Patterns of End-of-Life Care as Measured by Emergency Room Visits Among Cancer Patients in Puerto Rico

Background: Community palliative care (PC) services are scarce in Puerto Rico (PR). Patients with advanced cancer commonly visit the emergency department(ED) at the end of life (EoL). Recognition of patients with limited life expectancies and PC needs may improve the EoL trajectory of these patients. Our objective was to characterize ED visits of cancer patients at the EoL by examining the patterns of ED visits in PR using the PR Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD). Methods: The cohort consisted of patients aged ≥18 years with a primary invasive that died between 2011- 2017, with a recorded date of death, and who had insurance claims during their last three months. EoL indicators were ED visits, ED death, and hospice care use. Results: The study cohort included 10,755 cancer patients. 49.6% had ≥1 ED visit, 20.3% had ≥2 ED visits, and 9.7% died in the ED. In the adjusted model, female patients (aOR 0.80; 95% CI 0.68-0.93; p-value < 0.01), patients aged ≥80 years (aOR 0.47; 95% CI 0.36-0.63; p-value < 0.01), being enrolled in Medicare (aOR 0.74; 95% CI 0.61-0.90; p-value < 0.01) or being enrolled in Medicaid/Medicare (aOR 0.76; 95% CI 0.62-0.93; p-value = 0.01) were less likely to have an ED visit the date of death. Patients with distant stage are more likely to have ED ≥ 2visits (p-value < 0.05). Conclusions: ED visits at EoL can be interpreted as poor quality cancer care and awareness of the potential of ED-initiated PC is needed in PR.