Longer Duration of Palliative Care in Patients With COPD Is Associated With Death Outside the Hospital

Characterizing patient portal use of people with cognitive impairment and potentially inappropriate medications

BACKGROUND

People with cognitive impairment commonly use central nervous system-active potentially inappropriate medications (CNS-PIM), increasing risk of adverse outcomes. Patient portals may be a promising tool for facilitating medication-related conversations. Little is known about portal use by this population related to medications.

OBJECTIVE

To target portal interventions, we sought to identify individuals with cognitive impairment and CNS-PIM exposure who discussed medications through the portal and to determine how frequently their messages described possible adverse effects.

METHODS

We used electronic health record (EHR) data from an academic health system in Maryland (Site 1) from 2017 to 2022 and pharmacy and EHR data from an integrated health system in Colorado (Site 2) in 2022 to identify people with cognitive impairment and CNS-PIM exposure who communicated about medications through the portal. At Site 1, message threads were manually categorized based on content. At Site 2, messages were categorized using natural language processing (NLP).

RESULTS

The Site 1 cohort included 5543 patients aged ≥65 with cognitive impairment and ≥2 outpatient visits from 2017 to 2022. Over half (n = 3072; 55%) had CNS-PIM prescriptions. Most with CNS-PIM prescriptions had portal use (n = 1987; 65%); 1320 (66%) of those patients sent messages during possible CNS-PIM exposure. Coding of a 5% random sample of message threads revealed that 3% mentioned CNS-PIM and possible adverse effects, while 8% mentioned possible adverse effects without referencing CNS-PIM. At Site 2, 4270 people had cognitive impairment and CNS-PIM exposure in 2022; of these, 1984 (46%) had portal use and 1768 (41%) sent medication-related messages during CNS-PIM exposure. NLP identified 663 (8%) messages that mentioned CNS-PIM and possible adverse effects, while 726 (41%) mentioned possible adverse effects without referencing CNS-PIM.

CONCLUSIONS

People with cognitive impairment and care partners frequently send portal messages about medications and possible adverse effects. Identifying such messages can help target deprescribing interventions.

Veterans' use of inpatient and outpatient palliative care: The national landscape

BACKGROUND

Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters).

METHODS

This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245).

RESULTS

Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64).

CONCLUSIONS

This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

Specialist Palliative Care Consultation for Patients with Nonmalignant Pulmonary Diseases: A Retrospective Study

Background

Few patients with chronic nonmalignant pulmonary diseases receive specialist palliative care consultation, despite their high symptom burden in end of life.

Objectives

To study palliative care decision making, survival, and hospital resource usage in patients with nonmalignant pulmonary diseases with or without a specialist palliative care consultation.

Methods

A retrospective chart review of all patients with a chronic nonmalignant pulmonary disease and a palliative care decision (palliative goal of therapy), who were treated in Tampere University Hospital, Finland, between January 1, 2018 and December 31, 2020.

Results

A total of 107 patients were included in the study, 62 (58%) had chronic obstructive pulmonary disease (COPD), and 43 (40%) interstitial lung disease (ILD). Median survival after palliative care decision was shorter in patients with ILD than in patients with COPD (59 vs. 213 days, p = 0.004). Involvement of a palliative care specialist in the decision making was not associated with the survival. Patients with COPD who received palliative care consultation visited less often emergency room (73% vs. 100%, p = 0.019) and spent fewer days in the hospital (7 vs. 18 days, p = 0.007) during the last year of life. When a palliative care specialist attended the decision making, the presence and opinions of the patients were recorded more often, and the patients were more frequently referred to a palliative care pathway.

Conclusions

Specialist palliative care consultation seems to enable better end-of-life care and supports shared decision making for patients with nonmalignant pulmonary diseases. Therefore, palliative care consultations should be utilized in nonmalignant pulmonary diseases preferably before the last days of life.

Palliative home care for older patients with respiratory disease in Japan: Practices and opinions of physicians

AIM

Older adults at the end-of-life stage receiving home visits from physicians often experience symptoms such as dyspnea, pain and fatigue, among others. This study aimed to investigate the practices and opinions of physicians providing home visits regarding palliative care for older adults with respiratory symptoms due to non-malignant diseases in Japan.

METHODS

A nationwide questionnaire survey on home palliative care for non-cancer chronic respiratory diseases was sent to 2988 home-care physicians in 2020 through postal mail and/or email. The questions focused on their background, their use of rating scales to evaluate the intensity of dyspnea, and their practices and opinions regarding home palliative care for respiratory diseases or symptoms.

RESULTS

Valid responses were collected from 592 physicians (19.8%). A total of 251 participants (43.1%) used a rating scale to evaluate the intensity of dyspnea. While 87.8%, 86.6%, 67.3%, and 60.0% of physicians considered pulmonary rehabilitation, morphine, sedative medications, and non-invasive positive pressure ventilation (NPPV), respectively, as effective in relieving respiratory distress, 73.0%, 66.9%, 57.3%, and 55.2% of those physicians, respectively, used each modality to relieve respiratory distress. Frequently involved physicians in the aforementioned care prescribed morphine or sedative medications and used NPPV more frequently.

CONCLUSIONS

This study found a discrepancy between the proportion of physicians who considered palliative care as effective and those who prescribed it. Geriatr Gerontol Int 2022; ••: ••-••.

The association between varying levels of palliative care involvement on costs during terminal hospitalizations in Canada from 2012 to 2015

Background

Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs.

Methods

Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital.

Results

There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement).

Conclusions

Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06335-1.

Referral criteria to palliative care for patients with respiratory disease: a systematic review

BACKGROUND

Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

AIM

To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

DESIGN

Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

RESULTS

Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.