Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care

Cluster Analysis of Palliative Care Patients' Trajectories in Primary Care: Hospitalization Yes, but Home and Nursing Home Care Above All

Background: Understanding the environment in which patients live at the end of their lives is essential to improving palliative care for these patients and their families. Objectives: We aimed to explore the different living places and trajectories of palliative care patients in the last three months of life in primary care and to identify patient characteristics associated with these trajectories. Methods: This retrospective national study was carried out among a population of adult patients who died a non-sudden death. The trajectories were modeled and classified using sequence analysis, optimal matching, and hierarchical ascendant clustering. Univariate and multivariate multinomial logistic regression compared patient characteristics associated with these trajectories. The focus was on primary care. Patients had to have spent at least one day at home or in a nursing home in the last three months before their death. The research took place between November 2020 and November 2021 in mainland France. Results: Three hundred adult patients were included in the study. Cluster analysis revealed three main trajectories during the last three months of life: "staying at home" (57%), "staying in a nursing home" (29%), and "moving from home to hospital" (14%). Dementia and having children limited hospitalization. Not having an informal caregiver and having dementia were associated with staying in a nursing home. Conclusions: Palliative care patients' living situations and transitions can be tracked using primary care practice data. This study highlights the unique needs of palliative care in home and nursing home settings. Additionally, factors such as dementia and family dynamics play a significant role in determining where patients live, which can help inform clinical practices and research strategies in palliative care.

Quality of outpatient palliative care assessed by direct service providers, regional palliative care organisations and healthcare authorities - A nationwide survey from Switzerland

PURPOSE

A prior study used 13 indicators to assess overall palliative care quality: Switzerland scored 88 points (top quartile: 82-93). This study assessed the quality of outpatient palliative care in Switzerland, and identified criteria associated with higher quality.

METHOD

Cross-sectional study surveying direct service providers, 14 palliative care organisations, 26 healthcare authorities. The 13 indicators assessed outpatient palliative care quality. Multivariable regression analysed associations between established criteria and higher scores.

RESULTS

The survey was completed by 141 participants (≥4 per canton) including 96 (68%) direct service providers, all palliative care organisations and cantonal authorities. Nurses accounted for 52% (n = 73, including 61 providers). Participants agreed with 'treated kindly' (98% agreed), 'controlled pain and discomfort' (98%), 'appropriate levels of life extending treatments' (95%) but disagreed with 'costs are no barrier' (44% disagreed), 'good coordination' (19%), 'cared for/die at place of choice' (14%). All 13 indicator questions were answered by 100 participants (71%), resulting in a median score of 82. Of participants seeing patients, 85% (82/97) answered all 13 questions, only 41% (18/44) of those without patient contact (p < 0.001). 'Recording desired place of death' (odds ratio [OR] 6.7, 95% confidence interval [95%CI] 2.7-21.3), 'preventing critical incidents' (OR 5.8, 95%CI 2.8-13.0), 'recording critical incidents' (OR 2.1, 95%CI 1.3-3.7) were independently associated with higher scores.

CONCLUSIONS

A score of 82 indicates high quality. Recording desired place of death, preventing critical incidents, costs, and coordination require attention. Only those with patient contact are best suited to assess the quality of outpatient palliative care.

Comprehensive geriatric assessment and palliative care

The geriatric vision of palliative care is based on a multidisciplinary, patient-centered approach, looking for a balance between human dignity and medical treatments with a particular focus on the social and ethical aspects. In order to develop the best care models, there is a rising need for a tighter collaboration of all the involved players (i.e., doctors, nurses, social workers). Indeed, the idea of a fragmented system without considering the patient or his/her family is not at all applicable to older patients with chronic disease. The causes of death, the phase of death changes, and the extend of last period of life could be a long phase characterized by complicated treatment decisions, difficult management of symptoms, multiple psychosocial problems, and complex spiritual distress. Recently, Italian guidelines on Comprehensive Geriatric Assessment (CGA) have been published. However, none of the identified studies on patients in hospice and other palliative care facilities met the criteria for inclusion. These findings underscore the need for further research to determine the potential benefits of a multidimensional approach for patients in hospice and other palliative care settings. Our reflections and suggestions on the CGA use for older persons in palliative care may be a starting point for an open and continuous dialogue with all the operators concerned.

End-of-life care in Germany between 2016 and 2020 - A repeated cross-sectional analysis of statutory health insurance data

BACKGROUND

The Hospice and Palliative Care Act of 2015 aimed at developing and regulating the provision of palliative care (PC) services in Germany. As a result of the legal changes, people with incurable diseases should be enabled to experience their final stage of life including death according to their own wishes. However, it remains unknown whether the act has impacted end-of-life care (EoLC) in Germany.

OBJECTIVE

The present study examined trends in EoLC indicators for patients who died between 2016 and 2020, in the context of Lower Saxony, Germany.

METHODS

Repeated cross-sectional analysis was conducted on data from the statutory health insurance fund AOK Lower Saxony (AOK-LS), referring to the years 2016-2020. EoLC indicators were: (1) the number of patients receiving any form of outpatient PC, (2) the number of patients receiving generalist outpatient PC and (3) specialist outpatient PC in the last year of life, (4) the onset of generalist outpatient PC and (5) the onset of specialist outpatient PC before death, (6) the number of hospitalisations in the 6 months prior to death and (7) the number of days spent in hospital in the 6 months prior to death. Data for each year were analysed descriptively and a comparison between 2016 and 2020 was carried out using t-tests and chi-square tests.

RESULTS

Data from 160,927 deceased AOK-LS members were analysed. The number of patients receiving outpatient PC remained almost consistent over time (2016 vs. 2020 p = .077). The number of patients receiving generalist outpatient PC decreased from 28.4% (2016) to 24.5% (2020; p < .001), whereas the number of patients receiving specialist outpatient PC increased from 8.5% (2016) to 11.2% (2020; p < .001). The onset of generalist outpatient PC moved from 106 (2016) to 93 days (2020; p < .001) before death, on average. The onset of specialist outpatient PC showed the reverse pattern (2016: 55 days before death; 2020: 59 days before death; p = .041).

CONCLUSION

Despite growing needs for PC at the end of life, the number of patients receiving outpatient PC did not increase between 2016 and 2020. Furthermore, specialist outpatient PC is being increasingly prescribed over generalist outpatient PC. Although the early initiation of outpatient PC has been proven valuable for the majority of people at the end of life, generalist outpatient PC was not initiated earlier in the disease trajectory over the study period, as was found to be true for specialist outpatient PC. Future studies should seek to determine how existing PC needs can be optimally met within the outpatient sector and identify factors that can support the earlier initiation of especially generalist outpatient PC.

TRIAL REGISTRATION

The study "Optimal Care at the End of Life" was registered in the German Clinical Trials Register (DRKS00015108; 22 January 2019).

[Nursing ethics and the mandate of care-current limits using the example of inpatient care for the elderly]

The central guiding ethical principles of professional care are dignity, care, justice, and respect. The current framework conditions and circumstances in the care of the elderly mean that professional care ethics are no longer feasible in many cases. This leads not only to enormous (moral) burdens among the nursing staff, but also to a comprehensive degree to professional dissatisfaction and to leaving the profession. The term "Pflexit" (based on the German word "Pflege" = care) was first raised during the corona pandemic and has not faded. In order to ensure ethically justified and dignified care for the elderly that is also oriented towards human rights, as is conveyed politically in charters and rightly expected by people in need of care, rapid and comprehensive social and political intervention is required.In this context, dignity and respect are also a social mandate. Dignified professional care based on ethical values can only be implemented if nurses are shown this same respect. The clear warnings of a "nursing climate crisis" must finally be followed by action to stop the exodus from the profession. In this discussion paper, the importance of a professional care ethic is first explained. In a second step, the framework and current problems that oppose a comprehensive implementation of core values in nursing care for the elderly are highlighted. The focus here is on the effects of the precarious personnel situation.

[Utilization of palliative care at the end of life in Germany: temporal trend (2016-2019) and regional variability]

BACKGROUND

In Germany, palliative care (PC) is provided on a homecare, inpatient, general, and specialized basis. Since little is currently known about the temporal course and regional differences in the forms of care, the present study was aimed to investigate this.

METHOD

In a retrospective routine data study with 417,405 BARMER-insured persons who died between 2016 and 2019, we determined the utilization rates of primary PC (PPC), specially qualified and coordinated palliative homecare (PPC+), specialized palliative homecare (SPHC), inpatient PC, and hospice care on the basis of services billed at least once in the last year of life. We calculated time trends and regional variability and controlled for needs-related patient characteristics and access-related county of community characteristics.

RESULTS

From 2016 to 2019, total PC increased from 33.8 to 36.2%, SPHC from 13.3 to 16.0% (max: Rhineland-Palatinate), and inpatient PC from 8.9 to 9.9% (max: Thuringia). PPC decreased from 25.8 to 23.9% (min: Brandenburg) and PPC+ came in at 4.4% (max: Saarland) in 2019. Hospice care remained constant at 3.4%. Regional variability in utilization rates remained high, increased for PPC and inpatient PC from 2016 to 2019, and decreased for SPHC and hospice care. The regional differences were also evident after adjustment.

CONCLUSION

Increasingly more SPHC, less PPC, and high regional variability, which cannot be explained by demand- or access-related characteristics, indicate that the use of PC forms is oriented less to demand than to regionally available care capacities. In view of the growing need for palliative care due to demographic factors and decreasing personnel resources, this development must be viewed critically.

Increasing the chance of dying at home: roles, tasks and approaches of general practitioners enabling palliative care: a systematic review of qualitative literature

BACKGROUND

Many elderly people wish to die at home but end up dying at the hospital. If the patient wishes to die at home, palliative care provided by General Practitioners (GPs) may increase the chance of dying at home, however, there is a lack of knowledge on how GPs should provide palliative care. We aimed to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and relatives through a systematic review of the qualitative literature.

METHODS

We searched PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL in March 2022. Thematic analysis was used for synthesizing the results.

RESULTS

Four thousand five hundred sixty three unique records were retrieved, and 12 studies were included for review. Of these, ten were interview or focus group studies and two were survey studies with additional open-ended questions. Only qualitative findings from the studies were used in synthesizing the results. Thematic analysis produced four main themes describing the roles, tasks and approaches of GPs enabling palliative care to increase the chance for patients to die at home. GPs can support patients in the final phases of life by applying a holistic, patient-centred, and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient.

CONCLUSIONS

The roles, tasks and approaches of the GPs enabling palliative care include being aware of elements in the palliative care consultation and elements surrounding the consultation and by having sufficient education and training and a broad, proactive, and patient-centred approach.

Experiences with long-term care for geriatric patients by an interprofessional outpatient care approach - a qualitative study

BACKGROUND

Outpatient care for geriatric patients is complex and requires the collaboration of different professions for supporting long-term care. Care and case management (CCM) could provide support with that. The long-term care of geriatric patients could be optimized with an interprofessional, cross-sectoral CCM. Therefore, the aim of the study was to evaluate the experiences and attitudes of those involved in the care with regard to the interprofessional design of the care for geriatric patients.

METHODS

A qualitative study design was used. Focus group interviews were conducted with those involved in the care (general practitioners (GP), health care assistants (HCA) as well as care and case managers (CM)). The interviews were digitally recorded, transcribed and analysed by qualitative content analysis.

RESULTS

Overall, ten focus groups were conducted in the five practice networks with n = 46 participants (n = 15 GP, n = 14 HCA and n = 17 CM). The participants evaluated the care they received from a CCM positively. The HCA and the GP were the primary points of contact for the CM. The close collaboration with the CM was experienced to be rewarding and relieving. Through their home-visitations, the CM gained a deep insight into the homelives of their patients and were thus able to accurately reflect the gaps in the care back to the family physicians.

CONCLUSIONS

The different health care professionals involved in this type of care experience that an interprofessional and cross-sectoral CCM is able to optimally support the long-term care of geriatric patients. The different occupational groups involved in the care benefit from this type of care arrangement as well.

How Do Health Care Professionals Perceive a Holistic Care Approach for Geriatric Patients? A Focus Group Study

BACKGROUND

Geriatric patients require holistic care in order to meet their complex care needs. The project RubiN (Continuous Care in a Regional Network) provides case and care management (CCM) for older people to address these needs in a primary care setting in Germany. This study aimed to explore the experiences of health care professionals who provided CCM for geriatric patients.

METHODS

Focus group interviews with general practitioners (GPs), health care assistants (HCAs), and case managers (CMs) were conducted. Transcribed data were analyzed by using qualitative content analysis.

RESULTS

Ten focus group discussions (n = 15 GPs, n = 14 HCAs, n = 17 CMs) were conducted. The different health care professionals emphasized the importance of a holistic care approach to geriatric care. Moreover, the GPs stated that the CMs supported the patients in organizing their care. A CCM could help encourage patients to remain at their own homes, which would have an effect on patients' quality of life and satisfaction.

CONCLUSION

A well-functioning and effective cooperation between those health professionals involved is a prerequisite for a trustful relationship in the holistic care of older people. This creates a feeling of security for all people involved in the care process.

A Consensus Definition of End of Life from an International and Interdisciplinary Perspective: A Delphi Panel Study

Background: Those working in the field of palliative care have recognized that many terms are being used synonymously and that clear definitions (or any definitions) for many of these terms are lacking. The synonymous use of the terms palliative and end of life (EOL) can especially lead to conflicts in clinical practice, such as a tardy referral to palliative care. Such conflicts may then result in poorer treatment of patients, for instance, pain management. In research, the lack of clear definitions or even of any established definition for central concepts, such as EOL, weakens study validity and research outcomes. Objective: The aim of this study was to establish a concise definition for the EOL phase. Design: A modified Delphi study design was chosen. A structured questionnaire based on a previously conducted concept analysis about the EOL was used. Setting: A panel of international and interdisciplinary experts was established. Between 34 (1st round) and 21 (4th round) individuals participated in the anonymous online expert panel. Results: After four panel rounds, we were able to provide a definition which covers physical and psychosocial aspects that should be considered at the beginning of the EOL phase and possible predictions about the remaining time. The definition also covers aspects of EOL care, such as considerations related to the individual's dignity, spirituality, and maintenance of relationships. Conclusion: EOL is a term which is defined by considering multiple aspects that affect the process of identifying the EOL phase, the EOL phase itself and the resulting care options.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

[End-of-life care in a rural small-town region in Lower Saxony: a retrospective cross-sectional analysis based on routinely collected general practice data]

INTRODUCTION

Up to 90% of people at the end of life are in need of palliative care. The majority can be cared for within general outpatient palliative care (AAPV) by general practitioners. Previous studies have described outpatient palliative care to fall short behind the estimated needs and to be initiated rather late in the health care process. Yet, little is known about the development of outpatient palliative care in recent years and about the parameters influencing its utilisation. Therefore, this study aimed to investigate the number and time of initiation for AAPV and specialised outpatient palliative care (SAPV) in a rural and small-town region in Lower Saxony on the basis of routinely collected general practice data. Furthermore, this study sought to estimate the influence of various parameters related to patients, practices and physicians on the provision of AAPV and SAPV.

METHODS

All general practitioners (n=190) in two counties in Lower Saxony were invited to take part in the project "Optimal care at the end of life - OPAL" (Innovation Fund, 01VSF17028) between autumn 2018 and spring 2019. In the participating practices, clinical data pertaining to patients with statutory health insurance, who had died in the second or third quarter of 2018, were collected in pseudonymised form and analysed using selected indicators for end-of-life care. The number of hospital stays and the provision of AAPV and SAPV were the subject of the descriptive analyses. In order to take the cluster effect of the practices into account, mixed-model analyses were carried out.

RESULTS

The data of 279 deceased patients (48% female; median age 82 years) from 31 general practices were analysed. In the last year of life, AAPV was provided for 78 deceased patients (28.0%) with a median onset of 20 days before death. 52 deceased patients (18.6%) received SAPV with a median onset of 28 days before death, respectively. In the last six months of life, 207 deceased patients (74.2%) were hospitalised at least once. The mixed-model analyses showed a greater probability of receiving AAPV (odds ratio (OR)=3.3) or SAPV (OR=3.2) in the last year of life for patients with oncological diseases. It was also shown that GPs with a higher value on the subscale practice organisation billed more AAPV (OR=1.4).

DISCUSSION

The number of patients with SAPV is at least equivalent to the estimated needs known from the literature in both selected regions. In contrast, AAPV seems to be provided relatively rarely and rather late in the health care process. Relevant reasons for this may be the lack of concrete criteria for AAPV (e. g., ambiguities and competing codes for billing) as well as prognostic uncertainties of health care providers especially for patients with non-oncological diseases.

CONCLUSION

Strategies to further develop end-of-life care should especially strengthen the AAPV provided by general practitioners and focus on patients with non-oncological diseases.

Generalist-Specialist Collaboration in Primary Care for Frail Older Persons: A Promising Model for the Future

OBJECTIVES

The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success.

DESIGN

A qualitative multiple case study with semistructured interviews.

SETTING AND PARTICIPANTS

A selection of 22 participants from 7 "established collaboration practices" within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice.

METHODS

Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes.

RESULTS

Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration's urgency by organizations and national policy makers).

CONCLUSIONS AND IMPLICATIONS

For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons.

The frequency and time point of outpatient palliative care integration for people before death: an analysis of health insurance data in Lower Saxony, Germany

Aim

This study aimed to analyse the number of deceased people who received different types of outpatient palliative care, the length of time prior to death that care was initiated, and their palliative care trajectory including the rate of hospital death.

Subject and methods

Data on 35,514 adults insured by the statutory health insurance who died in 2017 in Lower Saxony, Germany, were analysed. The study examined the provision of three different types of outpatient palliative care: general (GPC), intermediate (IPC) and specialised palliative care (SPC). In addition, oncological palliative care services (OS) were considered. Descriptive analyses include frequencies, timing and duration of these services, the number of inpatient hospital stays and hospital deaths.

Results

Prior to death, 31.4% of the deceased received outpatient palliative care: 21.3% GPC, 6.4% GPC with IPC and/or SPC and/or OS; and 3.7% IPC and/or SPC and/or OS, but no GPC. On average, GPC and OS were initiated 9 months and SPC 3 months prior to death. Six percent of the analytic sample received outpatient palliative care more than 2 years before death. Compared to those without outpatient palliative care, patients who received outpatient palliative care had more and longer inpatient hospital stays, but less frequently died in hospital.

Conclusion

Early outpatient palliative care took place in a minor percentage of deceased. Outpatient palliative care starts late before death for most patients, but enables more people not to die in hospital. However, significantly fewer people receive outpatient palliative care relative to current demand estimates. This is particularly true of general outpatient palliative care.

Palliative care competencies for geriatricians across Europe: a Delphi consensus study

Aim

to develop a set of specific palliative care competencies to be recommended for training at a postgraduate level of geriatricians across Europe.

Findings

A list of 35 palliative care competencies for geriatricians is now available for implementation in the different European countries.

Message

Future action are needed to support implementation and evaluation of the recommendations based upon key performance indicators within different health care systems.

Purpose

Integration of palliative care competencies with geriatric medicine is important for quality of care for older people, especially in the last years of their life. Therefore, knowledge and skills about palliative care for older people should be mandatory for geriatricians. The European Geriatric Medicine Society (EuGMS) has launched a postgraduate curriculum for geriatric medicine recently.

Aim

Based on this work, the Special Interest Group (SIG) on Palliative care in collaboration with the SIG in Education and Training aimed to develop a set of specific palliative care competencies to be recommended for training at a postgraduate level.

Methods

Competencies were defined using a modified Delphi technique based upon a Likert like rating scale. A template to kick off the first round and including 46 items was developed based on pre-existing competencies developed in Switzerland and Belgium.

Results

Three Delphi rounds were necessary to achieve full consensus. Experts came from 12 EU countries. In the first round, the wording of 13 competencies and the content of 10 competencies were modified. We deleted or merged ten competencies, mainly because they were not specific enough. At the end of the 2nd round, one competence was deleted and for three questions the wordings were modified. These modifications had the agreement of the participants during the last round.

Conclusion

A list of 35 palliative care competencies for geriatricians is now available for implementation in European countries.

"I Have Such a Great Care" - Geriatric Patients' Experiences with a New Healthcare Model: A Qualitative Study

PURPOSE

Coordinated care is important for the health and well-being of geriatric patients. However, continuity of care is lacking in many countries. Several studies have shown that case management can help to meet these requirements in health care and investigated positive effects. The project RubiN (Regional ununterbrochen betreut im Netz; Continuous care in a regional network) was developed to provide regional care- and case management for outpatient care of the elderly (age >70 years) in a primary care setting. The aim of this qualitative approach was to explore experiences and attitudes of geriatric patients towards the newly developed complex care- and case-management intervention RubiN.

PATIENTS AND METHODS

Qualitative interviews with a purposive sample of geriatric patients enlisted in the RubiN intervention networks were conducted. The collected data was transcribed and evaluated using qualitative content analysis. A deductive-inductive approach was used in generating thematic categories.

RESULTS

Forty-four telephone interviews were performed. Two key categories were identified to describe patients' experiences regarding care delivered by a care- and case manager (CCM), namely "role of CCM" and "changes through RubiN". Results demonstrated that care performed by CCMs is perceived positively by geriatric patients. A main finding of this study was that geriatric patients experienced a sense of security through the care provided by CCMs. CCMs were perceived as highly competent people, having all the necessary skills to provide continuity of care.

CONCLUSION

This study illustrates the importance of trust between care provider and care recipient. It also shows that geriatric patients appreciate the continuous, professional care and structural and functional support provided by qualified CCMs.

[Palliative care at the end of life in Germany : Utilization and regional distribution]

Hintergrund

Das Angebot an Palliativversorgung hat in Deutschland stark zugenommen. Weitgehend unbekannt ist, wie viele Menschen am Lebensende welche palliativen Versorgungsformen in Anspruch nehmen und welche regionalen Unterschiede bestehen.

Methode

Retrospektive Kohortenstudie mit GKV-Routinedaten (BARMER) über Versicherte mit Sterbedatum im Jahr 2016: Anhand einer mindestens einmalig abgerechneten Leistung in den letzten 6 Lebensmonaten wurde die Inanspruchnahme allgemeiner ambulanter Palliativversorgung (AAPV), spezialisierter ambulanter Palliativversorgung (SAPV) sowie stationärer Palliativ- und Hospizversorgung ermittelt. Erstmals wurden auch Abrechnungsziffern kassenärztlicher Vereinigungen und selektivvertragliche Sonderziffern für palliativmedizinische Leistungen sowie SAPV-Leistungsabrechnungen herangezogen.

Ergebnisse

Von den 95.962 Verstorbenen der Studienpopulation wurden bundesdurchschnittlich 32,7 % palliativ versorgt, mit Schwankungen zwischen 26,4 % in Bremen und 40,8 % in Bayern. AAPV-Leistungen wurden bei 24,4 % abgerechnet (16,9 % in Brandenburg bis 34,1 % in Bayern). SAPV-Leistungen erhielten 13,1 % (6,3 % in Rheinland-Pfalz bis 18,9 % in Brandenburg bzw. 22,9 % in Westfalen-Lippe mit abweichender SAPV-Praxis). Stationär palliativmedizinisch versorgt wurden 8,1 % (6,7 % in Schleswig-Holstein/Hessen bis 13,0 % in Thüringen), Hospizleistungen wurden für 3,3 % abgerechnet (1,6 % in Bremen bis 5,6 % in Berlin).

Diskussion

SAPV wird häufiger in Anspruch genommen als bisher berichtet, AAPV ist rückläufig. Die jeweilige Inanspruchnahme scheint weniger durch objektiven Bedarf als durch regionalspezifische Rahmenbedingungen begründet. Die Weiterentwicklung der Palliativversorgung sollte zukünftig neben Bedarfskriterien mehr an Outcomes sowie dafür relevanten Rahmenbedingungen orientiert werden.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-020-03240-6) enthalten.