Palliative care consultation and hospital length of stay

Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial

Importance

Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking.

Objective

To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes.

Design, Setting, and Participants

A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019.

Intervention

Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care.

Main Outcomes and Measures

The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality.

Results

Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]).

Conclusions and Relevance

Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02505035.

'Thank goodness you're here'. Exploring the impact on patients, family carers and staff of enhanced 7-day specialist palliative care services: A mixed methods study

BACKGROUND

Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear.

AIM

To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services.

DESIGN

An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals.

SETTING/PARTICIPANTS

Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2).

RESULTS

The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff).

CONCLUSIONS

Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff.

Palliative care for case managers: Building capacity to extend community-based palliative care to underserved older adults

Palliative care has demonstrated effectiveness in alleviating the biological, emotional, social, and spiritual symptoms that accompany serious illness, and improving quality of life for seriously ill individuals and their family members. Despite increasing availability, there are significant disparities in access to and utilization of palliative care, particularly among diverse, low-income, and community-dwelling older adults with chronic illness. Training frontline service providers is a novel approach to expanding access to palliative care among underserved elders. This article presents a process and outcome evaluation of a palliative care curriculum that was developed and piloted for geriatric case managers in a large urban area. We describe the background, planning, design, implementation, and preliminary outcomes associated with a pilot implementation of the curriculum. We conclude with implications for replicating efforts to enhance frontline providers' knowledge, skills, and self-efficacy in extending palliative care to communities that lack access to critical supports for their burdensome symptoms.

The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation

BACKGROUND

Inpatient palliative care may reduce length-of-stay, costs, mortality, and prevent readmissions. Timing of consultation may influence outcomes. The aim of this study was to explore the timing of consultation and its influences patient outcomes.

METHOD

This retrospective study of hospital consultations between July 1, 2019 and December 31, 2019 compared patients seen within 72 hours of admission with those seen after 72 hours. Outcomes length of stay and mortality. Chi-square analyses for categorical variables and independent t-tests for continuous normally distributed variables were done. For nonparametrically distributed outcome variables, Wilcoxon rank sum test was used. For mortality, a time-to-event analysis was used. 30-day readmissions were assessed using the Fine-Gray sub-distribution hazard model. Multiple regression models were used, controlling for other variables.

RESULTS

696 patients were seen, 424 within 72 hours of admission. The average age was 73 and 50.6% were female. Consultation within 72 hours was not associated with a shorter stay for cancer but was for patients with non-cancer illnesses. Inpatient mortality and 30-days mortality were reduced but there was a higher 30-day readmission rate.

DISCUSSION

Palliative consultations within 72 hours of admission was associated with lower hospital stays and inpatient mortality but increased the risk of readmission. Benefits were largely observed in patients followed in continuity.

CONCLUSION

Early inpatient palliative care consultation was associated with reduced hospital mortality, 30-day mortality and length of stay particularly if patients were seen by palliative care prior to hospitalization.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Association of an Emergency Department-embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Use

Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression.Results: In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (β = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; P = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; β = -0.26 d; 95% CI, -0.58 to 0.06; P = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (β = -3.25 d; 95% CI, -7.86 to 1.36; P = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (β = -0.64 d; 95% CI, -1.12 to -0.17; P = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099; 95% CI, -0.153 to -0.044; P = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (β = 0.011; 95% CI, 0.003-0.019; P = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.

A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes

BACKGROUND

Despite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal.

OBJECTIVE

To examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care-symptom management, and ethical aspects-advance care planning).

DESIGN

Systematic review.

METHODS

We searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias.

RESULTS

We screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution.

CONCLUSIONS AND IMPLICATIONS

Heterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.

Waiting it out: consultation delays prolong in-patient length of stay

BACKGROUND

Decreasing delays for hospitalised patients results in improved hospital efficiency, increased quality of care and decreased healthcare expenditures. Delays in subspecialty consultations and procedures can cause increased length of stay due to reasons outside of necessary medical care.

OBJECTIVE

To quantify, describe and record reasons for delays in consultations and procedures for patients on the general medicine wards.

METHODOLOGY

We conducted weekly audits of all admitted patients on five Internal Medicine teams over 8 weeks. A survey was reviewed with attending physicians and residents on five internal medicine teams to identify patients with a delay due to consultation or procedure, quantify length of delay and record reason for delay.

RESULTS

During the study period, 316 patients were reviewed and 48 were identified as experiencing a total of 53 delays due to consultations or procedures. The average delay was 1.8 days for a combined total of 83 days. Top reasons for delays included scheduling, late response to page and a busy service. The frequency in length of consult delays vary among different specialties. The highest frequency of delays was clustered in procedure-heavy specialties.

CONCLUSION

This report highlights the importance of reviewing system barriers that lead to delayed service in hospitals. Addressing these delays could lead to reductions in length of stay for inpatients.

Association of Inpatient Palliative Care with Health Care Utilization and Postdischarge Outcomes among Medicare Beneficiaries with End Stage Kidney Disease

BACKGROUND AND OBJECTIVES

Palliative care may improve quality of life and reduce the cost of care for patients with chronic illness, but utilization and cost implications of palliative care in ESKD have not been evaluated. We sought to determine the association of inpatient palliative care with health care utilization and postdischarge outcomes in ESKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In analyses stratified by whether patients died during the index hospitalization, we identified Medicare beneficiaries with ESKD who received inpatient palliative care, ascertained by provider specialty codes, between 2012 and 2013. These patients were matched to hospitalized patients who received usual care using propensity scores. Primary outcomes were length of stay and hospitalization costs. Secondary outcomes were 30-day readmission and hospice enrollment.

RESULTS

Inpatient palliative care occurred in <1% of hospitalizations lasting >2 days. Among the decedent cohort (n=1308), inpatient palliative care was associated with a 21% shorter length of stay (-4.2 days; 95% confidence interval, -5.6 to -2.9 days) and 14% lower hospitalization costs (-$10,698; 95% confidence interval, -$17,553 to -$3843) compared with usual care. Among the nondecedent cohort (n=5024), inpatient palliative care was associated with no difference in length of stay (0.4 days; 95% confidence interval, -0.3 to 1.0 days) and 11% higher hospitalization costs ($4275; 95% confidence interval, $1984 to $6567) compared with usual care. In the 30-day postdischarge period, patients who received inpatient palliative care had higher likelihood of hospice enrollment (hazard ratio, 8.3; 95% confidence interval, 6.6 to 10.5) and lower likelihood of rehospitalization (hazard ratio, 0.8; 95% confidence interval, 0.7 to 0.9).

CONCLUSIONS

Among patients with ESKD who died in the hospital, inpatient palliative care was associated with shorter hospitalizations and lower costs. Among those who survived to discharge, inpatient palliative care was associated with no difference in length of stay and higher hospitalization costs but markedly higher hospice use and fewer readmissions after discharge.

Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial

The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).

Prospective Cohort Study of Hospitalized Adults With Advanced Cancer: Associations Between Complications, Comorbidity, and Utilization

BACKGROUND

Inpatient hospital stays account for more than a third of direct medical cancer care costs. Evidence on factors driving these costs can inform planning of services, as well as consideration of equity in access.

OBJECTIVE

To measure the association between hospital costs, and demographic, clinical, and system factors, for a cohort of adults with advanced cancer.

DESIGN

Prospective multisite cohort study.

SETTING

Four medical and cancer centers.

PATIENTS

Adults with advanced cancer admitted to a participating hospital between 2007 and 2011, excluding those with dementia. Final analytic sample included 1020 patients.

METHODS

With receipt of palliative care controlled for, the associations between hospital cost and patient factors were estimated. Factors covered the domains of demographics (age, sex, race), socioeconomics and systems (education, insurance, living will, proxy), clinical care (diagnoses, complications deemed to pose a threat to life or bodily functions, comorbidities, symptom burden, activities of daily living), and prior healthcare utilization (home help, analgesic prescribing).

OUTCOME MEASURE

Direct hospital costs.

RESULTS

A major (markedly abnormal) complication (+$8267; P < 0.01), a minor but not a major complication (+$5289; P < 0.01), and number of comorbidities (+$852; P < 0.01) were associated with higher cost, and admitting diagnosis of electrolyte disorders (-$4759; P = 0.01) and increased age (-$53; P = 0.03) were associated with lower cost.

CONCLUSIONS

Complications and comorbidity burden drive inhospital utilization for adults with advanced cancer. There is little evidence of sociodemographic associations and no apparent impact of advance directives. Attempts to control growth of hospital cancer costs require consideration of how the most resource-intensive patients are identified promptly and prioritized for cost-effective care. Journal of Hospital Medicine 2017;12:407-413.

Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from?

BACKGROUND

Studies report cost-savings from hospital-based palliative care consultation teams compared to usual care only, but drivers of observed differences are unclear.

AIM

To analyse cost-differences associated with palliative care consultation teams using two research questions: (Q1) What is the association between early palliative care consultation team intervention, and intensity of services and length of stay, compared to usual care only? (Q2) What is the association between early palliative care consultation team intervention and day-to-day hospital costs, compared to a later intervention?

DESIGN

Prospective multi-site cohort study (2007-2011). Patients who received a consultation were placed in the intervention group, those who did not in the comparison group. Intervention group was stratified by timing, and groups were matched using propensity scores.

SETTING/PARTICIPANTS

Adults admitted to three US hospitals with advanced cancer. Principle analytic sample contains 863 patients ( n_UC = 637; n_{PC EARLY} = 177; n_{PC LATE} = 49) discharged alive.

RESULTS

Cost-savings from early palliative care accrue due to both reduced length of stay and reduced intensity of treatment, with an estimated 63% of savings associated with shorter length of stay. A reduction in day-to-day costs is observable in the days immediately following initial consult but does not persist indefinitely. A comparison of early and late palliative care consultation team cost-effects shows negligible difference once the intervention is administered.

CONCLUSION

Reduced length of stay is the biggest driver of cost-saving from early consultation for patients with advanced cancer. Patient- and family-centred discussions on goals of care and transition planning initiated by palliative care consultation teams may be at least as important in driving cost-savings as the reduction of unnecessary tests and pharmaceuticals identified by previous studies.

Standardized Criteria for Palliative Care Consultation on a Solid Tumor Oncology Service Reduces Downstream Health Care Use

PURPOSE

Hospitalized patients with advanced cancer have a high symptom burden and need for support. Integration of palliative care (PC) improves symptom control and decreases unwanted health care use, yet many patients are never offered these services. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. To improve the quality of cancer care, we developed standardized criteria, or triggers, for PC consultation on the inpatient solid tumor service.

METHODS

Patients were eligible for this prospective cohort study if they met at least one of the following eligibility criteria: had an advanced solid tumor; prior hospitalization within 30 days; hospitalization > 7 days; and active symptoms. During the intervention, patients who met the criteria received automatic PC consultation.

RESULTS

When we compared patients in the intervention group with control subjects, there were increases in PC consultations (19 of 48 [39%] to 52 of 65 [80%]; P ≤ .001) and hospice referrals (seven of 48 [14%] to 17 of 65 [26%]; P = .03), and there were declines in 30-day readmission rates (17 of 48 [35%] to 13 of 65 [18%]; P = .04) and receipt of chemotherapy after discharge (21 of 48 [44%] to 12 of 65 [18%]; P = .03). There was an overall increase in support measures following discharge ( P = .004). Length of stay was unaffected.

CONCLUSION

To our knowledge, this is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, the standardized use of triggers for PC consultation is associated with substantial impact on 30-day readmission rates, chemotherapy following discharge, hospice referrals, and use of support services following discharge. Expansion of this model to other hospitals and health systems should improve the value of cancer care.

Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities

Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.

Implementing Evidence-Based Palliative Care Programs and Policy for Cancer Patients: Epidemiologic and Policy Implications of the 2016 American Society of Clinical Oncology Clinical Practice Guideline Update

The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: "Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.

Using Length of Stay to Control for Unobserved Heterogeneity When Estimating Treatment Effect on Hospital Costs with Observational Data: Issues of Reliability, Robustness, and Usefulness

OBJECTIVE

To evaluate the sensitivity of treatment effect estimates when length of stay (LOS) is used to control for unobserved heterogeneity when estimating treatment effect on cost of hospital admission with observational data.

DATA SOURCES/STUDY SETTING

We used data from a prospective cohort study on the impact of palliative care consultation teams (PCCTs) on direct cost of hospital care. Adult patients with an advanced cancer diagnosis admitted to five large medical and cancer centers in the United States between 2007 and 2011 were eligible for this study.

STUDY DESIGN

Costs were modeled using generalized linear models with a gamma distribution and a log link. We compared variability in estimates of PCCT impact on hospitalization costs when LOS was used as a covariate, as a sample parameter, and as an outcome denominator. We used propensity scores to account for patient characteristics associated with both PCCT use and total direct hospitalization costs.

DATA COLLECTION/EXTRACTION METHODS

We analyzed data from hospital cost databases, medical records, and questionnaires. Our propensity score weighted sample included 969 patients who were discharged alive.

PRINCIPAL FINDINGS

In analyses of hospitalization costs, treatment effect estimates are highly sensitive to methods that control for LOS, complicating interpretation. Both the magnitude and significance of results varied widely with the method of controlling for LOS. When we incorporated intervention timing into our analyses, results were robust to LOS-controls.

CONCLUSIONS

Treatment effect estimates using LOS-controls are not only suboptimal in terms of reliability (given concerns over endogeneity and bias) and usefulness (given the need to validate the cost-effectiveness of an intervention using overall resource use for a sample defined at baseline) but also in terms of robustness (results depend on the approach taken, and there is little evidence to guide this choice). To derive results that minimize endogeneity concerns and maximize external validity, investigators should match and analyze treatment and comparison arms on baseline factors only. Incorporating intervention timing may deliver results that are more reliable, more robust, and more useful than those derived using LOS-controls.

Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect

PURPOSE

Previous studies report that early palliative care is associated with clinical benefits, but there is limited evidence on economic impact. This article addresses the research question: Does timing of palliative care have an impact on its effect on cost?

PATIENTS AND METHODS

Using a prospective, observational design, clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011. The sample for economic evaluation was 969 patients; 256 were seen by a palliative care consultation team, and 713 received usual care only. Subsamples were created according to time to consult after admission. Propensity score weights were calculated, matching the treatment and comparison arms specific to each subsample on observed confounders. Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within subsamples.

RESULTS

Earlier consultation is associated with a larger effect on total direct cost. Intervention within 6 days is estimated to reduce costs by -$1,312 (95% CI, -$2,568 to -$56; P = .04) compared with no intervention and intervention within 2 days by -$2,280 (95% CI, -$3,438 to -$1,122; P < .001); these reductions are equivalent to a 14% and a 24% reduction, respectively, in cost of hospital stay.

CONCLUSION

Earlier palliative care consultation during hospital admission is associated with lower cost of hospital stay for patients admitted with an advanced cancer diagnosis. These findings are consistent with a growing body of research on quality and survival suggesting that early palliative care should be more widely implemented.

Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review

OBJECTIVE

We conducted a systematic review to answer three questions: 1) Do advance care planning and palliative care interventions lead to a reduction in ICU admissions for adult patients with life-limiting illnesses? 2) Do these interventions reduce ICU length of stay? and 3) Is it possible to provide estimates of the magnitude of these effects?

DATA SOURCES

We searched MEDLINE, EMBASE, Cochrane Controlled Clinical Trials, and Cumulative Index to Nursing and Allied Health Literature databases from 1995 through March 2014.

STUDY SELECTION

We included studies that reported controlled trials (randomized and nonrandomized) assessing the impact of advance care planning and both primary and specialty palliative care interventions on ICU admissions and ICU length of stay for critically ill adult patients.

DATA EXTRACTION

Nine randomized controlled trials and 13 nonrandomized controlled trials were selected from 216 references.

DATA SYNTHESIS

Nineteen of these studies were used to provide estimates of the magnitude of effect of palliative care interventions and advance care planning on ICU admission and length of stay. Three studies reporting on ICU admissions suggest that advance care planning interventions reduce the relative risk of ICU admission for patients at high risk of death by 37% (SD, 23%). For trials evaluating palliative care interventions in the ICU setting, we found a 26% (SD, 23%) relative risk reduction in length of stay with these interventions.

CONCLUSIONS

Despite wide variation in study type and quality, patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay. Although SDs are wide and study quality varied, the magnitude of the effect is possible to estimate and provides a basis for modeling impact on healthcare costs.

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

Background

Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay.

Objectives

This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs.

Data sources

We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type.

Methods

We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England.

Results

A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.

Limitations

We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review.

Conclusions

The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economy.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study

BACKGROUND

Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients.

METHODS

A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH.

RESULTS

Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55).

CONCLUSIONS

Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.

High burden of palliative needs among older intensive care unit survivors transferred to post-acute care facilities. a single-center study

RATIONALE

Adults with chronic critical illness (tracheostomy after ≥ 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities.

OBJECTIVES

To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs.

METHODS

We examined electronic records from a 1-year cohort of 228 consecutive adults ≥ 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality.

MEASUREMENTS AND MAIN RESULTS

The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%.

CONCLUSIONS

Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.

Economic impact of hospitalisations among patients in the last year of life: an observational study

BACKGROUND

Hospital admissions among patients at the end of life have a significant economic impact. Avoiding unnecessary hospitalisations has the potential for significant cost savings and is often in line with patient preference.

OBJECTIVE

To determine the extent of potentially avoidable hospital admissions among patients admitted to hospital in the last year of life and to cost these accordingly.

DESIGN

An observational retrospective case note review with economic impact assessment.

SETTING

Two large acute hospitals in the North of England, serving contrasting socio-demographic populations.

PATIENTS

A total of 483 patients who died within 1 year of admission to hospital.

MEASUREMENTS

Data were collected across a range of clinical, demographic, economic and service use variables and were collected from hospital case notes and routinely collected sources. Palliative medicine consultants identified admissions that were potentially avoidable.

RESULTS

Of 483 admissions, 35 were classified as potentially avoidable. Avoiding these admissions and caring for the patients in alternative locations would save the two hospitals £5.9 million per year. Reducing length of stay in all 483 patients by 14% has the potential to save the two hospitals £47.5 million per year; however, this cost would have to be offset against increased community care costs.

LIMITATIONS

A lack of accurate cost data on alternative care provision in the community limits the accuracy of economic estimates.

CONCLUSIONS

Reducing length of hospital stay in palliative care patients may offer the potential to achieve higher hospital cost savings than preventing avoidable admissions. Further research is required to determine both the feasibility of reducing length of hospital stay for patients with palliative care needs and the economic impact of doing so.

Comparison of Early Versus Late Palliative Care Consultation in End-of-Life Care for the Hospitalized Frail Elderly Patients

To examine the effects of early palliative care (PC; EPC; ≤3 days after admission) consultation versus late PC (>3 days) on number of days from day of consult to discharge (DCDAYS), a retrospective review of PC data (2009-2012) included 531 patients with age ≥65 and Palliative Performance Scale ≤50. Early PC was independently associated with lower DCDAYS ( P = .019). Persons admitted to hospice ( P = .010) as well as those discharged to home ( P = .003) and subacute rehabilitation (SAR; P = .015) were more likely to have an EPC compared to those who died. Admitting to hospice was associated with lower DCDAYS than discharging to long-term acute care ( P < .001) or SAR ( P < .001). Early PC resulted in lower DCDAYS, fewer inpatient deaths, and higher hospice admissions. Hospice resulted in fewer DCDAYS.

Palliative care consultation versus palliative care unit: which is associated with shorter terminal hospitalization length of stay among patients with cancer?

Hospital length of stay (LoS) may be used to assess end-of-life care aggressiveness and health care delivery efficiency. We describe the terminal hospitalization LoS of patients with cancer managed by a hospital-based palliative care (PC) program comprising a palliative care consultation (PCC) service and an inpatient palliative care unit (PCU). A total of 328 in-hospital cancer deaths were divided into 2 groups. The PCU group included patients admitted by the PC team directly to the PCU. The PCC group included patients admitted by other specialties and referred to the PCC team. The LoS of the PCU group was significantly shorter than that of the PCC group (9.9 [±9.4] vs 17.8 [±19.7] days, respectively; P < .001). Direct terminal hospitalization to PCU is not associated with longer LoS among cancer deaths managed by a hospital-based PC service.

Preliminary data from an advanced dementia consult service: integrating research, education, and clinical expertise

Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow-up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, 24 subjects received usual care. In the subsequent 3-month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care after discharge.

Cost savings vary by length of stay for inpatients receiving palliative care consultation services

BACKGROUND

Cost savings associated with palliative care (PC) consultation have been demonstrated for total hospital costs and daily costs after PC involvement. This analysis adds another approach by examining costs stratified by hospital length of stay (LOS).

OBJECTIVE

To examine cost savings for patients who receive PC consultations during short, medium, and long hospitalizations.

METHODS

Data were analyzed for 1815 PC patients and 1790 comparison patients from two academic medical centers between 2005 and 2008, matched on discharge disposition, LOS category, and propensity for a PC consultation. We used generalized linear models and regression analysis to compare cost differences for LOS of 1 to 7 days (38% of consults), 8 to 30 days (48%), and >30 days (14%). Comparisons were done for all patients in both hospitals (n=3605) and by discharge disposition: survivors (n=2226) and decedents (n=1379); analyses were repeated for each hospital.

RESULTS

Significant savings per admission were associated with shorter LOS: For stays of 1 to 7 days, costs were lower for all PC patients by 13% ($2141), and for survivors by 19.1% ($2946). For stays of 8 to 30 days, costs were lower for all PC patients by 4.9% ($2870), and for survivors by 6% ($2487). Extrapolating the per admission cost across the PC patient groups with lower costs, these programs saved about $1.46 million for LOS under a week and about $2.5 million for LOS of 8 to 30 days. Patients with stays >30 days showed no differences in costs, perhaps due to preferences for more aggressive care for those who stay in the hospital more than a month.

CONCLUSION

Cost savings due to PC are realized for short and medium LOS but not stays >30 days. These findings suggest savings can be achieved by earlier involvement of palliative care, and support screening efforts to identify patients who can benefit from PC services early in an admission.

Palliative care programs for patients with breast cancer: the benefits of home-based care

SUMMARY Improving breast cancer care means enhancing end-of-life care with specialized palliative care services. Palliative care embodies a holistic approach to care that focuses on symptom management of individuals with incurable diseases, whereas end-of-life care specifically focuses on a period of time, such as the last 6 months of life, where a rapid state of decline is often evident. The purpose of this article is to explore the benefits and limitations of end-of-life care provided in the hospital and community settings, with an emphasis on the benefits of home-based care. A key strength of home-based palliative care is the ability to expand the reach of palliative care to more cancer patients beyond residential hospice or hospital settings, which are limited in bed availability. The essential features of quality end-of-life services, regardless of setting, are care that offers seamless transitions, around-the-clock access to the same providers and an interdisciplinary, whole-person approach.

Impact of a palliative care consult service

Established hospital palliative care consult services (PCCS) have been associated with reduced costs and length of stay, decreased symptom burden, and increased satisfaction with care. Using a retrospective case-control design, we analyzed administrative data of patients seen by PCCS while hospitalized at the Rochester, Minnesota Mayo Clinic hospitals from 2003 to 2008. The PCCS patients were matched to 3:1. A total of 1477 patients seen by the PCCS were matched with 4431 patients not seen. Costs for patients seen and discharged alive were US $35,449 (95% confidence interval [CI] US $34,157-US $36,686) compared to US $37,447 (95% CI US $36,734-US $38,126), without PCCS consultation. Costs for PCCS patients that died during hospitalization were US $54,940 (95% CI US $51,483-US $58,576) and non-PCCS patients were US $79,660 (95% CI US $76,614-US $83,398).

Palliative oncology: identity, progress, and the path ahead

Palliative care is a rapidly growing subspecialty of medicine entailing expert and active assessment, evaluation and treatment of the physical, psychological, social and spiritual needs of patients and families with serious illnesses. It provides an added layer of support to the patient's regular medical care. As cancer is detected earlier and its treatments improve, palliative care is increasingly playing a vital role in the oncology population. Because of these advances in oncology, the role of palliative care services for such patients is actively evolving. Herein, we will highlight emerging paradigms in palliative care and attempt to delineate key education, research and policy areas that lie ahead for the field of palliative oncology. Despite the critical need for improving multi-faceted and multi-specialty symptom management and patient-physician communication, we will focus on the interface between palliative care and oncology specialists, a relationship that can lead to better overall patient care on all of these levels.

Palliative care and hematologic oncology: the promise of collaboration

Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.

Integrative palliative care, advance directives, and hospital outcomes of critically ill older adults

OBJECTIVE

To examine the associations between palliative care types and hospital outcomes for patients who have or do not have advance directives.

METHOD

Using administrative claims and clinical data for critically ill older adults (n = 1291), multivariable regressions examined the associations between palliative care types and hospital outcomes by advance directive status.

RESULTS

Integrative palliative care was associated with lower hospital costs, lower adjusted probability of in-hospital deaths, and higher adjusted probability of hospice discharges. There was no difference in hospital outcomes by palliative care types in those with advance directives.

CONCLUSION

Significantly lower hospital costs and in-hospital deaths with higher hospice discharges were observed in integrative palliative care compared to consultative palliative care, but these findings were diminished with the presence of advance directives.