Factors influencing death at home in terminally ill patients with cancer: systematic review
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38740.614954.55 (Published 02 March 2006) Cite this as: BMJ 2006;332:515Data supplement
QUALITY ASSESSMENT SCALE [posted as supplied by author]The scale is adapted from the NHS Centre for Reviews and Dissemination guidelines for quality assessment of observational studies. It is divided into three parts, each with several items. A score is given in each item. These are summed to calculate an overall total for the scale (maximum of 24 points). The final score is converted in a proportion for an easier understanding of the quality score.
PART 1: Study Design
High quality (1.5)
Fair quality (1)
Poor quality (0.5)
Unknown (0)
Study design
Prospective
Cross-sectional
Retrospective
Inclusion and
exclusion criteria
Detailed description of both & appropriate
Sufficient description & appropriate
Basic and insufficient information
Baseline
characteristics
No imp. confounders
One important confounder
More than one imp. confounder
Generalisability of sample
Randomised & diverse sample
Some criteria that may indicate selectivity
Highly selected sample (place of care, wishes)
Sample size
More than 200
100-200
Less than 100
Assessment of
place of death
Death certificates or files with clear and standard assessment
Files or reliable accounts (proximity of respondent, time distance)
Accounts poorly reliable
Assessment of
the factor(s)
Standardized & appropriated for the variable(s)
Reliable accounts
(proximity of respondent, time distance)
Non systematic, unreliable or inappropriate
Appropriateness of study design
High appropriateness
(1.5)
Appropriate (1)
Poor appropriateness
(0.5)
Not appropriate (0)
Can the study be generalized, can it offer a reliable account of reality and is it appropriate to the issue, having in mind ethical issues?
PART 2: Conduct of the Study
High quality (1.5)
Fair quality (1)
Poor quality (0.5)
Unknown (0)
Response rate *
80% or more
60-79
Less than 60
Reasons for non-response/
drop-out/missing data
Low & controlled or incontrollable
Acceptable & if reasons are not imp for results
High and reasons with predicted impact on results
*Flexible criteria
PART 3: Analysis
Description
Well reported (1)
Sufficiently reported (0.5)
Poorly reported or unknown (0)
Analysis procedures/
statistical tests
Tests used & significance criteria presented
General analysis & significance criteria (even if not presented, easily inferred)
Results
P values or CIs
One of the two
Quality
High quality (2)
Fair quality (1)
Poor quality (0)
Analysis procedures/statistical tests
Multivariate
Bivariate
Results
No errors in presentation and interpretation
Few minor errors
Important errors
Appropriateness
High appropriateness
(3)
Appropriate (2)
Poor appropriateness
(1)
Not appropriate (0)
Was the analysis appropriate, rigorously applied and correctly interpreted? Does it offer a reliable account of reality?
Table A Electronic databases and journals handsearched [posted as supplied by author]
Electronic searches
Journals handsearched
Databases
Keywords
MESH headings
MEDLINE (on OVID, 1966-3rd Sep2004)
1. death adj2 (place or site or location or home$ or hospital$ or hospice$).mp.
2. dying adj2 (place or site or location or home$ or hospital$ or hospice$).mp.
3. 1 or 2
4. (factor$ or determinant$ or predict$ or affect$ or influence$ or associat$ or difference$ or relat$) adj3 3
5. terminal$ or palliative or end of life or advanced disease or hospice$
6. 5 or (subject headings)
7. 4 and 6
Palliative care
Terminal care
Hospice care
Palliative Medicine (2003/4)
Journal of Palliative Care (2003/4)
Journal of Pain and Symptom Management (2003/4)
Journal of Palliative Medicine (1998 to 2000; 2003/4)
Supportive Care in Cancer (2003/4)
BMC Palliative Care (2002 to 2004) -available online
PsycINFO (on OVID, 1972-3rd Sep2004)
Palliative care
Terminal cancer
Terminally ill patients
Hospice
Death and Dying
CINAHL (on OVID, 1982-3rd Sep2004)
Palliative care
Terminal care
Hospice and palliative nursing
Hospices
ASSIA (1987-3rd Sep2004)
1. death within 2 (place or site or location or home* or hospital* or hospice*)
2. dying within 2 (place or site or location or home* or hospital* or hospice*))
3. 1 or 2
4. (factor* or determinant* or predict* or affect* or influence* or associat* or difference* or relat*)
5. 3 and 4
6. terminal* or palliative or end of life or advanced disease or hospice* or (subject headings)
7. 5 and 6
Palliative care
Terminal care
Hospices
The journals selected for handsearching were the most frequent sources of studies included in the review or were suggested for further consultation by a library expert. Journal of Palliative Medicine was additionally handsearched for 1998-2000 as it is not indexed during this period in any of the used databases.
Table B High quality studies: multivariate analysis and quality score of 70% or greater (n studies=25; n patients=1,413,612) [posted as supplied by author]
Authors and reference
Year of publication (study period)
Country
Study design
Setting
Sample size
Data collection methods
Categories of
place of death
Analysis
Home death
%
Quality score
%
Burge et al. (w1)
2003
(1992-97)
Canada,
Nova Scotia
Retrospective cohort
General population
13936
2 health databases, including death certificate data
Hospital vs. out of hospital
Multivariate logistic regression
?
88%
Hunt et al. (w2)
1993
(1990)
South Australia
Retrospective cohort
General population
2715
Central cancer registry and death certificate data
Metropolitan public hospital, vs. home (among others)
Unconditional logistic regression
14%
88%
Jordhoy et al. (w17) *
Ahlner-Elmqvist et al. (w16)
2003
2000
(1995-97)
Norway, Trondheim
RCT
RCT: palliative vs conventional care
395
Clinical records
Home vs. elsewhere
Multivariate regression
20%
88%
77%
Bruera et al. (w3)
2003
(1996/98)
US,
Houston
Retrospective cohort
General population
11694
Death certificates
Home vs. hospital
Multivariate logistic regression
35%
85%
Costantini et al. (w4)
1993
(1986-90)
Italy,
Genoa
Retrospective cohort
General population
12343
Death certificates
Home vs. hospital
Multivariate logistic regression
28-33%
85%
Costantini et al. (w5)
2000
(1991)
Italy,
Liguria
and Toscana
Cross-sectional, with ecological analysis
General population
17597
Death certificates
Home vs. hospital
Multivariate logistic regression
31-73%
83%
Mor and Hiris (w6)
1983
(1981-82)
US
Cross-sectional
Hospice (home and inpatient)
3257
National Hospice Study: clinical records
Home vs. medical setting
Discriminant function analysis
48%
83%
Burge et al. (w7)
2003
(1992-97)
Canada,
Nova Scotia
Retrospective cohort
Patients with a minimum of 3 home visits
9714
4 health databases, including death certificate data
Hospital vs. out of hospital
Multivariate logistic analysis
?
81%
Cantwell et al. (w8)
2000
(10 months)
Canada, Edmonton
Cross-sectional
Palliative home care
67
Questionnaires
Home vs. hospital or hospice
Logistic regression
47%
81%
Gallo et al. (w9)
2001
(1994)
US,
Connecticut
Retrospective cohort
General population
4766
Tumour registry
Home vs. institutional
Multivariate relative risk regression
29%
81%
Higginson et al. (w10) *
Higginson et al. (w11) *
1999
1998
(1985-94)
UK, England
Ecological cross-sectional
General population
1.3 million
Death certificates
Home vs. elsewhere
Multiple regression analysis
27%
(5-75%)
81%
63%
Moinpour and Polissar (w12)
1989
(1980-85)
US,
Washington
Retrospective cohort
General population
26500
Cancer surveillance system and clinical records
Home vs. elsewhere
Logistic regression
33%
81%
Higginson and Costantini (w13)
2002
(6 months)
UK, Italy, Ireland
Prospective cohort
Palliative care teams (mainly community)
1326
Clinical records
Home vs. elsewhere
Multivariate logistic regression
45-72%
79%
Karlsen and Addington-Hall (w14)
1998
(1995-96)
UK,
London
Retrospective cohort survey
General population
229
Death certificates and questionnaires
Home vs. elsewhere
Logistic regression
21%
79%
McCusker (w15)
1983
(1976-78)
US,
New York
Retrospective cohort
General population
2989
Tumour registry, including death certificate data
Home vs. acute hospital or chronic care facility
Logit model
18%
79%
Bruera et al. (w18)
2002
(1997-98)
US,
Texas
Retrospective cohort
Cancer centre
1305
Tumour registry and death certificates
Hospital vs. home
Multivariate logistic regression
34%
77%
Hunt and McCaul (w19)
1996
(1990)
South Australia
Retrospective cohort
Hospice and palliative care services
2207
Cancer registry, death certificates
Metropolitan public hospital vs. private hospital, country hospital, nursing home or home
Polytomous logistic regression
14%
77%
Tang (w20)
2002
(1991-97)
Taiwan
Cross-sectional
Home care programme
264
Clinical records
Home vs. hospital
Logistic regression
69%
77%
Izquierdo-Porrera et al. (w21)
2001
(1995-97)
Spain,
Catalonia
Cross-sectional
Palliative care unit
199
Clinical records
General hospital vs. elsewhere
Multivariate Logistic regression
36%
75%
De Conno et al. (w22)
1996
(1989-91)
Italy,
Milan
Cross-sectional
Home care programme
348
Clinical records, routine interviews
Hospital vs. elsewhere
Multivariate Log-linear model
86%
73%
Edmonds et al. (w23)
2000
(1995)
Ireland
Cross-sectional
6 home care teams
508
Clinical records
Hospital vs. elsewhere
Logistic regression analysis
75%
73%
Fukui et al. (w24)
2004
(2002)
Japan
Retrospective cohort survey
241 home palliative care agencies
428
Questionnaires
Home vs. hospital
Multiple logistic regression
65%
73%
Bass et al. (w25) *
Bass et al. (w26) *
1984
1985
(1980-81)
US,
Ohio
Cross-sectional
Home hospice programme
146
Clinical records and interviews
Home vs. elsewhere
Regression analysis
57%
71%
Brazil et al. (w27)
2002
(1997-99)
Canada,
Ontario
Retrospective cohort survey
Home palliative care
151
Interviews
Home vs. elsewhere
Multivariate logistic regression
63%
71%
Fukui et al. (w28)
2003
(2001)
Japan
Retrospective cohort survey
259 home palliative care agencies
528
Questionnaires
Home vs. hospital
Multiple logistic regression
65%
71%
- Studies with 2 papers reporting the same set of data.
Table C Medium quality studies: multivariate analysis and quality score less than 70% or univariate analysis and quality score of 60% or greater (n studies=17; n patients=77,828) [posted as supplied by author]
Authors and reference
Year of publication
(study period)
Country
Study design
Setting
Sample size
Data collection methods
Categories of place of death
Analysis
Home death
%
Quality score
%
Mann et al. (w29)
1993
(1980-90)
US,
New York
Retrospective cohort
Gynaecologic patients of tertiary care facility
454
Gynaecologic tumour registry
Hospital vs. home
Discriminant function analysis
22%
65%*
Gyllenhammar et al. (w30)
2003
(1999)
Sweden
Cross-sectional
5 palliative home care teams
221
Clinical records
Home vs. elsewhere
Logistic regression analysis
53%
56%*
Higginson and Wilkinson (w31)
2002
(1997-99)
UK
Cross-sectional
Marie Curie home nursing services
13311
Marie Curie NurseLink System
Home vs. elsewhere
Multivariate analysis
94%
52%*
Sims et al. (w32)
1997
(1995)
UK, Doncaster
Retrospective cohort
General population
820
Death certificates
Home, hospital, hospice, other
χ²
27%
77%
Grande et al. (w33)
1999
(?)
UK, Cambridge
RCT
RCT: hospital at home vs. standard care
229
Death certificates and unknown method
Home
χ²
58; 78%
73%
Addington-Hall et al. (w34)
1998
(1990)
UK
Retrospective cohort survey
General population
2051
Death certificates and interviews
Home, hospital, hospice, other
χ²
29%
69%
Grande et al. (w35)
2003
(16 months)
UK, Cambridge
Case control
Trial: hospital
at home and
cancer registry
327
Cancer registry, clinical records
Home, inpatient care
χ², t-tests, Mann-
Whitney U
39%
69%
Roder et al. (w36)
1987
(1981;85)
South Australia
Retrospective cohort
General population
1582
Death certificates
Hospital, hospice, nursing home, home
χ²
14%
69%
Davison et al. (w37)
2001
(1977; 87; 97)
Ireland, Belfast
Retrospective cohort
General population
1324
Death certificates
Home, hospital, hospice
χ²
35-28%
67%
Catalan-Fernandez et al. (w38)
1991
(1984-86)
Spain, Majorca
Retrospective cohort survey
General population
335
Tumour registry, clinical records and interviews
Home, hospital
χ², Kruskal-Wallis test
46%
67%
Thorne et al. (w39)
1994
(1991-92)
UK,
Exeter
Retrospective cohort
General population
1022
Death certificates
Home, community hospital, specialist services, nursing or residential home, hospice
χ², t-tests
34%
67%
Flynn and Stewart (w40)
1979
(1957-74)
US,
Ohio
Retrospective cohort
General population
55288
Death certificates
Hospital, nursing home, home
χ²
20%
65%
Goodwin et al. (w41)
2003
(8 months)
UK
Quasi-experimental comparative
Trial - palliative day care
173
Interviews
Home, hospital, hospice
χ²
31%
65%
Hinton (w42)
1994
(2 years)
UK,
London
Cross-sectional
Hospice home care service
338
Clinical records
Home, inpatient
χ²
27%
65%
McWhinney et al. (w43)
1995
(1988-90)
Canada, Ontario
Case control
Palliative care home team
150
Clinical records
Home, hospital
χ² and t-tests
28%
65%
Axelsson and Christensen (w44)
1996
(1990)
Sweden, Jamtland
Cross-sectional
General population
203
Death certificates and clinical records
Home, nursing home, hospital
χ²
12%
63%
Higginson et al. (w45)
1994
(1988-92)
UK,
London
Retrospective cohort
General population
?
Death certificates
Home
Spearman’s r
5-46%
63%
* - Studies that performed multivariate analysis but scored lower than 70% in the quality assessment.
Table D Low quality studies: univariate analysis and quality score less than 60% (n studies=16; n patients= 38,502) [posted as supplied by author]
Authors and references
Year of publication (study period)
Country
Study design
Setting
Sample size
Data collection methods
Categories of place of death
Analysis
Home death
%
Quality score
%
Hinton (w42) *
Hinton (w46) *
1994
1998
(2 years)
UK,
London
Prospective cohort
Hospice home care service
77
Interviews
Home, hospital, hospice
McNemar, χ², t-tests
28%
58%
50%
Maida (w47)
2002
(1997-99)
Canada,
Ontario
Retrospective cohort
Home palliative care
402
Clinical records
Home, hospital
χ², t-tests, Mann-Whitney U
55%
58%
Woo et al. (w48)
1991
(1982-90)
Australia,
Sydney
Retrospective cohort
Veterans hospital, patients with colorectal cancer
69
Colorectal cancer registry, clinical records and interviews with the patient’s doctor
Home, nursing home, hospice, hospital
χ²
12%
58%
Andershed and Ternestedt (w49)
1997
(1990-94)
Sweden,
örebro
Cross-sectional + retrospective cohort data
Hospital and hospital based home care
1464
Cancer registry and clinical records
Home, hospital, hospice, geriatric department, acute hospital
χ²
?
56%
Jimeno Aranda et al. (w50)
1993
(1980-89)
Spain,
Zaragoza
Retrospective cohort
Patients with gastric cancer
539
Cancer registry
Home, hospital
χ², t-tests
46%
54%
Dunphy and Amesbury (w51)
1990
(1988)
UK,
London
Retrospective cohort
Hospice (inpatient and home care)
140
Clinical records
Home, hospice, hospital
χ²
61%
52%
Loven et al. (w52)
1990
(one year)
Israel,
Petah Tiqva
Cross-sectional
Home care service
58
Clinical records
Home, general hospital, chronic hospital
Fisher’s exact test
29%
52%
Ward (w53)
1974
(1971)
UK,
Sheffield
Retrospective cohort survey
General population
279
Death certificates and interviews
Home, hospital
χ²
44%
52%
Duke (w54)
1997
(1978, 89)
UK,
Oxford
Comparison of 2 cross-sectional groups
Hospice (inpatient and home care)
467
Clinical records
Hospice, home, hospital, other
χ²
19%
50%
Gomas (w55)
1993
(1985-91)
France
Cross-sectional
Home care
171
Medical records?
Home, institution
?
37%
46%
Johnson et al. (w56)
1988
(1984-86)
UK,
Sheffield
Cross-sectional
Home relative support scheme
171
?
Home, hospice, hospital
‘analysis for trend’
60%
44%
Polissar et al. (w57)
1987
(1968-81)
US,
Washington
Retrospective cohort
General population
33865
Death certificates and cancer surveillance system
Home, hospital, nursing home, other
‘cross-tabulation and simple graphs’
15%
42%
Gilbar and Steiner (w58)
1996
(1992-93)
Israel,
Haifa
Retrospective cohort
Home care unit
171
Clinical records
?
ANOVA analysis
?
40%
Malden et al. (w59)
1984
(1979-81)
Australia,
Sydney
Case control
2 medical oncology units
225
Clinical records
Oncology unit, home, nursing care facility, others
?
18%
40%
Kane et al.(w60)
1984
(?)
US,
Los Angeles
RCT
RCT – hospice vs. conventional care
247
Clinical records, interviews
Hospice, hospital, home
?
3; 7%
33%
Herd (w61)
1990
(1987)
UK,
West Cumbria
Retrospective cohort survey
General population
157
Death certificates and interviews
Home, hospital
?
53%
33%
* Studies with 2 papers reporting the same set of data.
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