Mapping the future for research in emergency medicine palliative care: A research roadmap

Characteristics of patients enrolled in hospice presenting to the emergency department

OBJECTIVES

Emergency Departments (EDs) frequently care for patients with life-limiting illnesses, with nearly 1 in 5 patients enrolled in hospice presenting to an ED during their hospice enrollment. This study investigates the reasons patients enrolled in hospice seek care in the ED, the interventions they receive, and their outcomes.

METHODS

Multicenter, retrospective cohort study of patients enrolled in hospice who presented to an ED within a health system between 2018 and 2023. Descriptive analysis included patient characteristics, chief complaint, interventions, disposition, ED return visits and mortality. Comparisons were made via logistic regression between patients with a hospice enrollment diagnosis of cancer vs non-cancer diagnosis, patients enrolled in hospice for <30 days vs those enrolled for ≥30 days, and patients admitted to the hospital compared with patients not admitted.

RESULTS

A total of 119 ED visits by patients enrolled in hospice were identified. Patient median age was 85 (IQR: 68-92) years, 38 % were female, and 86 % were White. Hospice diagnoses included cancer (31 %), heart disease (21 %), lung disease (13 %), and dementia (13 %). At the time of ED visit, patients were enrolled in hospice for a median of 71 (IQR: 17-162) days. Patients primarily presented via emergency medical services (EMS) (76 %) from a home residence (51 %). The most common reasons for ED visit were trauma (36 %), pain (15 %) and catheter/tube malfunction (12 %). Most patients received laboratory studies (60 %), medications (66 %) and imaging (64 %). A total of 45 % were admitted to the hospital, with 2 % expiring in the ED. Patients admitted to the hospital were more likely to be receiving hospice services at home (66 % vs. 34 %, p = 0.003). Seven-day mortality was 20 % and 30-day mortality was 38 %. Ten percent returned to the ED within 7 days and 17 % within 30 days. Patients enrolled in hospice for ≥30 days were less likely to return (30 % vs. 51 %, OR 0.26, 95 % CI 0.075-0.94) or die (30 % vs 51 %, OR 0.40, 95 % CI 0.19-0.87) within 30 days compared to those enrolled for <30 days. Patients with a hospice diagnosis of cancer were more likely to die within 7 days (32 % vs 15 %, OR 2.78, 95 % CI 1.11-7.04) compared to patients with a non-cancer hospice diagnosis. In addition, those with a cancer hospice diagnosis (62 % vs 27 %, OR 4.48, 95 % CI 1.96-10.22) and those admitted to the hospital (48 % vs 16 %, OR 2.38, 95 % CI 1.11-5.11) were more likely to die at 30 days than those with a non-cancer enrollment diagnosis or those not admitted, respectively.

CONCLUSION

Patients enrolled in hospice most frequently presented to the ED for trauma. Most received laboratory studies and imaging. Nearly half of patients were admitted to the hospital and short-term mortality was high, particularly for patients enrolled in hospice for <30 days, enrolled with a hospice diagnosis of cancer, or admitted to the hospital. Understanding the care patients enrolled in hospice receive in the ED can help prevent avoidable visits and ensure care aligns with patients' goals.

End-of-life emergency department use and healthcare expenditures among older adults: A nationally representative study

BACKGROUND

Emergency department (ED) visits at end-of-life may cause financial strain and serve as a marker of inadequate access to community services and health care. We sought to examine end-of-life ED use, total healthcare spending, and out-of-pocket spending in a nationally representative sample.

METHODS

Using Medicare Current Beneficiary Survey data, we conducted a pooled cross-sectional analysis of Medicare beneficiaries aged 65+ years with a date of death between July 1, 2015 and December 31, 2021. Our primary outcomes were ED visits, total healthcare spending, and out-of-pocket spending in the 7, 30, 90, and 180 days preceding death. We estimated a series of zero-inflated negative binomial models identifying patient characteristics associated with the primary outcomes.

RESULTS

Among 3812 older adult decedents, 610 (16%), 1207 (31.7%), 1582 (41.5%), and 1787 (46.9%) Medicare beneficiaries had ED visits in the final 7, 30, 90, and 180 days, respectively, of life. For Medicare beneficiaries with at least one ED visit in the final 30 days of life, the median total and out-of-pocket costs were, respectively, $12,500 and $308, compared, respectively, with $278 and $94 for those without any ED visits (p < 0.001 for both comparisons). Having a diagnosis of dementia (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.51-0.99; p = 0.04) and being on hospice status during the year of death (OR 0.56; 95% CI 0.48-0.66; p = <0.001) were associated with a decreased likelihood of having an ED visit. Having dementia was associated with a decreased likelihood of having any healthcare spending (OR 0.50; 95% CI 0.36-0.71; p = 0.001) and any out-of-pocket spending (OR 0.51; 95% CI 0.36-0.72; p = <0.001).

CONCLUSIONS

One in three older adults visit the ED in the last month of life, and approximately one in two utilize ED services in the last half-year of life, with evidence of associated considerable total and out-of-pocket spending.

Identifying emergency department patients with life-limiting illnesses may be getting a little easier

This editorial comments on the article by Haimovich et al. in this issue.

Emergency Department Embedded Palliative Care Service Creates Value for Health Systems

Background: Emergency department (ED)-initiated palliative care consultation facilitates goal-concordant care while stewarding resource utilization. Delivery models are being piloted without clear operational and financial sustainability. Objective: To demonstrate that embedding a palliative care consultation service in the ED is clinically meaningful, operationally viable, and yields significant return on investment (ROI). Methods: Quasi-experimental study from August 17, 2020 to August 17, 2021. We established an ED-embedded palliative care consultation service at a 350-bed urban community hospital with 45,000 annual ED visits. A singe palliative care provider stationed in the main ED workstation area from 11 am to 7 pm daily. Matched analysis compared ED-embedded consultations against Floor and intensive care unit (ICU) consultations originating from usual practice. Results: ED consultations increased 10x, without cannibalization, to become the hospital's primary source of palliative care consultations. Clinical outcomes were meaningful, with 49% changing code status, 11% admitting to lower level of care, 11% avoiding hospitalization, 17% newly referred to hospice, and 21% newly referred to palliative care clinic. ED length of stay (LOS) did not lengthen, and ED staff strongly agreed that the service was valuable and unobtrusive. Compared with Floor, ED consultations had 8.1 days shorter hospital LOS (3.0 vs. 11.1 days, p < 0.01) with $5,974 lower median direct costs for index hospitalization ($6,211 vs. $12,005, p < 0.01). Compared with ICU, ED consultations had 4.2 days shorter hospital LOS (3.0 vs. 7.2 days, p < 0.01) with $9,332 lower median direct costs for index hospitalization ($14,093 vs. $23,425, p < 0.01). ROI was 6.7x net of foregone revenue and labor expenses. Conclusions and Relevance: This ED-embedded palliative care consultation service was clinically meaningful, operationally viable, and delivered a 6.7x ROI. ED-palliative partnerships present a quadruple aim opportunity to improve care for seriously ill patients.