scholarly journals Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

2021 ◽  
pp. 026921632110020
Author(s):  
Kieran L Quinn ◽  
Amy T Hsu ◽  
Christopher Meaney ◽  
Danial Qureshi ◽  
Peter Tanuseputro ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Major Surgery ◽  
Life Care ◽  
Healthcare Use ◽  
National Cohort ◽  
Acute Healthcare ◽  
Invasive Intervention

Background: Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. Aim: The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. Settings and participants: We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person’s hospitalization in which they died. Results: Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. Conclusions: Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

End of life in hospitalised prisoners: a group comparison of palliative medicine and hospital use

2021 ◽  
pp. bmjspcare-2020-002703
Author(s):  
Stacey Panozzo ◽  
Tamsin Bryan ◽  
David Marco ◽  
Anna Collins ◽  
Carrie Lethborg ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Public Hospital ◽  
Prison Population ◽  
Care Hospital ◽  
Life Care ◽  
Comparator Group ◽  
Population Demographic

BackgroundProviding optimal palliative and end-of-life care for people in prison with advanced progressive disease is a growing challenge. This study aimed to examine hospital and palliative care utilisation for people in prison who are hospitalised during the final 3 months of life and to compare with a disease-matched non-incarcerated patient cohort.MethodsA retrospective cohort study of people in prison who died between 2009 and 2019 in an Australian public hospital that provides tertiary-level healthcare for 18% of Australia’s prison population. Demographic, clinical and service use data were extracted from medical records of eligible patients experiencing incarceration (prison group) and a disease-matched, non-incarcerated patient comparator group (comparator group).ResultsAt the time of death, patients in the prison group were aged a median of 20 years younger than the comparator group (median age 58 vs 78 years, p<0.01). The prison group experienced more than double the mean length of acute care hospital stay at the end of life. A higher proportion of patients in the prison group experienced an intensive care unit episode (22% vs 12%). More than two-thirds (71%) of the prison group patients were seen by palliative care prior to death, similar to the comparator group (p=0.44). Those transferred to the palliative care unit had a shorter length of stay and were admitted later, just prior to death (median 5 vs 8 days).ConclusionsPeople in prison have prolonged acute care public hospital stays and are more likely to experience escalation of care at the end of life. Future opportunity may exist for increased access to formal subacute care settings for people in prison with life-limiting illness to receive optimal palliative and end-of-life care.

A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities

2011 ◽  
Vol 35 (3) ◽  
pp. 350 ◽  
Author(s):  
Liz Reymond ◽  
Fiona J. Israel ◽  
Margaret A. Charles
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Care Pathway ◽  
Aged Care ◽  
Residential Aged Care ◽  
Life Care ◽  
Care Facilities ◽  
Aged Care Facilities

The objective of this study was to develop, implement and evaluate an end-of-life (terminal) care pathway and associated infrastructure suitable for Australian residential aged care facilities that improves resident and health system outcomes. The residential aged care end-of-life care pathway was developed by a multidisciplinary collaboration of government and non-government professionals and incorporated best clinical management for dying residents to guide care and increase palliative care capacity of generalist staff. Implementation included identifying and up-skilling Link Nurses to champion the pathway, networking facilities with specialist palliative care services, delivering education to generalists and commencing a Palliative Care Medication Imprest System in each facility. The primary outcome measure for evaluation was transfer to hospital; secondary measures included staff perceived changes in quality of palliative care provided and family satisfaction with care. Results indicated that the pathway, delivered within a care framework that guides provision of palliative care, resulted in improved resident outcomes and decreased inappropriate transfers to acute care settings. What is known about the topic? Residential aged care facilities (RACFs) are the hospices of today. Many RACF staff are not confident in the delivery of high quality palliative care, resulting in inappropriate transfers of dying residents to acute care facilities. Needs-based palliative care pathways are being used increasingly to direct care in a variety of healthcare environments. What does this paper add? Provides the first evidence in Australia that a residential aged care end-of-life care pathway (RAC EoLCP) improves outcomes of care for dying residents and results in fewer residents being inappropriately transferred to acute care facilities. What are the implications for practitioners? Use of the RAC EoLCP will improve resident and health system outcomes by guiding the delivery of high quality palliative care and improving the palliative care capacity of generalist health providers.

The effect of a lay health worker intervention on acute care use, patient experiences and end-of-life care: Results from a randomized clinical trial.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 1508-1508
Author(s):  
Manali I. Patel ◽  
Kim Smith ◽  
Sana Khateeb ◽  
David J. Park
Keyword(s):  
Clinical Trial ◽  
Emergency Department ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Patient Experiences ◽  
Life Care ◽  
Healthcare Use ◽  
Goals Of Care

1508 Background: Previously, among Veterans with cancer, lay health workers (LHWs) trained to discuss patients’ goals of care reduced acute care use, improved patient experiences and reduced total costs of care at the end-of-life. Among Medicare-Advantage beneficiaries with cancer, LHWs trained to proactively assess patient symptoms reduced symptom burden, acute care use and total costs of care. It is unknown whether LHWs can assist with both goals of care and symptom assessments in community settings. The objective of this randomized clinical trial was to determine the effect of a LHW-led goals of care and symptom assessment intervention on acute care use and secondarily goals of care documentation, satisfaction and end-of-life healthcare use among patients with advanced cancer in a community practice. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies who planned to receive care at the oncology practice were randomized from 8/11/2016 through 2/5/2020 into intervention and control groups. Patients completed validated satisfaction surveys at randomization and 9 months follow-up and were followed for 12 months. We compared risk of death using Cox Models, healthcare use and satisfaction using generalized regression models adjusted for length of follow-up. Results: 128 patients were randomized; 64 in the intervention and 64 in the control. The mean age was 67 years; 22% identified as Hispanic/Latino; 57% White, 30% Asian Pacific Islander, 8% Black or African American, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no survival differences. Intervention patients were less likely to utilize the emergency department (OR: 0.35; 95% CI 0.17-0.72) and hospital (OR: 0.48; 95% CI 0.23-0.98) and had lower mean emergency department visits (1.05 +/- 1.74 versus 1.84 +/- 2.55, p = 0.04) and hospitalizations per year (0.63 +/- 1.28 versus 1.26 +/- 2.23, p = 0.04) as compared to control patients. More intervention patients had their goals of care documented (94% versus 52% p < 0.001) and used hospice (35% versus 14% p = 0.004) as compared to control patients. There were no differences in palliative care use (89% versus 77% p = 0.09). At 9 months follow-up as compared to baseline, intervention patients experienced greater improvements in satisfaction with care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p < 0.001). Among 30 patients who died (n = 16 intervention; n = 16 control), more patients in the intervention used hospice (81% versus 43%) and fewer used acute care in the last month (37% versus 81%, p = 0.012) than in the control. Conclusions: An LHW intervention reduced acute care use among patients with cancer, improved patient experiences and end-of-life care. This intervention may be a scalable approach to improve care delivery and experiences for patients after a diagnosis of cancer. Clinical trial information: NCT03154190.

Enhancing Care for Long-Term Care Residents Approaching End-of-Life: A Mixed-Methods Study Assessing a Palliative Care Transfer Form

2020 ◽  
pp. 104990912097664
Author(s):  
Madelaine Baetz-Dougan ◽  
Leora Reiter ◽  
Laura Quigley ◽  
Daphna Grossman
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Long Term Care ◽  
Transitions Of Care ◽  
Life Care ◽  
Term Care ◽  
Major Barrier

Background: Many barriers exist in providing quality end-of-life care in long-term care (LTC), including transitions of care between acute care and LTC. Transfer forms can be beneficial in ensuring resident’s end-of-life care needs are coordinated between different settings. The NYGH-LTC Transfer Form is a newly developed tool created to enhance care for residents transferred from acute care back to their LTC home for end-of-life. Study Aim: Assess the perceived ease of use, usefulness, and care-enhancing potential of the NYGH-LTC Transfer Form by interprofessional LTC staff. Methods: The study population included interprofessional staff members at 2 LTC homes in Toronto, Canada. Quantitative data was obtained through surveys and qualitative data was obtained through focus groups. Results: There were a total of 34 participants. 79.4% of participants agreed the form was easy to use and 82.4% agreed it would improve care. Subgroup analysis demonstrated that participants with greater than 20 years experience were less likely to agree that it would improve care (p = 0.01). Qualitative analysis generated 4 themes: 1) Strengths, 2) Areas of Improvement, 3) Information Sharing, and 4) Communication. Conclusions: The NYGH-LTC Transfer Form was overall well-evaluated. The form was seen as most useful for those with less experience or less confidence in palliative care. Communication was identified as a major barrier to successful transitions of care and increased bidirectional verbal communication is needed in addition to the form.

scholarly journals Access to Palliative Care for Cancer Patients Living in a Northern and Rural Environment in Ontario, Canada: The Effects of Geographic Region and Rurality on End-of-Life Care in a Population-Based Decedent Cancer Cohort

2019 ◽  
Vol 13 ◽  
pp. 117955491982950 ◽  
Author(s):  
Michael SC Conlon ◽  
Joseph M Caswell ◽  
Stacey A Santi ◽  
Barbara Ballantyne ◽  
Margaret L Meigs ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
End Of Life Care ◽  
Acute Care Hospital ◽  
Geographic Region ◽  
Administrative Databases ◽  
Care Hospital ◽  
Life Care ◽  
To Receive

Background: Access to palliative care has been associated with improving quality of life and reducing the use of potentially aggressive end-of-life care. However, many challenges and barriers exist in providing palliative care to residents in northern and rural settings in Ontario, Canada. Aim: The purpose of this study was to examine access to palliative care and associations with the use of end-of-life care in a decedent cohort of northern and southern, rural and urban, residents. Design: Using linked administrative databases, residents were classified into geographic and rural categories. Regression methods were used to define use and associations of palliative and end-of-life care and death in acute care hospital. Setting/Participants: A decedent cancer cohort of Ontario residents (2007-2012). Results: Northern rural residents were less likely to receive palliative care (adjusted odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.83-0.97). Those not receiving palliative care were more likely to receive potentially aggressive end-of-life care and die in an acute care hospital (adjusted OR = 1.20, 95% CI: 1.02-1.41). Conclusions: Palliative care was significantly associated with reduced use of aggressive end-of-life care; however, disparities exist in rural locations, especially those in the north. Higher usage of emergency department (ED) and hospital resources at end of life in rural locations also reflects differing roles of rural community hospitals compared with urban hospitals. Improving access to palliative care in rural and northern locations is an important care issue and may reduce use of potentially aggressive end-of-life care.

scholarly journals Acute-Care Hospital Use Patterns Near End-of-Life for Cancer Patients Who Die in Hospital in Canada

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 109s-109s
Author(s):  
J. Tung ◽  
K. Decaria ◽  
D. Dudgeon ◽  
E. Green ◽  
R. Shaw Moxam ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
End Of Life ◽  
Cancer Patients ◽  
Acute Care ◽  
End Of Life Care ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Life Care

Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.

Measuring palliative and end-of-life care for cancer patients who die in hospital in Canada.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 58-58
Author(s):  
Kristen Decaria ◽  
Deborah Dudgeon ◽  
Esther Green ◽  
Raquel Shaw Moxam ◽  
Rami Rahal ◽  
...  
Keyword(s):  
Emergency Department ◽  
Palliative Care ◽  
End Of Life ◽  
Cancer Patients ◽  
Acute Care ◽  
End Of Life Care ◽  
Acute Care Hospital ◽  
Hospital Utilization ◽  
Care Hospital ◽  
Life Care

58 Background: High acute hospital utilization rates near end-of-life can signal that community-based palliative care may not be suiting patients’ needs. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce multiple admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improving the quality of life of advanced cancer patients. This analysis reports on indicators that describe the current landscape of acute-care hospital utilization at end-of-life and indirectly examines access to palliative care in patients who died of cancer in a hospital. Methods: Data were provided by the Canadian Institute for Health Information. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on ICU admissions include only facilities that report ICU data. Emergency department visit data were obtained from the National Ambulatory Care Reporting System. The analysis was restricted to adults aged 18+ who died in an acute-care hospital in fiscal years 2014/15 and 2015/16 for nine provinces and three territories. Results: A total of 48,987 (43%) cancer patient deaths occurred in an acute-care hospitals, with 70% admitted through the emergency department. Preliminary analysis revealed interprovincial variation in the cumulative length of stay in hospital 6 months prior to death from a median stay of 17 to 25 days. Some variation was also seen in the proportion of patients admitted to hospital two or more times in the last month of life (ranging from 18% to 33%), and the proportion of cancer patients admitted to ICU in the last 14 days of life (ranging from 15% to 6%). Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life. Conclusions: This study provides information on the current landscape of acute-care hospital utilization by cancer patients at end-of-life across Canada and identifies interprovincial variations in management of end-of-life care. An area of focus for the Palliative and End-of-Life National Network continue to be developing nationally agreed upon system-wide palliative care indicators.

scholarly journals Honoring Preferences—The Consistency Between End-of-Life Care and a Veteran’s Goal for Comfort Care

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 752-752
Author(s):  
Joan Carpenter ◽  
Winifred Scott ◽  
Mary Ersek ◽  
Cari Levy ◽  
Jennifer Cohen ◽  
...  
Keyword(s):  
Palliative Care ◽  
Logistic Regression ◽  
End Of Life ◽  
End Of Life Care ◽  
Life Care ◽  
Multivariate Logistic Regression ◽  
Comfort Care ◽  
Lower Odds ◽  
Medicare Data ◽  
Life Sustaining Treatment

Abstract This study examined the alignment between Veterans’ end-of-life care and a Life-Sustaining Treatment (LST) goal “to be comfortable.” It includes Veterans with VA inpatient or community living center stays overlapping July 2018--January 2019, with a LST template documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). Using VA and Medicare data, we found 80% of decedents with a comfort care goal received hospice and 57% a palliative care consult (compared to 57% and 46%, respectively, of decedents without a comfort care goal). Using multivariate logistic regression, a comfort care goal was associated with significantly lower odds of EOL hospital or ICU use. In the last 30 days of life, Veterans with a comfort care goal had 43% lower odds (AOR 0.57; 95% CI: 0.51, 0.64) of hospitalization and 46% lower odds of ICU use (AOR 0.54; 95% CI: 0.48, 0.61).

Help Me Understand: Providing Palliative Care to Individuals With Serious Mental Illness

2021 ◽  
pp. 104990912110107
Author(s):  
Kate L. M. Hinrichs ◽  
Cindy B. Woolverton ◽  
Jordana L. Meyerson
Keyword(s):  
Mental Illness ◽  
Palliative Care ◽  
End Of Life ◽  
Serious Mental Illness ◽  
End Of Life Care ◽  
Psychosocial Support ◽  
Life Care ◽  
Case Examples ◽  
Increased Risk ◽  
Palliative Care Teams

Individuals with serious mental illness (SMI) have shortened life expectancy with increased risk of developing comorbid medical illnesses. They might have difficulty accessing care and can be lost to follow-up due to complex socioeconomic factors, placing them at greater risk of dying from chronic or undiagnosed conditions. This, in combination with stigma associated with SMI, can result in lower quality end-of-life care. Interdisciplinary palliative care teams are in a unique position to lend assistance to those with SMI given their expertise in serious illness communication, values-based care, and psychosocial support. However, palliative care teams might be unfamiliar with the hallmark features of the various SMI diagnoses. Consequently, recognizing and managing exacerbations of SMI while delivering concurrent palliative or end-of-life care can feel challenging. The goal of this narrative review is to describe the benefits of providing palliative care to individuals with SMI with concrete suggestions for communication and use of recovery-oriented language in the treatment of individuals with SMI. The salient features of 3 SMI diagnoses—Bipolar Disorders, Major Depressive Disorder, and Schizophrenia—are outlined through case examples. Recommendations for working with individuals who have SMI and other life-limiting illness are provided, including strategies to effectively manage SMI exacerbations.

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