Evaluating causes for unplanned hospital readmissions of palliative care patients

Shared decision making with Oncologists and Palliative care specialists (SOP) model help advanced pancreatic cancer patients reaching goal concordant care: A prospective cohort study

BACKGROUND

Pancreatic cancer is often diagnosed at a late stage with a poor prognosis due to insidious symptoms and lack of evidence-based screening in general population. Palliative care's acceptance in Asian cultures is hindered by misconceptions and ineffective communication about management that improve quality of life other than cancer directed treatment. Our study aimed to determine the effect of the Shared decision-making with Oncologists and Palliative care specialists (SOP) model developed from the traditional shared decision-making (SDM) model on the palliative care acceptance rate and medical resource utilization.

METHODS

This is a prospective cohort study implementing the SOP model at the National Taiwan University Hospital from January 2018 to December 2019 for patients with advanced pancreatic cancer. Medical resource utilization was defined and recorded as the rate of hospitalization, emergency room (ER), and intensive care unit admissions. We compared the results between two groups: patients who received the SOP model in 2019 and patients who did not receive it in 2018.

RESULTS

137 patients with advanced pancreatic cancer were included in our study. The result showed that the acceptance rate of palliative care significantly increased from 50% to 78.69% after the SOP model (p = 0.01). The hospitalization rate did not show a significant difference between 2018 (93.42%, 95% CI: 0.88-0.99) and 2019 (93.44%, 95% CI: 0.87-1.00). 83.61% (95% CI: 0.74-0.93) of our patients in 2019 had at least one ER visit; the rate was 81.5% (95% CI: 0.73-0.91) in 2018 (p = 0.28). The percentage of patients admitted to the ICU increased from 3.95% in 2018 to 8.2% (95% CI: -0.05-0.08) in 2019 (95% CI: 0.11-0.15) (p = 0.00). The hospitalization and ER visit showed no statistically difference between 2 years.

CONCLUSIONS

The modified SOP model markedly augmented palliative care's acceptance of patients with advanced pancreatic cancer. Adoption of the SOP model would provide these patients a more proactive and systematic approach to deliver needed healthcare.

Supporting Carers as Patients Move between Hospital and Home: A Systematic Review of Interventions to Support These Transitions in Care

Background: Hospital-to-home transitions become more frequent and complex as people approach end of life. Although carers are critical to enabling these transitions, they report high levels of unmet need. A review of the interventions to assist these care transitions, along with understanding those intervention components and mechanisms that support carers of people with advanced illness, is required to inform an optimal care model for palliative care practice. Aim: To describe the characteristics and reporting quality of intervention studies aimed at improving hospital-to-home transitions for carers of people with advanced illness. Design: This is a systematic review with a narrative synthesis. (international prospective register of systematic reviews [PROSPERO] ID: CRD42020192088). Data Sources: MEDLINE, EMCare, and PsychINFO databases were searched (2000-2021) for prospective studies reporting on interventions that (1) aimed to improve hospital-to-home transitions and (2) targeted carers of people with advanced illness. The Template for Intervention Description and Replication (TIDieR) checklist and constructs of the Care Transition Framework were used to assess the reporting quality of intervention design, delivery, and outcomes. Results: In total, 37 articles were analyzed that included a range of study designs, interventions, and outcomes. Health care utilization (n = 29) and clinical patient-related (n = 21) measures were the most reported outcome. Theoretical discussion was minimal (n = 5) with most studies using efficacy data from past research to justify intervention choice. Conclusion: Carers are critical partners in hospital-to-home transitions at end of life; yet they are largely under-represented in intervention design, delivery, and outcomes. Improving the reporting quality of carer-focused care transition interventions will inform future study design and support translation into practice and policy.

Integration of Specialist Palliative Care into Tertiary Hospitals: A Multicenter Point Prevalence Survey from Thailand

Background: Accessibility and quality of hospital-based palliative care in Thailand have received scant attention. Objective: To determine the prevalence of inpatients who require in-hospital palliative care, to identify the proportion with access to specialist palliative care, and to define the factors associated with accessibility to specialist palliative care. Design: A cross-sectional analysis of a multicenter survey. Setting/Subjects: We surveyed all hospitalized patients from Thailand's four regions admitted to 14 tertiary care hospitals. Measurements: We used the Supportive and Palliative Care Indicators Tool to identify palliative care patients then reviewed their medical records. We categorized hospitalized palliative care patients into a palliative care consultation group and a nonconsultation group. The odds ratio (OR) between patient characteristics and patient groups was estimated using binary logistic regression. Results: One-fifth (18.7%) of hospitalized patients were palliative care patients, whereas only 17.3% received a specialist palliative care consult. Of these, one-third (28.4%) received advance care planning (ACP) documentation. One-quarter of patients in pain were not prescribed analgesics. The logistic regression analysis revealed that palliative care consultations were associated with patients >65 years (OR = 1.830, 95% confidence interval [CI]: 1.122-2.987), a cancer diagnosis (OR = 2.640, 95% CI: 1.478-4.718), strong opioids prescription (OR = 5.519, 95% CI: 3.217-9.469), and ACP documentation (OR = 50.149, 95% CI: 28.239-89.059). Conclusions: The prevalence of hospitalized palliative care patients in Thailand is comparable with that in developed countries; however, accessibility remains a significant gap, as specialist palliative care is associated with the quality of palliative care service.

Comparing the effect of a consult model versus an integrated palliative care and medical oncology co-rounding model on health care utilization in an acute hospital - an open-label stepped-wedge cluster-randomized trial

BACKGROUND

The benefit of specialist palliative care for cancer inpatients is established, but the best method to deliver specialist palliative care is unknown.

AIM

To compare a consult model versus a co-rounding model; both provide the same content of specialist palliative care to individual patients but differ in the level of integration between palliative care and oncology clinicians.

DESIGN

An open-label, cluster-randomized trial with stepped-wedge design. The primary outcome was hospital length of stay; secondary outcomes were 30-day readmissions and access to specialist palliative care. ClinicalTrials.gov number NCT03330509.

SETTING/PARTICIPANTS

Cancer patients admitted to the oncology inpatient service of an acute hospital in Singapore.

RESULTS

A total of 5681 admissions from December 2017 to July 2019 were included, of which 5295 involved stage 3-4 cancer and 1221 received specialist palliative care review. Admissions in the co-rounding model had a shorter hospital length of stay than those in the consult model by 0.70 days (95%CI -0.04 to 1.45, p = 0.065) for all admissions. In the sub-group of stage 3-4 cancer patients, the length of stay was 0.85 days shorter (95%CI 0.05-1.65, p = 0.038). In the sub-group of admissions that received specialist palliative care review, the length of stay was 2.62 days shorter (95%CI 0.63-4.61, p = 0.010). Hospital readmission within 30 days (OR1.03, 95%CI 0.79-1.35, p = 0.822) and access to specialist palliative care (OR1.19, 95%CI 0.90-1.58, p = 0.215) were similar between the consult and co-rounding models.

CONCLUSIONS

The co-rounding model was associated with a shorter hospital length of stay. Readmissions within 30 days and access to specialist palliative care were similar.

Inpatient Palliative Care Consult: A Marker for High Risk of Readmission or Death in Discharged Oncology Inpatients

BACKGROUND

Emergency department visits or readmission to hospital are common particularly among those with advanced illness. Little prospective data exist on early outcomes specifically for patients seen by a palliative care consult service during their acute care admission, who are subsequently discharged home.

METHODS

This study followed 62 oncology patients who had had a palliative care consult during their admission to acute care with weekly phone calls postdischarge for 4 weeks. Events recorded included death, readmission, emergency department visits, and admission to a palliative care unit.

RESULTS

By the end of the study, 32 (52%) of 62 had had at least 1 event, (readmission, emergency department visit, or death), with the majority of these occurring in the first 2 weeks postdischarge. The overall 4-week death rate was 14 (22.6%) of 62.

CONCLUSIONS

These data suggest that the need for a palliative care consult identifies inpatients at very high risk for early deterioration and underlines the critical importance of advance care planning/goals-of-care discussions by the oncology and palliative care teams to ensure patients and families understand their disease process and have the opportunity to direct their care decisions.

[Palliative care at home: patient care pathways and clinical characteristics]

INTRODUCTION

The great majority of French people express their desire to receive palliative care at home. The objective of this study was to describe the clinical care pathways and characteristics of patient receiving hospital at home palliative care.

METHODS

This study compared the care pathways and clinical characteristics of patients receiving palliative care at home in the Ile-de-France region in 2014. Retrospective data were extracted from the French medical information systems programme.

RESULTS

817 patients receiving palliative care at home were included in the study. They were older, more often referred to hospital at home by a primary care physician, had shorter lengths of stay and more often died at home compared to patients without palliative care. Palliative care patients mainly presented cancer and received frequent technical nursing care. The oldest patients (≥ 75 years old) more often presented neurodegenerative diseases, were less often transferred to hospital, and more often died at home compared to younger patients. A higher proportion of home deaths was observed in nursing home residents and patients who died at home required less technical nursing care.

CONCLUSION

This study provides important information concerning admission to hospital at home, the frequent changes of places of care and the complexity of maintaining palliative care at home until the patient's death.

Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital

BACKGROUND AND OBJECTIVES

Hospital readmission rates are increasingly used to assess quality. Little is known, however, about potential preventability of readmissions among children. Our objective was to evaluate potential preventability of 30-day readmissions using medical record review and interviews.

METHODS

A cross-sectional study in 305 children (<18 years old) readmitted within 30 days to a freestanding children's hospital between December 2012 and February 2013. Interviews (N = 1459) were conducted with parents/guardians, patients (if ≥13 years old), inpatient clinicians, and primary care providers. Reviewers evaluated medical records, interview summaries, and transcripts, and then rated potential preventability. Multivariate regression analysis was used to identify factors associated with potentially preventable readmission. Adjusted event curves were generated to model days to readmission.

RESULTS

Of readmissions, 29.5% were potentially preventable. Potentially preventable readmissions occurred sooner after discharge than non-potentially preventable readmissions (5 vs 9 median days; P < .001). The odds of a readmission being potentially preventable were greatest when the index admission and readmission were causally related (adjusted odds ratio [AOR]: 2.6; 95% confidence interval [CI]: 1.0-6.8) and when hospital (AOR: 16.3; 95% CI: 5.9-44.8) or patient (AOR: 7.1; 95% CI: 2.5-20.5) factors were identified. Interviews provided new information about the readmission in 31.2% of cases.

CONCLUSIONS

Nearly 30% of 30-day readmissions to a children's hospital may be potentially preventable. Hospital and patient factors are associated with potential preventability and may provide targets for quality improvement efforts. Interviews contribute important information and should be considered when evaluating readmissions.

Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care

Background:

Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission.

Methods:

We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes.

Results:

We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings.

Conclusion:

National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

Care trajectories and survival after discharge from specialized inpatient palliative care--results from an observational follow-up study

BACKGROUND

Little is known about the patients' individual care trajectories after discharge or transfer from inpatient palliative care units (PCU) to other care settings. This study aims to survey the further care trajectory and overall survival from the time of discharge of patients in a palliative care situation. Patient groups from either the PCU or the palliative care mobile support team (PCMT) are compared in order to analyze the demographic data, discharge settings, frequency of changes of care settings, overall survival from the time of discharge and place of death.

METHODS

In a mono-centre prospective observational study, patients discharged or transferred from a German inpatient PCU or from other hospital wards with support of the PCMT were invited to participate in this study. After discharge, the central care provider, such as inpatient hospices, nursing homes or general practitioners, was asked for information on the care trajectory and on readmissions to hospital in four weekly follow-up phone calls until the patients' death. Place of death and overall survival from the time of discharge were noted.

RESULTS

During the study period, 467 inpatients from the PCU and 554 inpatients from the PCMT were treated. Ultimately, 418 were discharged. Two hundred forty-five patients agreed to participate in the study, and the majority of them were either discharged home (60.8 %), to inpatient hospices (20.0 %) or to nursing homes (11.0 %). More than half of all of them (55.9 %) stayed continuously in their discharge setting. The remaining 44.1 % experienced a mean number of 3.1 ± 4.1 changes of care setting. Most frequently, patients changed their care setting from private home to hospital (N = 110; 32.4 %) and from hospital back to private home (N = 82; 24.4 %). Patients' mean overall survival from the time of discharge was 51.7 days (median 24.0 days, range 1-488 days). Most patients died in their private home (35.9 %), inpatient hospices (23.3 %) or inpatient PCUs (22.4 %).

CONCLUSIONS

The results show a high percentage of stable care trajectories at the end of life with few or no changes of care setting. To achieve this, well-considered discharge planning and an adequately chosen network of care providers are necessary.

Risk factors for potentially avoidable readmissions due to end-of-life care issues

BACKGROUND

Repeated hospitalizations are frequent toward the end of life, where each admission should be an opportunity to initiate advance-care planning to high-risk patients.

OBJECTIVE

To identify the risk factors for having a 30-day potentially avoidable readmission due to end-of-life care issues among all medical patients.

DESIGN

Nested case-control study.

SETTING/PATIENTS

All 10,275 consecutive discharges from any medical service of an academic tertiary medical center in Boston, Massachusetts between July 1, 2009 and June 30, 2010.

MEASUREMENTS

A random sample of all the potentially avoidable 30-day readmissions was independently reviewed by 9 trained physicians to identify the ones due to end-of-life issues.

RESULTS

Among 534, 30-day potentially avoidable readmission cases reviewed, 80 (15%) were due to an end-of-life care issue. In multivariable analysis, the following risk factors were significantly associated with a 30-day potentially avoidable readmission due to end-of-life care issues: number of admissions in the previous 12 months (odds ratio [OR]: 1.10 per admission, 95% confidence interval [CI]: 1.02-1.20), neoplasm (OR: 5.60, 95% CI: 2.85-10.98), opiate medications at discharge (OR: 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index (OR: 1.16 per 5-point increase, 95% CI: 1.10-1.22). The discrimination of the model (C statistic) was 0.85.

CONCLUSIONS

In a medical population, we identified 4 main risk factors that were significantly associated with 30-day potentially avoidable readmission due to end-of-life care issues, producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end-of-life care and possibly reduce unnecessary rehospitalizations.

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Background

Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.

Aims

(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.

Design

A mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.

Results

Of the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.

Conclusions

Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.

Funding

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

Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals

BACKGROUND

The requirement to meet the palliative needs of acute hospital populations has grown in recent years. With increasing numbers of frail older people needing hospital care as a result of both malignant and non-malignant conditions, emphasis is being placed upon understanding the physical, psychological and social burdens experienced by patients. This study explores the extent of burden in two large UK hospitals, focusing upon those patients who meet palliative care criteria. Furthermore, the paper explores the use of palliative services and identifies the most significant clinical diagnostic and demographic factors which determine physical and psychological burden.

METHODS

Two hospital surveys were undertaken to identify burden using the Sheffield Profile for Assessment and Referral to Care (SPARC). The Gold Standards Framework (GSF) is used to identify those patients meeting palliative care criteria. Participants were identified as being in-patients during a two-week data collection phase for each site. Data was gathered using face-to-face interviews or self-completion by patients or a proxy. Descriptive analyses highlight prevalence and use of palliative care provision. Binary logistic regression assesses clinical diagnostic predictor variables of physical and psychological burden.

RESULTS

The sample consisted of 514 patients and elevated physical, psychological and social burden is identified amongst those meeting palliative care criteria (n = 185). Tiredness (34.6%), pain (31.1%), weakness (28.8%) and psychological discomfort (low mood 19.9%; anxiety 16.1%) are noted as being prevalent. A small number of these participants accessed Specialist Palliative Care (8.2%). Dementia was identified as a predictor of physical (OR 3.94; p < .05) and psychological burden (OR 2.88; p < .05), being female was a predictor of psychological burden (OR 2.00; p < .05).

CONCLUSION

The paper highlights elevated levels of burden experienced by patients with palliative care requirements. Moreover, the paper also indicates that a large proportion of such patients are not in receipt of palliative approaches to their care. Furthermore, the paper identifies that those with non-malignant illnesses, especially dementia, may experience high levels of physical and psychological burden.