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Earp MA, Fassbender K, King S, Douglas M, Biondo P, Brisebois A, Davison SN, Sia W, Wasylenko E, Esau L, Simon J. Association between Goals of Care Designation orders and health care resource use among seriously ill older adults in acute care: a multicentre prospective cohort study. CMAJ Open 2022; 10:E945-E955. [PMID: 36319025 PMCID: PMC9633054 DOI: 10.9778/cmajo.20210155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The Goals of Care Designation (GCD) is a medical order used to communicate the focus of a patient's care in Alberta, Canada. In this study, we aimed to determine the association between GCD type (resuscitative, medical or comfort) and resource use during hospitalization. METHODS This was a prospective cohort study of newly hospitalized inpatients in Alberta conducted from January to September 2017. Participants were aged 55 years or older with chronic obstructive pulmonary disease, congestive heart failure, cirrhosis, cancer or renal failure; aged 55-79 years and their provider answered "no" to the "surprise question" (i.e., provider would not be surprised if the patient died in the next 6 months); or aged 80 years or older with any acute condition. The exposure of interest was GCD. The primary outcome was health care resource use during admission, measured by length of stay (LOS), intensive care unit hours, Resource Intensity Weights (RIWs), flagged interventions and palliative care referral. The secondary outcome was 30-day readmission. Adjusted regression analyses were performed (adjusted for age, sex, race and ethnicity, Clinical Frailty Scale score, comorbidities and city). RESULTS We included 475 study participants. The median age was 83 (interquartile range 77-87) years, and 93.7% had a GCD at enrolment. Relative to patients with the resuscitative GCD type, patients with the medical GCD type had a longer LOS (1.42 times, 95% confidence interval [CI] 1.10-1.83) and a higher RIW (adjusted ratio 1.14, 95% CI 1.02-1.28). Patients with the comfort and medical GCD types had more palliative care referral (comfort GCD adjusted relative risk (RR) 9.32, 95% CI 4.32-20.08; medical GCD adjusted RR 3.58, 95% CI 1.75-7.33) but not flagged intervention use (comfort GCD adjusted RR 1.06, 95% CI 0.49-2.28; medical GCD adjusted RR 0.98, 95% CI 0.48-2.02) or 30-day readmission (comfort GCD adjusted RR 1.00, 95% CI 0.85-1.19; medical GCD adjusted RR 1.05, 95% CI 0.97-1.20). INTERPRETATION Goals of Care Designation type early during admission was associated with LOS, RIW and palliative care referral. This suggests an alignment between health resource use and the focus of care communicated by each GCD.
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Affiliation(s)
- Madalene A Earp
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Konrad Fassbender
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Seema King
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Maureen Douglas
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Patricia Biondo
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Amanda Brisebois
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Sara N Davison
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Winnie Sia
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Eric Wasylenko
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - LeAnn Esau
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta
| | - Jessica Simon
- Division of Palliative Medicine, Department of Oncology (Earp), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Fassbender), Grey Nuns Community Hospital, St. Marguerite Health Services Centre; Division of Palliative Care Medicine, Department of Oncology (Fassbender), University of Alberta, Edmonton, Alta.; Department of Community Health Sciences (King), Cumming School of Medicine, University of Calgary; Division of Palliative Medicine, Department of Oncology (Douglas), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Covenant Health Palliative Institute (Douglas), Grey Nuns Community Hospital, St. Marguerite Health Services Centre, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Biondo), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine and Oncology (Palliative Care) (Brisebois) and Department of Medicine (Davison, Sia), University of Alberta, Edmonton, Alta.; Division of Palliative Medicine, Department of Oncology (Wasylenko), Cumming School of Medicine, University of Calgary, Calgary, Alta.; John Dossetor Health Ethics Centre, Faculty of Medicine and Dentistry (Wasylenko), University of Alberta, Edmonton, Alta.; Alberta Health Services, South Zone Seniors Health Integrated Home Care/Palliative Care (Esau), Edmonton, Alta.; Departments of Oncology, Medicine and Community Health Sciences (Simon), University of Calgary, Calgary, Alta.
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