [Google Scholar]
- 2.Ministry of Health, Labour and Welfare The Basic Plan to Promote Cancer Control Programs. [(accessed on 30 September 2021)];2007 Available online: https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/gan_keikaku03.pdf.
- 3.Hughes L.C., Hodgson N.A., Muller P., Robinson L.A., McCorkle R. Information needs of elderly postsurgical cancer patients during the transition from hospital to home. J. Nurs. Scholarsh. 2000;32:25–30. doi: 10.1111/j.1547-5069.2000.00025.x. [DOI] [PubMed] [Google Scholar]
- 4.Higginson I.J., Daveson B.A., Morrison R.S., Yi D., Meier D., Smith M., Ryan K., McQuillan R., Johnston B.M., Normand C., et al. Social and clinical determinants of preferences and their achievement at the end of life: Prospective cohort study of older adults receiving palliative care in three countries. BMC Geriatr. 2017;17:71. doi: 10.1186/s12877-017-0648-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tan W.S., Bajpai R., Low C.K., Ho A.H.Y., Wu H.Y., Car J. Individual, clinical and system factors associated with the place of death: A linked national database study. PLoS ONE. 2019;14:e0215566. doi: 10.1371/journal.pone.0215566. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Liu W.J., Hu W.Y., Chiu Y.F., Chiu T.Y., Lue B.H., Chen C.Y., Wakai S. Factors that influence physicians in providing palliative care in rural communities in Taiwan. Support. Care Cancer. 2005;13:781–789. doi: 10.1007/s00520-005-0778-7. [DOI] [PubMed] [Google Scholar]
- 7.Tateno Y., Ishikawa S. Clinical pathways can improve the quality of pain management in home palliative care in remote locations: Retrospective study on Kozu Island, Japan. Rural. Remote Health. 2012;12:1992. doi: 10.22605/RRH1992. [DOI] [PubMed] [Google Scholar]
- 8.Yamagishi A., Morita T., Miyashita M., Ichikawa T., Akizuki N., Shirahige Y., Akiyama M., Eguchi K. Providing palliative care for cancer patients: The views and exposure of community general practitioners and district nurses in Japan. J. Pain Symptom. Manag. 2012;43:59–67. doi: 10.1016/j.jpainsymman.2011.03.012. [DOI] [PubMed] [Google Scholar]
- 9.Imura C., Morita T., Kato M., Akizuki N., Kinoshita H., Shirahige Y., Suzuki S., Takebayashi T., Yoshihara R., Eguchi K. How and why did a regional palliative care program lead to changes in a region? A qualitative analysis of the Japan OPTIM study. J. Pain Symptom Manag. 2014;47:849–859. doi: 10.1016/j.jpainsymman.2013.06.002. [DOI] [PubMed] [Google Scholar]
- 10.Hirooka K., Miyashita M., Morita T., Ichikawa T., Yoshida S., Akizuki N., Akiyama M., Shirahige Y., Eguchi K. Regional medical professionals’ confidence in providing palliative care, associated difficulties and availability of specialized palliative care services in Japan. Jpn. J. Clin. Oncol. 2014;44:249–256. doi: 10.1093/jjco/hyt204. [DOI] [PubMed] [Google Scholar]
- 11.Brännström M., Fürst C.J., Tishelman C., Petzold M., Lindqvist O. Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study. Palliat. Med. 2016;30:54–63. doi: 10.1177/0269216315588007. [DOI] [PubMed] [Google Scholar]
- 12.Singer A.E., Goebel J.R., Kim Y.S., Dy S.M., Ahluwalia S.C., Clifford M., Dzeng E., O’Hanlon C.E., Motala A., Walling A.M., et al. Populations and interventions for palliative and end-of-life care: A systematic review. J. Palliat. Med. 2016;19:995–1008. doi: 10.1089/jpm.2015.0367. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Le B., Eastman P., Vij S., McCormack F., Duong C., Philip J. Palliative care in general practice: GP integration in caring for patients with advanced cancer. Aust. Fam. Physician. 2017;46:51–55. [PubMed] [Google Scholar]
- 14.Bergin R.J., Emery J., Bollard R.C., Falborg A.Z., Jensen H., Weller D., Menon U., Vedsted P., Thomas R.J., Whitfield K., et al. Rural-urban disparities in time to diagnosis and treatment for colorectal and breast Cancer. Cancer Epidemiol. Biomark. Prev. 2018;27:1036–1046. doi: 10.1158/1055-9965.EPI-18-0210. [DOI] [PubMed] [Google Scholar]
- 15.Ministry of Agriculture, Forestry and Fisheries Overview of Mountain Villages Development Act. [(accessed on 30 September 2021)];2019 Available online: http://www.maff.go.jp/j/nousin/tiiki/sanson/s_about/summary.html.
- 16.Ministry of Land, Infrastructure, Transport and Tourism Remote Islands Development Act. [(accessed on 11 September 2021)];2013 Available online: https://www.mlit.go.jp/common/001014058.pdf.
- 17.Ray R.A., Fried O., Lindsay D. Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations. BMC Health Serv. Res. 2014;14:272. doi: 10.1186/1472-6963-14-272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wiebe L.A., Von Roenn J.H. Working with a palliative care team. Cancer J. 2010;16:488–492. doi: 10.1097/PPO.0b013e3181f28ae6. [DOI] [PubMed] [Google Scholar]
- 19.Murray S.A., Firth A., Schneider N., Van den Eynden B., Gomez-Batiste X., Brogaard T., Villanueva T., Abela J., Eychmuller S., Mitchell G., et al. Promoting palliative care in the community: Production of the primary palliative care toolkit by the European Association of Palliative Care Taskforce in primary palliative care. Palliat. Med. 2015;29:101–111. doi: 10.1177/0269216314545006. [DOI] [PubMed] [Google Scholar]
- 20.Rotar Pavlič D., Aarendonk D., Wens J., Rodrigues Simões J.A., Lynch M., Murray S. Palliative care in primary care: European Forum for Primary Care position paper. Prim. Health Care Res. Dev. 2019;20:e133. doi: 10.1017/S1463423619000641. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data presented in this study are available on reasonable request and via the ethics committee judgement from the corresponding author.