Duration of referral-to-death and its influencing factors among cancer and non-cancer patients: perspective from a community palliative care setting in Malaysia

Objectives To compare the referral-to-death duration among palliative cancer and non-cancer patients and to determine its influencing factors in a Malaysian community hospice. Methods This retrospective cohort study included decedents referred to palliative care in a community hospice between January 2017 to December 2019. Referral-to-death is the interval between first referral date to date of death. Besides descriptive analyses, negative binomial regression analyses were conducted to identify factors associated with referral-to-death duration among both groups. Results Of 4346 patients referred, 86.7% (n=3766) and 13.3% (n=580) had primary diagnoses of cancer and non-cancer respectively. Median referral-to-death was 32 days (IQR:12-81) among cancer patients and 19 days (IQR:7-78) among non-cancer patients. The shortest referral-to-death duration among cancer patients were for liver cancer (Median:22 days,IQR:8-58.5). Non-cancer patients with dementia, heart failure and multisystem failure had the shortest referral-to-death duration at 14 days. Among cancer patients, longer referral-to-death duration was associated with women compared to men (IRR:1.26,95%CI:1.16-1.36) and patients aged 80 to 94 years old compared to below 50 years old (IRR:1.19,95%CI:1.02-1.38). Cancer patients with analgesics prescribed before palliative care had 29% fewer palliative care days compared to those with no analgesics prescribed before referral. Non-cancer patients aged 50 to 64 years old had shorter referral-to-death duration compared to below 50 years old (IRR:0.51,95%CI:0.28-0.91). Conclusion Shorter referral-to-death duration among non-cancer patients indicated possible access inequities with delayed palliative care integration. Factors influencing referral-to-death duration should be accounted for in developing targeted approaches to ensure timely and equitable access to all patients requiring palliative care. What is already known on this topic What this study adds How this study might affect research, practice or policy ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Medical Research Ethics Committee (MREC) of Ministry of Health (MOH) Malaysia gave ethical approval for this work. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the Malaysian Good Clinical Practice Guideline. The study was registered under the National Medical Research Register Malaysia (NMRR-19-3472-51996). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.