Potential overtreatment in end-of-life care in adults 65 years or older dying from cancer: applying quality indicators on nationwide registries

Background: Quality indicators are frequently used to measure the quality of care at the end of life. Whether quality indicators of potential overtreatment (i.e., when the risks outweigh the benefits) at the end of life can be reliably applied to routinely collected data remains uncertain. This study aimed to identify quality indicators of overtreatment at the end of life in the published literature and to investigate their tentative prevalence among older adults dying with solid cancer.

Materials and methods: Retrospective cohort study of decedents including all older adults (≥65 years) who died with solid cancer between 1 January 2013 and 31 December 2015 (n = 54,177) in Sweden. Individual data from the National Cause of Death Register were linked with data from the Total Population Register, the National Patient Register, and the Swedish Prescribed Drug Register. Quality indicators were applied for the last one and three months of life.

Results: From a total of 145 quality indicators of overtreatment identified in the literature, 82 (57%) were potentially operationalisable with routine administrative and healthcare data in Sweden. Unidentifiable procedures and hospital drug treatments were the reason for non-operationalisability in 52% of the excluded indicators. Among the 82 operationalisable indicators, 67 measured overlapping concepts. Based on the remaining 15 unique indicators, we tentatively estimated that overall, about one-third of decedents received at least one treatment or procedure indicative of 'potential overtreatment' during their last month of life.

Conclusion: Almost half of the published overtreatment indicators could not be measured in routine administrative and healthcare data in Sweden due to a lack of means to capture the care procedure. Our tentative estimates suggest that potential overtreatment might affect one-third of cancer decedents near death. However, quality indicators of potential overtreatment for specific use in routinely collected data should be developed and validated.