Duration of Referral-to-Death and its Associated Factors Among Cancer and Noncancer Patients: Retrospective Cohort Study of a Community Palliative Care Setting in Malaysia

Background: Addressing timely community palliative care integration is prioritized due to the increased burden of noncommunicable diseases. Objectives: To compare referral-to-death duration among palliative cancer and noncancer patients and to determine its associated factors in a Malaysian community palliative care center. Methods: This retrospective cohort study included decedents referred to a Malaysian community palliative care center between January 2017 and December 2019. Referral-to-death is the interval between the date of community palliative care referral and to date of death. Besides descriptive analyses, negative binomial regression analyses were conducted to identify factors associated with referral-to-death among both groups. Results: Of 4346 patients referred, 86.7% (n  =  3766) and 13.3% (n  =  580) had primary diagnoses of cancer and noncancer respectively. Median referral-to-death was 32 days (interquartile range [IQR]: 12-81) among cancer patients and 19 days (IQR: 7-78) among noncancer patients. The shortest referral-to-death among cancer patients was for liver cancer (median: 22 days; IQR: 8-58.5). Noncancer patients with dementia, heart failure, and multisystem organ failure had the shortest referral-to-death at 14 days. Among cancer patients, longer referral-to-death was associated with women compared to men (IRR: 1.26; 95% CI: 1.16-1.36) and patients 80 to 94 years old compared to those below 50 years old (IRR: 1.19; 95% CI: 1.02-1.38). Cancer patients with analgesics prescribed before or upon referral had 29% fewer palliative care days compared to no prescribing analgesics. In contrast, noncancer patients 50 to 64 years old had shorter referral-to-death compared to those below 50 years old (IRR: 0.51; 95% CI: 0.28-0.91). Conclusion: Shorter referral-to-death among noncancer patients indicated possible access inequities with delayed community palliative care integration. Factors associated with referral-to-death are considered in developing targeted approaches ensuring timely and equitable community palliative care.