Quality of End-of-Life Care in Gastrointestinal Cancers: A 13-Year Population-Based Retrospective Analysis in Ontario, Canada

Round 1

Reviewer 1 Report

This is an interesting study

A few points would help clarity and improve the paper:

1. Page 3 line 108- it is unclear what the palliative care service provided - visit / call ?

2.Tables - an extra column showing the results for the total group would be helpful

3. Table 2 would be clearer if the Headings were clearer - eg Patients not hospitalized during the entirety of the last 30 / 14 days of life" - this is similar to the text

4. Figure 1 - there are no statistics for the changes over the years.  Is this possible to compare 2006 and 2018 and show a statistically significant change, such as for supportive care involvement?

5. Page 4 line 134 and page 8 line 228 - it is not clear what other palliative care had been provided in the final year of life - could this be clarified?

6. Page 8 line 206 and page 9 line 257 - Advanced should be advance care planning

Author Response

The authors wish to thank the referees for their insightful comments and feedback on the manuscript entitled “Quality of end-of-life care in gastrointestinal cancers: A 13-year population-based retrospective analysis in Ontario, Canada,” which is currently being considered for publication in Current Oncology. To the best of our abilities, we have endeavoured to address each of the referees’ suggestions. Please see below for a detailed account of how each suggestion was addressed. We welcome any further feedback from the editor and/or reviewers.

1. Page 3 line 108- it is unclear what the palliative care service provided - visit / call ?

This was clarified in the text [line 108-109] to fully define the indicator as “≥1 palliative care home care service in last 30 days of life (any provision of service recorded in the HCD and designated as ‘end-of-life’).”

2. Tables - an extra column showing the results for the total group would be helpful

Thank you for this suggestion. This has been added to all tables.

3. Table 2 would be clearer if the Headings were clearer - eg Patients not hospitalized during the entirety of the last 30 / 14 days of life" - this is similar to the text

Thank you for this suggestion. Table 2 and Table 3 headings were changed accordingly, to read “Patients not hospitalized for the entirety of last 14 days of life/30 days of life”

4. Figure 1 - there are no statistics for the changes over the years.  Is this possible to compare 2006 and 2018 and show a statistically significant change, such as for supportive care involvement?

The figure was amended to include data labels for each indicator in 2006 and then in 2018, allowing readers to understand overall change through the study period. We have added in whether there were statistically significant changes over time with (not just comparison between 2006 and 2018) with the use of the Cochran-Armitage trend test. This is described in the methods section with p values reported in the text (lines 181-187).

5. Page 4 line 134 and page 8 line 228 - it is not clear what other palliative care had been provided in the final year of life - could this be clarified?

Thank you for suggesting this clarification. We amended line 134 to read, “The majority of patients received palliative care services within the last year of life, including home care services designated as ‘end-of-life’ or as specified by physician billing codes (n = 65,076, 93.0%).”

6. Page 8 line 206 and page 9 line 257 - Advanced should be advance care planning

Both lines have been corrected to read “advance care planning.”

Reviewer 2 Report

This manuscript is an original article that retrospectively investigated quality indicators of end of life (EOL) care for 69,983 GI malignancy decedents in Ontario, Canada with the objective of examining rates of indicators of supportive and aggressive EOL care, as well as factors associated with receiving such care. The authors showed most of the population received palliative care services in the last year of life and a palliative care home care service in the last 30 days of life. Furthermore, the authors elucidated that a significant number of patients experienced death in an acute care hospital bed or had a new hospitalization in the last 30 days of life.

This study was conducted well, and the methods are appropriate. The data are presented clearly, which will be of interest to clinicians in the field.

However, the following minor issues require clarification:

Minor

1.     I recommend that the authors discuss what kind of measures should be taken to overcome the problems shown in this study.

2.     The authors discuss the relationship between age and the rates of aggressive and supportive care. I recommend the authors also discuss other indicators based on the results of multivariable logistic regression analyses for aggressive and supportive care.

3.     (Table 1-3) Please provide total numbers and percentages in each indicator.

4.     The conclusion is too long. It should be more summarized.

Author Response

The authors wish to thank the referees for their insightful comments and feedback on the manuscript entitled “Quality of end-of-life care in gastrointestinal cancers: A 13-year population-based retrospective analysis in Ontario, Canada,” which is currently being considered for publication in Current Oncology. To the best of our abilities, we have endeavoured to address each of the referees’ suggestions. Please see below for a detailed account of how each suggestion was addressed. We welcome any further feedback from the editor and/or reviewers.

1. I recommend that the authors discuss what kind of measures should be taken to overcome the problems shown in this study.

We appreciate this important suggestion, as we ultimately want our findings to translate into improved patient care. We have suggested in the conclusion that “future study of interventions that may improve quality of care, using these benchmarks, are warranted.” Unfortunately, a more fulsome exploration of interventions to improve quality of care is beyond the scope of our study and keeping the paper concise and at a reasonable length.

2. The authors discuss the relationship between age and the rates of aggressive and supportive care. I recommend the authors also discuss other indicators based on the results of multivariable logistic regression analyses for aggressive and supportive care.

We appreciate the reviewer noting the many statistically significant associations we found with multivariable logistic regression. The authors had some debate over which indicators to discuss in our paper, but ultimately felt that in the interests of keeping our paper concise and at a reasonable length, we would allow the data to speak for itself.

3. (Table 1-3) Please provide total numbers and percentages in each indicator.

Thank you for this suggestion. This has been added to all tables.

4. The conclusion is too long. It should be more summarized.

Thank you for this suggestion. We have made edits so that the conclusion is now just 130 words and more concise.