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King D, Schockett E, Rizvi G, Fischer D, Amdur R, Benjenk I, Yamane D, DelPrete B, Davison D, Seneff M. The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit. J Intensive Care Med 2022; 37:1397-1402. [PMID: 35006025 DOI: 10.1177/08850666211069031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. INTERVENTIONS AND MEASUREMENTS We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.
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Affiliation(s)
- Daniel King
- 43963George Washington University Hospital, Washington, DC, USA
| | - Erica Schockett
- 43963George Washington University Hospital, Washington, DC, USA
| | - Ghazi Rizvi
- 43963George Washington University Hospital, Washington, DC, USA
| | - Daniel Fischer
- 43963George Washington University Hospital, Washington, DC, USA
| | - Richard Amdur
- 43963George Washington University Hospital, Washington, DC, USA
| | - Ivy Benjenk
- 43963George Washington University Hospital, Washington, DC, USA
| | - David Yamane
- 43963George Washington University Hospital, Washington, DC, USA
| | | | | | - Michael Seneff
- 43963George Washington University Hospital, Washington, DC, USA
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Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial. J Gen Intern Med 2021; 36:1928-1936. [PMID: 33547573 PMCID: PMC8298677 DOI: 10.1007/s11606-020-06482-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. OBJECTIVE To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). DESIGN Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. PARTICIPANTS One hundred thirty-two providers from PCCTs at 47 VAMCs. INTERVENTIONS Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. MAIN MEASUREMENTS Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. KEY RESULTS Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. CONCLUSION Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02383173.
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Davidoff AJ, Canavan ME, Prsic E, Saphire M, Wang SY, Presley CJ. End-of-life patterns of symptom management and cancer-directed care among Medicare beneficiaries with lung cancer: a claims-based analysis. Support Care Cancer 2021; 29:3921-3932. [PMID: 33389087 DOI: 10.1007/s00520-020-05964-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rather than early hospice enrollment, most Medicare beneficiaries receive "usual care" in the last months of life, outside of the hospice setting. While care intensity during the last weeks of life has been studied extensively, patterns of symptom management services (SMS) and/or cancer-directed therapies (CDT) received over a 6-month end-of-life period have not. METHODS This retrospective study used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify decedents diagnosed with lung cancer at age ≥ 66 years between January 2007 and December 2013 who survived ≥ 6 months from diagnosis. Medicare claims identified receipt of SMS and/or CDT. We created monthly indicators for care content (SMS-only, CDT-only, or both; otherwise full-month hospice or inpatient/skilled nursing). Multinomial logistic regression estimated associations between sociodemographics and comorbidity, with care content in the final month. RESULTS Between 6 and 1 months before death, full-month hospice and inpatient/skilled nursing increased; CDT decreased from 31.9 to 18.5%; SMS increased from 86.6 to 97.7%. Relative to full-month hospice, the percentage of patients receiving SMS-only was higher for males, unmarried, younger age, and higher comorbidity; the percentage receiving CDT was also higher for males, unmarried, and younger age, but decreased with increasing comorbidity and over calendar time. CONCLUSION Among lung cancer decedents observed in the outpatient, nonhospice setting, SMS receipt increased and was nearly universal as death approached. CDT diminished dramatically over the end-of-life period. Associations between sociodemographic characteristics and care setting suggest differences in care preferences or access barriers. Claims represent an important resource for characterizing end-of-life care patterns.
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Affiliation(s)
- Amy J Davidoff
- Department of Health Policy and Management, Yale School of Public Health, PO Box 208034, 60 College Street, New Haven, CT, 06520-8034, USA. .,Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA. .,Yale Cancer Center, New Haven, CT, USA.
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA
| | | | - Maureen Saphire
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Shi-Yi Wang
- Department of Health Policy and Management, Yale School of Public Health, PO Box 208034, 60 College Street, New Haven, CT, 06520-8034, USA.,Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Center, New Haven, CT, USA
| | - Carolyn J Presley
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, CT, USA.,The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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Cox CE, Olsen MK, Casarett D, Haines K, Al-Hegelan M, Bartz RR, Katz JN, Naglee C, Ashana D, Gilstrap D, Gu J, Parish A, Frear A, Krishnamaneni D, Corcoran A, Docherty SL. Operationalizing needs-focused palliative care for older adults in intensive care units: Design of and rationale for the PCplanner randomized clinical trial. Contemp Clin Trials 2020; 98:106163. [PMID: 33007442 DOI: 10.1016/j.cct.2020.106163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The number of older adults who receive life support in an intensive care unit (ICU), now 2 million per year, is increasing while survival remains unchanged. Because the quality of ICU-based palliative care is highly variable, we developed a mobile app intervention that integrates into the electronic health records (EHR) system called PCplanner (Palliative Care planner) with the goal of improving collaborative primary and specialist palliative care delivery in ICU settings. OBJECTIVE To describe the methods of a randomized clinical trial (RCT) being conducted to compare PCplanner vs. usual care. METHODS AND ANALYSIS The goal of this two-arm, parallel group mixed methods RCT is to determine the clinical impact of the PCplanner intervention on outcomes of interest to patients, family members, clinicians, and policymakers over a 3-month follow up period. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 1 week post-randomization. Secondary outcomes include goal concordance of care, patient-centeredness of care, and quality of communication at 1 week post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use general linear models for repeated measures to compare outcomes across the main effects and interactions of the factors. We hypothesize that compared to usual care, PCplanner will have a greater impact on the quality of ICU-based palliative care delivery across domains of core palliative care needs, psychological distress, patient-centeredness, and healthcare resource utilization.
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Affiliation(s)
- Christopher E Cox
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States of America.
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, United States of America.
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North, Carolina;, United States of America.
| | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Raquel R Bartz
- Department of Anesthesia, Division of Critical Care Medicine, Duke University, Durham, NC, United States of America.
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, United States of America.
| | - Colleen Naglee
- Department of Anesthesia, Division of Neurology, Duke University, Durham, NC, United States of America
| | - Deepshikha Ashana
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Daniel Gilstrap
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America.
| | - Allie Frear
- Department of Medicine, Division of Pulmonary & Critical Care Medicine and the Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, United States of America.
| | - Deepthi Krishnamaneni
- Duke Health Technology Solutions, Duke University, Durham, NC, United States of America.
| | - Andrew Corcoran
- Office of Academic Solutions and Information Systems, Duke University, Durham, NC, United States of America.
| | - Sharron L Docherty
- School of Nursing, Duke University, Durham, NC, United States of America.
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5
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Determining the Association Between End-of-Life Care Resources and Patient Outcomes in Pennsylvania ICUs. Crit Care Med 2020; 47:1591-1598. [PMID: 31464767 DOI: 10.1097/ccm.0000000000003969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES As ICUs are increasingly a site of end-of-life care, many have adopted end-of-life care resources. We sought to determine the association of such resources with outcomes of ICU patients. DESIGN Retrospective cohort study. SETTING Pennsylvania ICUs. PATIENTS Medicare fee-for-service beneficiaries. INTERVENTIONS Availability of any of one hospital-based resource (palliative care consultants) or four ICU-based resources (protocol for withdrawal of life-sustaining therapy, triggers for automated palliative care consultation, protocol for family meetings, and palliative care clinicians embedded in ICU rounds). MEASUREMENTS AND MAIN RESULTS In mixed-effects regression analyses, admission to a hospital with end-of-life resources was not associated with mortality, length of stay, or treatment intensity (mechanical ventilation, hemodialysis, tracheostomy, gastrostomy, artificial nutrition, or cardiopulmonary resuscitation); however, it was associated with a higher likelihood of discharge to hospice (odds ratio, 1.58; 95% CI, 1.11-2.24), an effect that was driven by ICU-based resources (odds ratio, 1.37; 95% CI, 1.04-1.81) rather than hospital-based resources (odds ratio, 1.19; 95% CI, 0.83-1.71). Instrumental variable analysis using differential distance (defined as the additional travel distance beyond the hospital closest to a patient's home needed to reach a hospital with end-of-life resources) demonstrated that among those for whom differential distance would influence receipt of end-of-life resources, admission to a hospital with such resources was not associated with any outcome. CONCLUSIONS ICU-based end-of-life care resources do not appear to change mortality but are associated with increased hospice utilization. Given that this finding was not confirmed by the instrumental variable analysis, future studies should attempt to verify this finding, and identify specific resources or processes of care that impact the care of ICU patients at the end of life.
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Saphire ML, Prsic EH, Canavan ME, Wang SYJ, Presley CJ, Davidoff AJ. Patterns of Symptom Management Medication Receipt at End-of-Life Among Medicare Beneficiaries With Lung Cancer. J Pain Symptom Manage 2020; 59:767-777.e1. [PMID: 31778783 PMCID: PMC7338983 DOI: 10.1016/j.jpainsymman.2019.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/26/2022]
Abstract
CONTEXT Older adults with advanced lung cancer experience high symptom burden at end of life (EOL), yet hospice enrollment often happens late or not at all. Receipt of medications to manage symptoms in the outpatient setting, outside the Medicare hospice benefit, has not been described. OBJECTIVES We examined patterns of symptom management medication receipt at EOL for older adults who died of lung cancer. METHODS This retrospective cohort used the Surveillance, Epidemiology, and End Results-Medicare database to identify decedents diagnosed with lung cancer at age 67 years and older between January 2008 and December 2013 who survived six months and greater after diagnosis. Using Medicare Part B and D claims, we identified monthly receipt of outpatient medications for symptomatic management of pain, emotional distress, fatigue, dyspnea, anorexia, and nausea/vomiting. Multivariable logistic regression estimated associations between medication receipt and patient demographic characteristics, comorbidity, and concurrent therapy. RESULTS Of the 16,246 included patients, large proportions received medications for dyspnea (70.7%), pain (62.5%), and emotional distress (49.4%), with lower prevalence for other symptoms. Medication receipt increased from six months to one month before death. Women and dual Medicaid enrolled were more likely to receive medications for pain, emotional distress, dyspnea, and nausea/vomiting. Receipt of symptom management medications decreased with increasing age and racial/ethnical minorities. CONCLUSION Symptom management medication receipt was common and increasing toward EOL. Lower use by males, older adults, and nonwhites may reflect poor access or poor patient-provider communication. Further research is needed to understand these patterns and assess adequacy of symptom management in the outpatient setting.
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Affiliation(s)
- Maureen L Saphire
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | | | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA
| | - Shi-Yi J Wang
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Public Health, New Haven, Connecticut, USA; Yale Cancer Center, New Haven, Connecticut, USA
| | - Carolyn J Presley
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA; Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, New Haven, Connecticut, USA; Yale School of Public Health, New Haven, Connecticut, USA; Yale Cancer Center, New Haven, Connecticut, USA.
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7
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Taylor R, Ellis J, Gao W, Searle L, Heaps K, Davies R, Hawksworth C, Garcia-Perez A, Colclough G, Walker S, Wee B. A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence. BMC Palliat Care 2020; 19:24. [PMID: 32103745 PMCID: PMC7045380 DOI: 10.1186/s12904-020-0526-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/12/2020] [Indexed: 11/26/2022] Open
Abstract
Background Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days. Methods Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category. Results A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed. Conclusions A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent. Trial registration N/A
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Affiliation(s)
| | | | - Wei Gao
- Cicely Saunders Institute, London, UK
| | | | | | - Robert Davies
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK.,Stgilesmedical GmbH, Berlin, Germany
| | - Claire Hawksworth
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | - Angela Garcia-Perez
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | | | - Steven Walker
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK. .,Stgilesmedical GmbH, Berlin, Germany.
| | - Bee Wee
- Harris Manchester College, University of Oxford, Oxford, UK.,Sir Michael Sobell House, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Wen Y, Jiang C, Koncicki HM, Horowitz CR, Cooper RS, Saha A, Coca SG, Nadkarni GN, Chan L. Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis. J Am Soc Nephrol 2019; 30:1687-1696. [PMID: 31387926 DOI: 10.1681/asn.2018121256] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. METHODS To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. RESULTS We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. CONCLUSIONS Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.
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Affiliation(s)
- Yumeng Wen
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Changchuan Jiang
- Department of Medicine, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, New York
| | - Holly M Koncicki
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Carol R Horowitz
- Department of Medicine, Mount Sinai Hospital, New York, New York.,Department of Population Health Science and Policy and
| | - Richard S Cooper
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Aparna Saha
- Department of Public Health Sciences, Loyola University, Maywood, Illinois
| | - Steven G Coca
- Division of Nephrology and.,Department of Medicine, Mount Sinai Hospital, New York, New York
| | - Girish N Nadkarni
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York.,Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Lili Chan
- Division of Nephrology and .,Department of Medicine, Mount Sinai Hospital, New York, New York
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Palliative Care Planner: A Pilot Study to Evaluate Acceptability and Usability of an Electronic Health Records System-integrated, Needs-targeted App Platform. Ann Am Thorac Soc 2019; 15:59-68. [PMID: 29121480 DOI: 10.1513/annalsats.201706-500oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The quality and patient-centeredness of intensive care unit (ICU)-based palliative care delivery is highly variable. OBJECTIVE To develop and pilot an app platform for clinicians and ICU patients and their family members that enhances the delivery of needs-targeted palliative care. METHODS In the development phase of the study, we developed an electronic health record (EHR) system-integrated mobile web app system prototype, PCplanner (Palliative Care Planner). PCplanner screens the EHR for ICU patients meeting any of five prompts (triggers) for palliative care consultation, allows families to report their unmet palliative care needs, and alerts clinicians to these needs. The evaluation phase included a prospective before/after study conducted at a large academic medical center. Two control populations were enrolled in the before period to serve as context for the intervention. First, 25 ICU patients who received palliative care consults served as patient-level controls. Second, 49 family members of ICU patients who received mechanical ventilation for at least 48 hours served as family-level controls. Afterward, 14 patients, 18 family members, and 10 clinicians participated in the intervention evaluation period. Family member outcomes measured at baseline and 4 days later included acceptability (Client Satisfaction Questionnaire [CSQ]), usability (Systems Usability Scale [SUS]), and palliative care needs, assessed with the adapted needs of social nature, existential concerns, symptoms, and therapeutic interaction (NEST) scale; the Patient-Centeredness of Care Scale (PCCS); and the Perceived Stress Scale (PSS). Patient outcomes included frequency of goal concordant treatment, hospital length of stay, and discharge disposition. RESULTS Family members reported high PCplanner acceptability (mean CSQ, 14.1 [SD, 1.4]) and usability (mean SUS, 21.1 [SD, 1.7]). PCplanner family member recipients experienced a 12.7-unit reduction in NEST score compared with a 3.4-unit increase among controls (P = 0.002), as well as improved mean scores on the PCCS (6.6 [SD, 5.8]) and the PSS (-0.8 [SD, 1.9]). The frequency of goal-concordant treatment increased over the course of the intervention (n = 14 [SD, 79%] vs. n = 18 [SD, 100%]). Compared with palliative care controls, intervention patients received palliative care consultation sooner (3.9 [SD, 2.7] vs. 6.9 [SD, 7.1] mean days), had a shorter mean hospital length of stay (20.5 [SD, 9.1] vs. 22.3 [SD, 16.0] patient number), and received hospice care more frequently (5 [36%] vs. 5 [20%]), although these differences were not statistically significant. CONCLUSIONS PCplanner represents an acceptable, usable, and clinically promising systems-based approach to delivering EHR-triggered, needs-targeted ICU-based palliative care within a standard clinical workflow. A clinical trial in a larger population is needed to evaluate its efficacy.
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Abstract
As the Medicare program struggles to control expenditures, there is increased focus on
opportunities to manage patient populations more efficiently and at a lower cost. A major
source of expense for the Medicare program is beneficiaries at end of life. Estimates of
the percentage of Medicare costs that arise from patients in the last year of life differ,
ranging from 13% to 25%, depending on methods and assumptions. We analyze the most
recently available Medicare Limited Data Set to update prior studies of end-of-life costs
and examine different methods of performing this calculation. Based upon these findings,
we conclude that higher estimates that take into account the spending over the 12 months
leading up to death more accurately reflect the full cost of a patient’s last year of
life. Comparing current year costs of decedents with Medicare’s current year costs
understates the full budgetary impact of end-of-life patients. Because risk-taking
entities such as Medicare Advantage plans and Accountable Care Organizations (ACOs) need
to reduce costs while improving the quality of care, they should initiate programs to
better manage the care of patients with serious or advanced illness. We also calculate
costs for beneficiaries dying in different settings and conclude that more effective use
of palliative care and hospice benefits offers a lower cost, higher quality alternative
for patients at end of life.
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Affiliation(s)
- Ian Duncan
- 1 Department of Statistics and Applied Probability, University of California, Santa Barbara, Santa Barbara, CA, USA
| | - Tamim Ahmed
- 2 Santa Barbara Actuaries Inc, Santa Barbara, CA, USA
| | - Henry Dove
- 3 Turn-Key Health, Philadelphia, PA, USA
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Liu X, Shen JJ, Kim P, Kim SJ, Ukken J, Choi Y, Hwang IC, Lee JH, Chun SY, Hwang J, Choi H, Yeom H, Lee YJ, Yoo JW. Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014. J Palliat Care 2019; 34:232-240. [PMID: 30767641 DOI: 10.1177/0825859719827313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. METHODS AND MATERIALS A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. RESULTS Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). CONCLUSIONS Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.
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Affiliation(s)
- Xibei Liu
- Department of Medicine, University of Arizona College of Medicine, Tuscon, AZ, USA
| | - Jay J Shen
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soon Chun Hyang University, Asan, Chungcheongnam-do, Korea
| | - Johnson Ukken
- University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Younseon Choi
- Department of Family Medicine, Korea University of College of Medicine, Seoul, Korea
| | - In Choel Hwang
- Department of Family Medicine, Gachon University College of Medicine, Inchon, Korea
| | - Jae-Hoon Lee
- Department of Family Medicine, University of Nevada, Las Vegas
| | - Sung-Youn Chun
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jinwook Hwang
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Haneul Choi
- Honors College, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hyeyoung Yeom
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Yong-Jae Lee
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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12
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Heller DR, Jean RA, Chiu AS, Feder SI, Kurbatov V, Cha C, Khan SA. Regional Differences in Palliative Care Utilization Among Geriatric Colorectal Cancer Patients Needing Emergent Surgery. J Gastrointest Surg 2019; 23:153-162. [PMID: 30328071 PMCID: PMC6751557 DOI: 10.1007/s11605-018-3929-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of palliative care (PC) in critical illness are validated across a range of diseases, yet it remains underutilized in surgical patients. This study analyzed patient and hospital factors predictive of PC utilization for elderly patients with colorectal cancer (CRC) requiring emergent surgery. METHODS The National Inpatient Sample was queried for patients aged ≥ 65 years admitted emergently with CRC from 2009 to 2014. Patients undergoing colectomy, enterectomy, or ostomy formation were included and stratified according to documentation of PC consultation during admission. Chi-squared testing identified unadjusted group differences, and multivariable logistic regression identified predictors of PC. RESULTS Of 86,573 discharges meeting inclusion criteria, only 3598 (4.2%) had PC consultation. Colectomy (86.6%) and ostomy formation (30.4%) accounted for the operative majority. PC frequency increased over time (2.9% in 2009 to 6.2% in 2014, P < 0.001) and was nearly twice as likely to occur in the West compared with the Northeast (5.7 vs. 3.3%, P < 0.001) and in not-for-profit compared with proprietary hospitals (4.5 vs. 2.3%, P < 0.001). PC patients were more likely to have metastases (60.1 vs. 39.9%, P < 0.001) and die during admission (41.5 vs. 6.4%, P < 0.001). On multivariable logistic regression, PC predictors (P < 0.05) included region outside the Northeast, increasing age, more recent year, and metastatic disease. CONCLUSIONS In the USA, PC consultation for geriatric patients with surgically managed complicated CRC is low. Regional variation appears to play an important role. With mounting evidence that PC improves quality of life and outcomes, understanding the barriers associated with its provision to surgical patients is paramount.
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Affiliation(s)
- Danielle R Heller
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Shelli I Feder
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, P.O. Box 208088, New Haven, CT, 06520-8088, USA
- US Department of Veterans Affairs, 950 Campbell Ave, West Haven, CT, 06516, USA
| | - Vadim Kurbatov
- Department of Surgery, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Charles Cha
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA
| | - Sajid A Khan
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, PO Box 208062, New Haven, CT, 06520-8062, USA.
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Hua M, Ma X, Morrison RS, Li G, Wunsch H. Association between the Availability of Hospital-based Palliative Care and Treatment Intensity for Critically Ill Patients. Ann Am Thorac Soc 2018; 15:1067-1074. [PMID: 29812967 PMCID: PMC6137683 DOI: 10.1513/annalsats.201711-872oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/29/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of nonbeneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown. OBJECTIVES To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients. METHODS Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice. RESULTS Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 d [interquartile range, 3-12] vs. 6 d [interquartile range, 3-11]; adjusted rate ratio, 1.04 [95% confidence interval 1.03-1.05]; P < 0.001), as were other healthcare use outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%; adjusted odds ratio, 1.46 [95% confidence interval 1.30-1.64]; P < 0.001). CONCLUSIONS The availability of hospital-based palliative care was not associated with differences in in-hospital treatment intensity, but it was associated with significantly increased hospice use for ICU patients. Currently, the measurable benefit of palliative care programs for critically ill patients may be the increased use of hospice facilities, as opposed to decreased healthcare use during an ICU-associated hospitalization.
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Affiliation(s)
- May Hua
- Department of Anesthesiology and
| | - Xiaoyue Ma
- Department of Anesthesiology and
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Guohua Li
- Department of Anesthesiology and
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Hannah Wunsch
- Department of Anesthesiology and
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; and
- Department of Anesthesia and
- Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals. J Palliat Care 2018; 33:159-166. [DOI: 10.1177/0825859718777375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.
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Khang PS, Wang SE, Liu ILA, Watson HL, Koyama SY, Huynh DN, Lee JS, Nguyen HQ. Impact of Inpatient Palliative Care on Quality of End-of-Life Care and Downstream Acute and Postacute Care Utilization. J Palliat Med 2018; 21:913-923. [PMID: 29649400 DOI: 10.1089/jpm.2017.0275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Additional evidence is needed regarding the impact of inpatient palliative care (IPC) on the quality of end-of-life care and downstream utilization. AIM Examine the effects of IPC on quality of end-of-life care and acute and postacute care use in a large integrated system. DESIGN Retrospective cohort design. SETTING/PARTICIPANTS Adult decedents from January 1, 2012, to December 31, 2014, who had at least one hospitalization at 11 Kaiser Permanente Southern California medical centers in the 12 months before death and not hospitalized for a trauma-related condition or receiving home-based PC or hospice were included in the cohort. MATERIALS AND METHODS Inverse probability of treatment weighting of propensity scores was used to compare outcomes between patients exposed to IPC (n = 3742) and controls (n = 12,755) who never received IPC before death. RESULTS Patients who received IPC were more likely to enroll in home-based PC or hospice (69% vs. 43%) and were less likely to die in a hospital (15% vs. 29%) or intensive care (2% vs. 9%) compared with controls (all, p < 0.001). IPC exposure was associated with higher risk for rehospitalization (HR: 1.18, 95% CI 1.11-1.25) and more frequent emergency department visits (RR: 1.16, 95% CI 1.07-1.26) with no increase in postacute care use compared with controls. Stratified analyses showed that IPC effects on acute care utilization were dependent on code status. CONCLUSION IPC exposure was associated with higher enrollment in home-based PC/hospice and more deaths at home. The increased acute care utilization by the IPC group may reflect persistent confounding by indication.
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Affiliation(s)
- Peter S Khang
- 1 Geriatric Palliative Care, Kaiser Permanente Southern California, Los Angeles Medical Center , Los Angeles, California
| | - Susan E Wang
- 2 Geriatric Palliative Care, Kaiser Permanente Southern California, West Los Angeles Medical Center , Los Angeles, California
| | - In-Lu Amy Liu
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Heather L Watson
- 4 Complete Care Programs, Kaiser Permanente Southern California , Pasadena, California
| | - Sandra Y Koyama
- 5 Internal Medicine, Kaiser Permanente Southern California , Baldwin Park, California
| | - Dan N Huynh
- 6 Hospital Medicine, Home Care Services, Kaiser Permanente Southern California , Pasadena, California
| | - Janet S Lee
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Huong Q Nguyen
- 3 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
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16
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Zhou K, Mao Y. Palliative care in heart failure : A meta-analysis of randomized controlled trials. Herz 2018; 44:440-444. [PMID: 29468259 DOI: 10.1007/s00059-017-4677-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/23/2017] [Accepted: 12/26/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Palliative care can play an important role in the management of heart failure. We conducted a systematic review and meta-analysis to compare the efficacy and safety of palliative care in patients with heart failure. METHODS PubMed, Embase, Web of Science, EBSCO, and the Cochrane Library databases were systematically searched. Randomized controlled trials (RCTs) on the impact of palliative care on heart failure were included. Two investigators independently searched the articles, extracted data, and assessed the quality of included studies. The primary outcome was mortality. RESULTS Seven RCTs were included in the meta-analysis. Compared with usual care for heart failure, palliative care was associated with a significantly increased quality of life (standardized mean difference = 1.46; 95% confidence interval [CI] = 0.12 to 2.79; p = 0.03) and reduced depression scores (standardized mean difference = -0.62; 95% CI = -0.99 to -0.25; p = 0.03), but demonstrated no impact on mortality (risk ratio [RR] = 1.28; 95% CI = 0.86 to 1.92; p = 0.22) and rehospitalization (RR = 0.84; 95% CI = 0.66 to 1.07; p = 0.16). CONCLUSION Palliative care can improve the quality of life and reduce the occurrence of depression in patients with heart failure.
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Affiliation(s)
- K Zhou
- Department Rehabilitation Medicine, Ningbo No. 2 Hospital, Ningbo, Zhejiang Province, China
| | - Y Mao
- Emergency Department, Ninghai First Hospital, Ninghai, Zhejiang Province, China.
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17
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Dzeng E, Dohan D, Curtis JR, Smith TJ, Colaianni A, Ritchie CS. Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life. J Pain Symptom Manage 2018; 55:282-289.e1. [PMID: 28865869 PMCID: PMC6329585 DOI: 10.1016/j.jpainsymman.2017.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
CONTEXT The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals. OBJECTIVE The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior. METHODS Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior. RESULTS The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes. CONCLUSION Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA.
| | - Daniel Dohan
- Institute of Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas J Smith
- Department of Oncology and Palliative Care, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Christine S Ritchie
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis. Palliat Support Care 2017; 15:741-752. [PMID: 28196551 DOI: 10.1017/s1478951516001164] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality. METHOD A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence. RESULTS Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively. SIGNIFICANCE OF RESULTS Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.
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Weissman DE. Are We Making a Difference? J Palliat Med 2017; 20:114. [DOI: 10.1089/jpm.2016.0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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