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Chu WM, Kuo WY, Tung YC. Effects of different palliative care models on decedents with kidney failure receiving maintenance dialysis: a nationwide population-based retrospective observational study in Taiwan. BMJ Open 2023; 13:e069835. [PMID: 37429693 DOI: 10.1136/bmjopen-2022-069835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVES Patients with kidney failure receiving maintenance dialysis are a particularly important population and carry a heavy disease burden. However, evidence related to palliative care for patients with kidney failure receiving maintenance dialysis remains scarce, especially in regard to palliative care consultation services and palliative home care. This study aimed to evaluate the effects of different palliative care models on aggressive treatment among patients with kidney failure receiving maintenance dialysis during the end of life. DESIGN A population-based retrospective observational study. SETTING This study used a population database maintained by Taiwan's Ministry of Health and Welfare in combination with Taiwan's National Health Research Insurance Database. PARTICIPANTS We enrolled all decedents who were patients with kidney failure receiving maintenance dialysis from the period 1 January 2017 to 31 December 2017 in Taiwan. MAIN EXPOSURE MEASURE Hospice care during the 1-year period before death. MAIN OUTCOME MEASURES Eight aggressive treatments within 30 days before death, more than one emergency department visit, more than one admission, a longer than 14-day admission, admission to an intensive care unit, death in hospital, endotracheal tube use, ventilator use and need for cardiopulmonary resuscitation. RESULTS A total of 10 083 patients were enrolled, including 1786 (17.7%) patients with kidney failure who received palliative care 1 year before death. Compared with patients without palliative care, patients with palliative care had significantly less aggressive treatments within 30 days before death (Estimates: -0.09, CI: -0.10 to -0.08). Patients with inpatient palliative care, palliative home care or a mixed model experienced significantly lower treatment aggressiveness within 30 days before death. CONCLUSIONS Palliative care, particularly use of a mixed care model, inpatient palliative care and palliative home care in patients with kidney failure receiving dialysis, could all significantly reduce the aggressiveness of treatment within 30 days before death.
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Affiliation(s)
- Wei-Min Chu
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Geriatrics and Gerontology Research Center, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Epidemiology on Aging, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Wen-Yu Kuo
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
- Population Health Research Center, National Taiwan University, Taipei, Taiwan
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Yu TH, Lu FL, Wei CJ, Wu WW. The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study. BMC Palliat Care 2023; 22:29. [PMID: 36978057 PMCID: PMC10053103 DOI: 10.1186/s12904-023-01146-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/09/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVES Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status. METHODS We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected. RESULTS There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics. CONCLUSION The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.
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Affiliation(s)
- Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Wei-Wen Wu
- School of Medicine, National Taiwan University, No.1 Jen-Ai Road section 1 Taipei 100, Taipei, Taiwan.
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
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Patient Factors Associated with Different Hospice Programs in Korea: Analyzing Healthcare Big Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031566. [PMID: 35162586 PMCID: PMC8834925 DOI: 10.3390/ijerph19031566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 12/10/2022]
Abstract
The Korean government has implemented a pilot project that introduces a new type of hospice care program called “Consultative Hospice Care” (COHC) since August 2017. The COHC is a new type of hospice program for terminally ill patients in acute care wards, which is different from the Independent Hospice Unit (IHU) care. This study aimed to compare the characteristics of two groups of hospice patients: COHC care only and both IHU care and COHC groups. Healthcare claim data from 1 April 2018 to 31 March 2020 were retrieved from the HIRA data warehouse system. The main outcome variable was patients receiving COHC only or both COHC and IHU care. The total number of hospice patients was 6482. A multivariate logistic regression analysis was used. Of 6482 hospice care recipients, 3789 (58.5%) received both COHC and IHU care. Those who received both COHC and IHU care were significantly associated with several factors: period from the first evaluation to death (adjusted odds ratio (aOR), 1.026; 95% confidence internal (CI), 1.024–1.029; p < 0.0001), disease severity measured by the Charlson Comorbidity Index (aOR, 1.032; CI, 1.017–1.047; p < 0.0001), consciousness (aOR, 3.654; CI, 3.269–4.085; p < 0.0001), and awareness of end-stage disease (aOR, 1.422; CI, 1.226–1.650; p < 0.0001). The COHC program had a critical role in hospice delivery to terminally ill patients. Policymakers on hospice care need to establish plans that promote efficient hospice care delivery systems.
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Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett MI. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med 2020; 18:368. [PMID: 33239021 PMCID: PMC7690105 DOI: 10.1186/s12916-020-01829-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature. METHODS We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death). RESULTS One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries. CONCLUSIONS Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.
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Affiliation(s)
- Roberta I Jordan
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Yousuf ElMokhallalati
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catriona E Jackson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Helen L Edwards
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emma J Chapman
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University, Ghent, Belgium.,Vrije Universiteit Brussel, Brussels, Belgium
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Lin CY, Lee YC. Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care - a nationwide matched-pair retrospective cohort study in Taiwan. BMC Palliat Care 2020; 19:87. [PMID: 32563245 PMCID: PMC7305586 DOI: 10.1186/s12904-020-00590-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan. METHODS A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan-Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation. RESULTS The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group. CONCLUSION Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Neurology, Taipei City Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health, Taipei, Taiwan
| | - Yue-Chune Lee
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Master Program on Trans-disciplinary Long-Term Care and Management, National Yang-Ming University, Taipei, Taiwan
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Chen B, Kuo CC, Huang N, Fan VY. Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study. Palliat Med 2018; 32:1389-1400. [PMID: 29793393 DOI: 10.1177/0269216318774899] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Costs of medical care have been found to be highest at the end of life. AIM To evaluate the effect of provider reimbursement for hospice care on end-of-life costs. DESIGN The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life. SETTING/PARTICIPANTS A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan. RESULTS Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%. CONCLUSION By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.
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Affiliation(s)
- Bradley Chen
- 1 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chi Kuo
- 2 Big Data Center, China Medical University Hospital and China Medical University, Taichung, Taiwan.,3 Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- 1 Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,4 Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Victoria Y Fan
- 5 Office of Public Health Studies, Myron B. Thompson School of Social Work, University of Hawaii at Manoa, Honolulu, HI, USA.,6 Department of Global Health and Population and François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Kuo FC, Wu MR, Hsiao CY, Chen CY, Wang KT, Yeh HI, Su MI. Palliative Care on Patients With Paraquat Poisoning: Analysis of 90 Cases From 2005–2016. INT J GERONTOL 2018. [DOI: 10.1016/j.ijge.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Chen B, Fan VY, Chou YJ, Kuo CC. Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study. BMC Nephrol 2017; 18:36. [PMID: 28122500 PMCID: PMC5267416 DOI: 10.1186/s12882-017-0456-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. Methods We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. Results During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. Conclusions Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.
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Affiliation(s)
- Bradley Chen
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Victoria Y Fan
- Department of Public Health Sciences & Epidemiology, University of Hawaii at Manoa, 1960 East-West Road, Biomed D204, Honolulu, HI, USA.,François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, USA.,Center for Global Development, Washington, D.C., USA
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University Hospital, Taichung, Taiwan. .,Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, 13F.-2, No.101, Kaixuan Rd., East Dist, Tainan City, Taiwan.
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Tiirola A, Korhonen T, Surakka T, Lehto JT. End-of-Life Care of Patients With Amyotrophic Lateral Sclerosis and Other Nonmalignant Diseases. Am J Hosp Palliat Care 2016; 34:154-159. [DOI: 10.1177/1049909115610078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Palliative care services extend to meet the needs of patients with nonmalignant diseases. Aim: To explore the diagnoses, symptoms, and treatment of patients dying in hospice due to nonmalignant diseases, with special emphasis on amyotrophic lateral sclerosis (ALS). Design: A retrospective study based on a detailed analysis of patient records. Setting/Participants: All patients with nonmalignant diseases who died in Pirkanmaa Hospice during the period 2004 to 2013 were included. Results: Of the 67 patients studied, 48% had ALS, and the remaining had pulmonary (18%), cardiovascular (13%), neurologic (10%), and other (10%) diseases. Dyspnea, followed by pain and fatigue, was the most common symptom reported, increasing in frequency from admission to the last day of life (31% vs 48%; P < .05). Compared with ALS, patients with other diseases had more comorbidities (3.8% vs 1.4%, P < .001) and were more likely to have very short (≤3 days) final care periods (31% vs 9%; P < .05). During the last day of life, patients with ALS were more frequently unable to swallow (87% vs 31%, P < .001) and received significantly more antidepressants, antibiotics, and laxatives but less corticosteroids and oxygen compared to other patients. Noninvasive ventilation was used in 31% of all patients. Conclusion: Respiratory symptoms are important in the management of nonmalignant diseases in hospice. Especially, units taking care of ALS should be prepared to meet the special needs involved in ventilation support. In contrast to ALS, late referrals to hospice are common in patients with other nonmalignant diseases.
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Affiliation(s)
- Anna Tiirola
- Department of Palliative Medicine, University of Tampere, Tampere, Finland
| | | | | | - Juho T. Lehto
- Department of Palliative Medicine, University of Tampere, Tampere, Finland
- Department of Oncology, Tampere University Hospital, Tampere, Finland
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