scholarly journals Goals-of-Care Consult and Future Costs, Acute Care and Hospice Use in Matched Cohorts of African Americans and Whites

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 521-521
Author(s):  
Lauren Starr ◽  
Connie Ulrich ◽  
Scott Appel ◽  
Paul Junker ◽  
Nina O’Connor ◽  
...  
Keyword(s):  
African Americans ◽  
End Of Life ◽  
Acute Care ◽  
Secondary Analysis ◽  
Care Utilization ◽  
Goals Of Care ◽  
Palliative Care Consultation ◽  
Significant Difference ◽  
Hospice Use ◽  
Care Costs

Abstract African Americans receive less hospice care and more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care (“PCC”) is associated with future acute care utilization and costs, or hospice use, by race. To compare future acute care costs and utilization and discharge to hospice between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC, we conducted a secondary analysis of 35,154 seriously-ill African American and White adults who had PCC at a high-acuity hospital and were discharged 2014-2016. We found no significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, P=0.09), 30-day readmissions (P=0.58), future hospital days (P=0.34), future ICU admission (P=0.25), or future ICU days (P=0.30), but found greater discharge to hospice among African Americans with PCC (36.5% vs. 2.4%, P<0.0001). We found significant differences between Whites with PCC vs. without PCC in mean future acute care costs ($8,095 vs. $16,799, P<0.001), 30-day readmissions (10.2% vs. 16.7%, P<0.0001), future days hospitalized (3.7 vs. 6.3 days, P<0.0001), and discharge to hospice (42.7% vs. 3.0%, P<0.0001). Results suggest PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans; and increases discharge to hospice in both races (15-fold in African Americans, 14-fold in Whites). Research is needed to understand how PCC supports end-of-life decision-making and hospice use across races and how systems and policies can enable effective goals-of-care consultations across settings.

Palliative Care Consultation for Goals of Care and Future Acute Care Costs: A Propensity-Matched Study

2017 ◽  
Vol 35 (7) ◽  
pp. 966-971 ◽  
Author(s):  
Nina R. O’Connor ◽  
Paul Junker ◽  
Scott M. Appel ◽  
Robert L. Stetson ◽  
Jeffrey Rohrbach ◽  
...  
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Acute Care ◽  
Care Utilization ◽  
Goals Of Care ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Care Costs

Background: Hospitals are under increasing pressure to manage costs across multiple episodes of care. Most studies of the financial impact of palliative care have focused on costs during a single hospitalization. Objective: To compare future acute health-care costs and utilization between patients who received inpatient palliative care consultation for goals of care (Palliative Care Service [PCS]) and a propensity-matched cohort of patients who did not receive palliative care consultation (non-PCS) in a single academic medical center. Methods: Data were extracted from the hospital’s electronic records for admissions and discharges between July 2014 and October 2016. A stratified propensity score matching was used to account for nonrandom assignment and potential inherent differences between PCS and non-PCS groups using variables of theoretical interest: age, gender, race, diagnosis, risk of mortality, and prior acute care costs. Results: The analytical sample for this study included 41 363 patients (PCS = 1853; non-PCS = 39 510). Future acute care costs were significantly higher in the non-PCS group after propensity score matching (highest tier = US$15 654 vs US$8831; second highest tier = US$12 200 vs US$5496; P = .0001). The non-PCS group also had significantly higher future acute care utilization across all propensity tiers and outcomes including 30-day readmission ( P = .0001), number of future hospital days ( P = .0001), and number of future intensive care unit days ( P = .0001). Conclusion: Palliative care consultations for goals of care may decrease future health-care utilization with cost savings that persist into future hospitalizations.

scholarly journals Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma

2017 ◽  
Vol 13 (3) ◽  
pp. e197-e206 ◽  
Author(s):  
Hanna K. Sanoff ◽  
YunKyung Chang ◽  
Melissa Reimers ◽  
Jennifer L. Lund
Keyword(s):  
Hepatocellular Carcinoma ◽  
End Of Life ◽  
Acute Care ◽  
Symptom Burden ◽  
Health Care Use ◽  
Care Utilization ◽  
Hospital Death ◽  
Medicare Beneficiaries ◽  
Care Needs ◽  
Hospice Use

Introduction: Hepatocellular carcinoma (HCC) is a poor-prognosis cancer with a high symptom burden. Multidisciplinary HCC care is complex and unique in cancer medicine. We sought to determine whether the distinct process affects hospice use and how hospice affects end-of-life acute care utilization. Patients and Methods: Patients dying after HCC diagnosed from 2004 to 2011 were identified within SEER-Medicare. Hospice use and associated factors were described using logistic regression. Coarse exact and propensity score matching created groups of hospice and nonhospice comparators balanced on clinical characteristics. Health care use from first hospice claim to death and the matched duration in the nonhospice group were compared. Results: Of 7,992 decedent patients with HCC, 63% used hospice before death, with a median duration of 18 days (interquartile range, 5-51 days). Initial treatment with surgery and ablation (odds ratio [OR], 0.63; 95% CI, 0.53 to 0.74) or chemoembolization/radioembolization (OR, 0.71; 95% CI, 0.62 to 0.80) was associated with decreased odds of subsequent hospice use compared with untreated patients. Hospice use was more likely in those consulting hematology/oncology (OR, 1.33; 95% CI, 1.13 to 1.56) but not in those consulting gastroenterology (OR, 0.79; 95% CI, 0.65 to 0.95). Hospice patients had lower rates of hospitalization (7.9% v 47.8%; risk ratio [RR], 0.16; 95% CI, 0.14 to 0.19), intensive care unit stay (2.8% v 25.3%; RR, 0.11; 95% CI, 0.09 to 0.14), and in-hospital death (3.5% v 58.4%; RR, 0.06; 95% CI, 0.05 to 0.07). Conclusion: Processes of care influence which patients with HCC are referred to hospice. Hospice use has a marked effect on acute care use at the end of life in patients with HCC. Efforts to incorporate cancer-focused palliative care might improve the quality of end-of-life care in HCC.

scholarly journals Effect of Psychiatric Illness on Acute Care Utilization at End of Life From Serious Medical Illness

2017 ◽  
Vol 54 (2) ◽  
pp. 176-185.e1 ◽  
Author(s):  
Kyle Lavin ◽  
Dimitry S. Davydow ◽  
Lois Downey ◽  
Ruth A. Engelberg ◽  
Ben Dunlap ◽  
...  
Keyword(s):  
End Of Life ◽  
Acute Care ◽  
Psychiatric Illness ◽  
Care Utilization ◽  
Medical Illness ◽  
Acute Care Utilization

Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning

2018 ◽  
Vol 36 (2) ◽  
pp. 97-104 ◽  
Author(s):  
Signe Peterson Flieger ◽  
Erica Spatz ◽  
Emily J. Cherlin ◽  
Leslie A. Curry
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
End Of Life ◽  
Advance Care Planning ◽  
Secondary Analysis ◽  
Care Quality ◽  
Care Planning ◽  
Goals Of Care ◽  
Patient Goals ◽  
Advance Care

Background: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. Objective: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. Methods: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Results: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Conclusions: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

scholarly journals Goals of care discussions for patients with blood cancers: Association of person, place, and time with end‐of‐life care utilization

Cancer ◽  
2019 ◽  
Vol 126 (3) ◽  
pp. 515-522 ◽  
Author(s):  
Oreofe O. Odejide ◽  
Hajime Uno ◽  
Anays Murillo ◽  
James A. Tulsky ◽  
Gregory A. Abel
Keyword(s):  
End Of Life ◽  
End Of Life Care ◽  
Care Utilization ◽  
Life Care ◽  
Goals Of Care

scholarly journals Describing the characteristics and healthcare use of high-cost acute care users at the end of life: a pan-Canadian population-based study

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Danial Qureshi ◽  
Sarina Isenberg ◽  
Peter Tanuseputro ◽  
Rahim Moineddin ◽  
Kieran Quinn ◽  
...  
Keyword(s):  
End Of Life ◽  
Acute Care ◽  
Significant Proportion ◽  
Population Based ◽  
Fiscal Year ◽  
Healthcare Use ◽  
Population Based Study ◽  
Canadian Population ◽  
Alternate Level Of Care ◽  
Care Costs

Abstract Background A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada. Methods We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC). Results We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs. Conclusions High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 80-80
Author(s):  
Mohammad Omar Atiq ◽  
Rahul Ravilla ◽  
Ajay Kumar ◽  
Sajjad Haider ◽  
Ji-Ling Tang ◽  
...  
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
End Of Life ◽  
Cancer Patients ◽  
Stage Iv ◽  
Goals Of Care ◽  
Significant Difference ◽  
Aggressive Care ◽  
Stage Iv Cancer ◽  
End Stage

80 Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]

Health care coach support in reducing acute care use in patients with cancer.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 4-4
Author(s):  
Manali I. Patel ◽  
Kim Smith ◽  
Etsegenet Sisay ◽  
David J. Park
Keyword(s):  
Palliative Care ◽  
Acute Care ◽  
Cancer Care ◽  
Emergency Department Visits ◽  
Control Group ◽  
Goals Of Care ◽  
Risk Of Death ◽  
Community Oncology ◽  
Hospice Use

4 Background: Lay health workers (LHWs) who are trained to proactively discuss goals of care and assess patient symptoms have improved value-based cancer care among Veterans and a Medicare Advantage population. Little data exists regarding the effect of integrating LHWs into community oncology care among commercially insured populations. In this study, we implemented an LHW intervention to assist with goals of care and symptom management in collaboration with a private community oncology practice among patients with advanced cancer. This randomized controlled trial evaluates the effect of the intervention on acute care use and secondarily on goals of care documentation and patient satisfaction. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies were randomized from 8/11/2016 through 6/5/2019 into the intervention and control groups. All patients were followed for 12 months or death, whichever was first. Patients reported satisfaction with care using the Consumer Assessment of Healthcare Providers and Systems survey at time of enrollment and 9 months follow-up. We compared risk of death using Cox Models and compared rates of acute care, palliative care and hospice use using generalized models adjusted for length of follow-up. Results: A total of 104 patients were randomized with 52 in the intervention and 52 in the control. In both groups, the mean age was 67 years; 70% were non-Hispanic white, 25% Asian Pacific Islander, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no differences in cancer diagnoses or stages. There were no differences in rates of survival between the two groups. Intervention patients as compared to the control had lower mean emergency department visits (0.80 +/- 0.17 versus 1.9 +/- 0.46, p = 0.02) and hospitalizations (0.67 +/- 0.19 versus 1.49 +/- 0.37, p = 0.04), greater rates of goals of care documentation (92% versus 33% p = 0.002) and no differences in palliative care (88% versus 77% p = 0.16) or hospice use (27% versus 21% p = 0.45). At 9 months follow-up as compared to baseline, patients in the intervention experienced greater improvements in satisfaction with their care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p < 0.001). Conclusions: An LHW intervention significantly reduced acute care use and improved patient experiences with cancer care as compared to a control group. This intervention may be a solution to improve care delivery and experiences for patients after a diagnosis of cancer in community oncology settings. Clinical trial information: NCT03154190 .

scholarly journals Patient Risk Factor Profiles Associated With Timing of Goals-of-Care Consultation Before Death

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 831-832
Author(s):  
Lauren Starr ◽  
Connie Ulrich ◽  
Paul Junker ◽  
Liming Huang ◽  
Nina O’Connor ◽  
...  
Keyword(s):  
Risk Factor ◽  
Age Groups ◽  
Secondary Analysis ◽  
Regression Tree ◽  
Classification And Regression Tree ◽  
Goals Of Care ◽  
Early Palliative Care ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Seriously Ill

Abstract Early palliative care consultation to discuss goals-of-care (“PCC”) benefits seriously ill patients. To identify risk factor profiles associated with inpatient PCC timing before death, we conducted a secondary analysis of seriously ill adults who had PCC at a high-acuity hospital and died 2014-2016. Of 1,141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15-60 days before death; 21% had PCC &gt;60 days before death (median 13 days). Classification and Regression Tree modeling showed Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%) were most likely to have PCC close to death, with age &lt;46 or &gt;75 increasing probability (98%). Among age groups, the highest proportion of patients with PCC close to death was &gt;75 years. Complex variable interactions associated with PCC timing suggests we need a systematic process for initiating PCC earlier and effective primary palliative training for providers across settings.

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