CONTEXT: Chronic obstructive pulmonary disease (COPD) and lung cancer patients report several symptoms at the end-of-life, and may share palliative care needs. However, these disease groups have distinct healthcare use.
OBJECTIVE: To compare the frequency and length of hospitalisations during the last month of life between COPD and lung cancer patients, assessing the main characteristics associated with these outcomes.
METHODS: Data was retrieved from the Portuguese Hospital Morbidity Database. Deceased patients in a public hospital from mainland Portugal (2010-2015), with COPD as the main diagnosis of the last hospitalisation (n=2942) were sex- and age-matched (1:1) with patients with lung cancer. The association of patients' main diagnosis, and individual, hospital and area of residence characteristics, on frequency (>1) and length (>14 days) of end-of-life hospitalisations were quantified through adjusted odds ratio (OR), and respective 95% confidence intervals (95%CI).
RESULTS: Hospitalisations for >14 days during the last month of life were more likely for lung cancer than COPD patients (OR=1.12, 95%CI:1.00-1.25). Among COPD patients, male sex (OR=1.50, 95%CI:1.25-1.80) and death in a large hospital (OR=1.82, 95%CI:1.41-2.35) were positively associated with longer hospitalisations; the occurrence of >1 hospitalisation and hospitalisations for >14 days were less likely among those from rural areas (OR=0.72, 95%CI:0.55-0.94; OR=0.67, 95%CI:0.54-0.83, respectively). In lung cancer patients, male sex was negatively associated with longer hospitalisations (OR=0.82, 95%CI:0.69-0.98).
CONCLUSIONS: At the end-of-life, lung cancer patients had longer hospitalisations than COPD patients, and the main characteristics associated with the frequency and length of hospitalisations differed according to the patients' main diagnosis.
BACKGROUND/OBJECTIVES: Experts have suggested that patients represented by professional guardians receive higher intensity end-of-life treatment than other patients, but there is little corresponding empirical data.
DESIGN: Retrospective cohort study.
SETTING AND PARTICIPANTS: Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non-VA).
MEASUREMENTS: Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home-to-hospital transfers in the last 90 days of life, and in-hospital death.
RESULTS: ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89–1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end-of-life hospitalizations, and in-hospital death were more common among matched controls.
CONCLUSION: Rates of high-intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high-intensity treatment occurred more frequently than expected among patients without guardians.
PURPOSE: There is limited evidence on the intensity of end-of-life (EOL) care for women < 65 years old, who account for about 40% of breast cancer deaths in the United States. Using established indicators, we estimated the intensity of EOL care among these women.
METHODS: We used 2000-2014 claims data from a large US insurer to identify women with metastatic breast cancer who, in the last month of their lives, had more than one hospital admission, emergency department visit, or an intensive care unit (ICU) admission and/or used antineoplastic therapy in the last 14 days of life. Using multivariate logistic regression, we assessed whether intensity of EOL care differed by demographic characteristics, socioeconomic factors, or regions.
RESULTS: Adjusted estimates show an increase in EOL ICU admissions between 2000-2003 and 2010-2014 from 14% (95% CI, 10% to 17%) to 23% (95% CI, 20% to 26%) and a small increase in emergency department visits from 10% (95% CI, 7% to 13%) to 12% (95% CI, 9% to 15%), both statistically significant. There was no statistically significant change in the proportions of women experiencing more than one EOL hospitalization (14% in 2010-2014; 95% CI, 11% to 17%) and of those receiving EOL antineoplastic treatment (24% in 2010-2014; 95% CI, 21% to 27%). Living in predominantly mixed, Hispanic, Black, or Asian neighborhoods correlated with more intense care (odds ratio, 1.39; 95% CI, 1.10 to 1.77 for ICU).
CONCLUSION: Consistent with findings in the Medicare population, our results suggest an overall increase in the number of ICU admissions at the EOL over time. They also suggest that patients from non-White neighborhoods receive more intense acute care.
CONTEXT: Delirium is a highly distressing neurocognitive disorder for patients at the end of life.
OBJECTIVES: To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life.
METHODS: Using linked administrative data from ICES, this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included length of stay, discharge location and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium.
RESULTS: Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization length of stay was 13.8 days in patients with delirium (standard deviation 21.1), or 1.80 times longer (95% confidence interval (CI) 1.75-1.84) compared to those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk 1.01 (0.98-1.05).
CONCLUSION: In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer length of stay and increased risk of post-discharge institution use, compared to those without delirium. These outcomes illustrate added burden for patients, their families and the healthcare system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.
One-quarter of annual Medicare expenses in the traditional program (non-Medicare Advantage) are expended for 5% of Medicare enrollees, with much of this expenditure occurring in the last year of life. Hospice use may reduce end-of-life costs. However, evidence has been inconclusive due to sample selection and differences in insurance coverage for hospice. Claims data for HIV-positive Californians enrolled in Medicare who died in the period 2008 to 2010 were used to examine the relationship between hospice use and costs in the last 6 months of life. Logit estimates related hospice use to sickness levels and demographics. Inpatient and outpatient costs were analyzed separately. Logit regressions examined hospitalization probability. Robust regressions were used to examine the determinants of conditional inpatient costs and non-inpatient costs. Bootstrapped post-estimates were then used to determine the marginal probability of costs for the sample by hospice use. Hospice users have greater disease burden and are less likely to be African American. Controlling for disease burden, hospice users would have non-inpatient costs that were $14 771 greater than hospice non-users, but inpatient costs that were $20 522 lower. Thus, hospice reduces costs on net. Hospice is chosen by patients with more comorbidities. Controlling for these comorbidities, hospice use is associated with lower inpatient costs, greater non-inpatient costs and reduced end-of-life costs.
OBJECTIVES: The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria.
DESIGN: Retrospective cohort.
SETTING: Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database.
PATIENTS: Hospitalized children with nonneonatal ICU admissions from 2007 to 2018.
MEASUREMENTS: The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria.
RESULTS: The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups.
CONCLUSIONS: Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
Background: A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada.
Methods: We conducted a population-based retrospective-cohort study of Canadian adults aged =18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC).
Results: We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had =2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had =2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs.
Conclusions: High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.
Acute respiratory failure is a frequent cause of hospitalizations among seriously ill older adults at or near the end of life. These terminal hospitalizations are often complicated by distressful respiratory symptoms and chaotic transitions that result in high-intensity, high-risk interventions such as invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV), which delivers positive pressure ventilation through a mask. In this issue of JAMA Internal Medicine, Sullivan and colleagues studied trends in IMV and NIV use among older decedents hospitalized at the end of life. The authors found a substantial increase in NIV use and a slight increase in IMV use in the past 2 decades, potentially signifying a major shift in the way that clinicians provide ventilatory support at the end of life. Although use of NIV in older adults with terminal respiratory failure may seem appealing, high-quality evidence supporting its use across serious illnesses remains elusive.
Importance: The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.
Objective: To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.
Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.
Study Selection: Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.
Data Extraction and Synthesis: Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.
Main Outcomes and Measures: Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).
Results: Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).
Conclusions and Relevance: In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.
Opioid availability and accessibility represent major challenges to cancer patients, particularly in low- and middle-income countries. When palliative care service is available, referrals mostly occur late during the course of disease. In this retrospective study, we examined the pattern and predictors of opioids utilization during the final hospitalization for patients admitted to a tertiary cancer center in Jordan, we assessed factors contributing to opioid use among patients with cancer during the final hospitalization and estimated opioid use in oral morphine equivalents (OME). A total of 297 patient files were reviewed. Patients received the highest doses of opioids at 48 and 24 h prior to death (median dose 34.8 mg OME and 34.5 mg OME, respectively). The palliative care service prescribed higher OME doses than other services (OR 3.54; P < 0.001). The median OME dose used by patients above 65 years was lower than the dose used by the younger group (OR 1.04/years of age; P < 0.001). Spine and bone metastasis were associated with increased opioid consumption (OR 2.45; P < 0.002). We concluded that palliative care patients received higher doses of opioids in the final hospitalization compared to patients in other services. A palliative care referral may be helpful for patients with pain requiring opioids.
Background: Health service planning in paediatric palliative care is complex, with the diverse geographical and demographic characteristics adding to the challenge of developing services across different nations. Accurate and reliable data are essential to inform effective, efficient and equitable health services.
Aim: To quantify health service usage by children and young people aged 0–21 years with a life-limiting condition admitted to hospital and health service facilities in Queensland, Australia during the 2011 and 2016 calendar years, and describe the clinical and demographic characteristics associated with health services usage.
Design: Retrospective health administrative data linkage of clinical and demographic information with hospital admissions was extracted using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Australian Modification (ICD-10-AM) diagnostic codes. Data were analysed using descriptive statistics.
Setting/participants: Individuals aged 0–21 years with a life-limiting condition admitted to a Queensland Public Hospital and Health Service or private hospital.
Results: Hospital admissions increased from 17 955 in 2011 to 23 273 in 2016, an increase of 5318 (29.6%). The greatest percentage increase in admissions were for those aged 16–18 years (58.1%, n=1050), and those with non-oncological conditions (36.2%, n=4256). The greatest number of admissions by ICD-10-AM chapter for 2011 and 2016 were by individuals with neoplasms (6174, 34.4% and 7206, 31.0% respectively). Overall, the number of admissions by Indigenous children and young people increased by 70.2% (n=838).
Conclusions: Administrative data are useful to describe clinical and demographic characteristics and quantify health service usage. Available data suggest a growing demand for health services by children eligible for palliative care that will require an appropriate response from health service planners.
AIM: Whilst transfer of Aged Care Facility ACF) residents to an acute hospital is sometimes necessary, for those at end-of-life this can cause fragmented care and disruption. This study explores the characteristics of ACF residents transferred to hospital in the last 24hours of life and factors that may influence this decision, including access to medical review, advance care planning and pre-emptive symptom management prescribing; an area not previously researched.
METHODS: A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 to 2017 who died within 24 hours of transfer.
RESULTS: 149 patients met the criteria. The median age was 87, 63(42%) were male. 83(56%) were transferred 'out-of-hours', the majority (71%) having no medical review in the 24hours prior. 43(29%) died within 4hours of arrival. The commonest reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and commonest cause of death was pneumonia (37%). Some form of advance care planning documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7(8%) had this pre-emptively prescribed on their ACF medication chart.
CONCLUSIONS: Appropriate decision making around hospital transfers and end-of-life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. Advance care planning is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end-of-life care needs of this cohort.
CONTEXT: Little is known about receipt of specialty-level palliative care by people with hepatocellular carcinoma (HCC), or its impact on healthcare utilization.
OBJECTIVES: Identify patient characteristics associated with receipt of specialty-level palliative care among hospitalized HCC patients and measure association with time to readmission.
METHODS: We used logistic regression to examine relationships between receipt of inpatient palliative care consultation by HCC patients at an academic center (N=811, 2012-2016), and clinical and demographic covariates at index hospitalization. We used a survival analysis model accounting for competing risk of mortality to compare time to readmission among individuals who did or did not receive palliative care during the admission and performed a sensitivity analysis using kernel weights to account for selection bias.
RESULTS: Overall, 16% received inpatient palliative care consults. Those who received consults had worse laboratory values than those who did not. In a multivariable model, higher MELD-Na, receipt of sorafenib, and higher pain scores were significantly associated with increased odds of palliative care, while liver transplantation and admission to a surgical service were associated with lower odds. For time to readmission (2,076 hospitalizations for 811 individuals with 175 palliative care visits), the sub-hazard ratio for readmission for patients who received consults was 0.26 (95% Confidence Interval [CI] 0.18-0.38) and 0.35 (CI 0.24-0.52) with a kernel-weighted sample.
CONCLUSION: Inpatient palliative care consultation was received by individuals with more advanced disease, and was associated with lower readmission hazard. These findings support further research and the development of HCC-specific programs that increase access to specialty-level palliative care.
CONTEXT: Cancer prognosis data often comes from clinical trials which exclude patients with acute illness.
OBJECTIVES: For patients with Stage IV cancer and acute illness hospitalization, to 1) describe predictors of 60-day mortality, and 2) compare documented decision-making for survivors and decedents.
METHODS: Investigators studied a consecutive prospective cohort of patients with Stage IV cancer and acute illness hospitalization. Structured health record and obituary reviews provided data on 60-day mortality (outcome), demographics, health status, and treatment; logistic regression models identified mortality predictors.
RESULTS: 492 patients with Stage IV cancer and acute illness hospitalization had median age of 60.2 (51% female, 38% minority race/ethnicity); 156 (32%) died within 60 days and median survival for decedents was 28 days. Nutritional insufficiency (OR 1.83), serum albumin (OR 2.15 per 1.0 g/dL) and hospital days (OR 1.04) were associated with mortality; age, gender, race, cancer and acute illness type were not predictive. On admission 79% of patients had orders indicating Full Code. During 60-day follow-up 42% of patients discussed goals of care. Documented goals of care discussions were more common for decedents than survivors (70% vs 28%, p<0.001), as were orders for DNR / DNI (68% vs 24%, p<0.001), stopping cancer-directed therapy (29% vs 10%, p<0.001), specialty Palliative Care (79% vs 44%, p<0.001) and Hospice (68% vs 14%, p<0.001).
CONCLUSION: Acute illness hospitalization is a sentinel event in Stage IV cancer. Short-term mortality is high; nutritional decline increases risk. For patients with Stage IV cancer, acute illness hospitalization should trigger goals of care discussions.
PURPOSE: Multimorbidity is associated with increased intensity of end-of-life healthcare. This association has been examined by number but not type of conditions. Our purpose was to understand how intensity of care is influenced by multimorbidity within specific chronic conditions to provide guidance for interventions to improve end-of-life care for these patients.
METHODS: We identified adults cared for in a multihospital healthcare system who died between 2010-2017. We categorized patients by 4 primary chronic conditions: heart failure, pulmonary disease, renal disease, or dementia. Within each condition, we examined the effect of multimorbidity (presence of 4 or more chronic conditions) on hospital and ICU admission in the last 30 days of life, in-hospital death, and advance care planning (ACP) documentation >30 days before death. We performed logistic regression to estimate associations between multimorbidity and end-of-life care utilization, stratified by the presence or absence of ACP documentation.
RESULTS: ACP documentation >30 days before death was associated with lower odds of in-hospital death for all 4 conditions both in patients with and without multimorbidity. With the exception of patients with renal disease without multimorbidity, we observed lower odds of hospitalization and ICU admission for all patients with ACP >30 days before death.
CONCLUSIONS: Patients with dementia and multimorbidity had the highest odds of high-intensity end-of-life care. For patients with dementia, heart failure, or pulmonary disease, ACP documentation >30 days before death was associated with lower likelihood of in-hospital death, hospitalization, and ICU use at end-of-life, regardless of multimorbidity.
Background: Despite evidence showing that goals of care (GOC) conversations increase the likelihood that patients facing a serious illness receive care that is concordant with their wishes, only a minority of at-risk patients receive the opportunity to engage in such conversations.
Objective: The Preventing Readmissions through Effective Partnerships—Communication and Palliative Care (PREP-CPC) intervention was designed to increase the frequency of GOC conversations for hospitalized patients facing serious illness.
Methods: The PREP-CPC employed a sequential, multicohort design using a yearlong mentored implementation approach to support nonpalliative care health-care professionals at participating hospitals to implement quality improvement projects focused on GOC conversations.
Results: Over the 3-year study period, 134 clinicians from 29 hospital teams were trained to facilitate GOC conversations. After the kickoff conference, participants reported improvements in their confidence in facilitating GOC conversations. The hospital teams then instituted site-specific pilot interventions to promote GOC conversations, identifying essential elements required for ongoing improvement. Since projects varied by hospital, results did as well, but reported positive outcomes included increased GOC conversations, increased Practitioner Orders for Life-Sustaining Treatment form completion rates, new screening and documentation methods, and increased support from leadership.
Conclusions: The PREP-CPC pilot successfully engaged a diverse set of hospitals to participate in quality improvement collaborative promoting primary palliative care and more frequent GOC conversations. This initiative revealed several lessons that should guide future interventions.
Objective: The aim of this study was to assess the clinical, economic and personal impacts of the nurse practitioner-led Sydney Adventist Hospital Community Palliative Care Service (SanCPCS)
Methods: Parallel economic analysis of usual care was conducted prospectively with patients from the enhanced SanCPCS. A convenient retrospective sample from the initial service was used to determine the impact of the enhanced service on patient care. A time series survey was used with patients and carers from within the expanded service group in order to measure patient outcomes and values as they approached death. Results: Patients of the SanCPCS were less likely to die in hospital and had fewer hospital admissions. In addition, the service halved the estimated hospitalisation cost per patient, but the length of hospital stay was not affected by the service. The SanCPCS was more beneficial for women in terms of fewer hospital admissions and lower costs. Patients’ choices regarding place of care and death and what was ‘important’ to them changed over time. For instance, patients tended to prefer being at home as they approached death, and being pain free doubled in importance.
Conclusions: Nurse practitioner-led community palliative care services have the potential to result in significant economic and personal benefits for patients and their families in need of such care. What is known about the topic? National trends show an emphasis on community services with the aim of promoting and supporting the choice of dying at home, and this coincides with drives to reduce hospital costs and length of stay. Community-based palliative care services may offer substantial economic and clinical benefits. What does this paper add? The SanCPCS was the first nurse practitioner-led community-based palliative care service in Australia. The expansion of this service led to significantly fewer admissions and deaths in hospital, and halved the estimated hospitalisation cost per patient. What are implications for practitioners? Nurse practitioner-led models for care in the out-patient or community setting are a logical direction for palliative services through the engagement of specialised providers uniquely trained to support, nurture, guide and educate patients and their carers.
Background: Emergency department (ED) initiated palliative consultation impacts downstream care utilization. Various admission consult triggers have been proposed without clear best practice or outcomes.
Objective: This 18-month single-center study evaluated the clinical, operational, and financial impact of simplified admission triggers for ED-initiated palliative consults as compared to downstream Floor and intensive care unit (ICU) palliative consults initiated per usual practice.
Methods: We distilled ED admission triggers into three criteria to ensure bedside actionability and sustainability: (1) end-stage illness, (2) functional limitation, and (3) clinician would not be surprised if the patient died this hospitalization. Eligible patients met all criteria, and received consultation within 24 hours of admission. We compared ED-initiated consults against Floor and ICU consults from March 1, 2018, to September 30, 2019, with matched cohort analysis to evaluate financial outcomes.
Results: While overall palliative consult volume remained intentionally steady, the proportion of ED-initiated consults significantly increased (7% vs. 19%, p < 0.001). ED consistently comprised 15–25% of all monthly palliative consults. Compared with Floor, ED had similar ED length of stay (LOS) and inpatient mortality. Among live discharges, ED were more likely to be referred to hospice than Floor (59% vs. 47%, p = 0.24) or ICU (59% vs. 34%, p = 0.02). In a matched cohort analysis, ED demonstrated median cost avoidance of $9,082 per patient versus Floor ($5,578 vs. $14,660, p < 0.001) and $15,138 per patient versus ICU ($5,578 vs. $20,716, p < 0.001). ED had significantly shorter median LOS before consult than Floor (0 vs. 3 days, p < 0.001) or ICU (0 vs. 3 days, p < 0.001), which did not differ between live discharges or inpatient deaths. Overall hospital LOS was disproportionately shorter for ED, with a net difference-in-differences of 1–3.5 days compared to Floor and ICU.
Conclusions: Simple ED admission triggers to expedite palliative engagement are associated with a 50–75% reduction in both hospital LOS and costs when compared against usual palliative consultation practice. ED initiation reduces both lead time before consultation and subsequent downstream hospitalization length.
The need for comprehensive palliative care is inevitable with the aging population. Incorporating home-based palliative care is a new frontier within healthcare. The purpose of this study was to embed home-based palliative care services within the visiting nursing association (VNA) at a health system in Pennsylvania, examining effect on quality of life and symptom control, and average number of hospital admission days. A convenience sample of patients with one or more chronic conditions was selected from the existing VNA census (n = 22). A series of topics were outlined for discussion at each weekly visit for the pilot length of up to 6 months, scripted by evidence-based guidelines from the ENABLE II: Charting Your Course booklet (). A pretest/posttest survey method was conducted by utilizing results of the Edmonton Symptom Assessment System (ESAS) and the National Comprehensive Cancer Network Distress Thermometer. The effectiveness of the program was assessed using Spearman correlation to compare the difference in scores to the number of weeks in the program. The average number of hospital admission days during the pilot period was compared with admission days 6 months before enrollment in the pilot using the Wilcoxon signed-rank test. A significant relationship was found between the number of weeks in the program and reduction in the total ESAS symptom scores (rho = -0.484, p = .022), indicating that a reduction in symptoms was significantly more likely the longer a patient was in the program. Percentage of patients hospitalized decreased from 86% during preintervention period to 32% while enrolled. There was a noted reduction in the average number of days patients spent in the hospital while enrolled in the pilot (z = -2.24, p = 0.025).
BACKGROUND: Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs.
PURPOSE: To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life.
METHOD: Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted.
RESULTS: In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%).
CONCLUSIONS: Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.