Effects of hospice palliative care on medical service utilisation by patients on prolonged mechanical ventilation: A nationwide cohort study

Background: Several studies have shown that hospice palliative care interventions for cancer patients can reduce medical utilisation. In Taiwan, 20–25% of mechanical ventilation patients have been on prolonged mechanical ventilation (PMV), but only a few studies have discussed the effectiveness of hospice palliative care on these patients. This study aimed to explore the effectiveness of medical utilisation on patients undergoing PMV in hospice palliative care.Methods: From the Health Insurance database of a nationwide population-based study, we identified patients who had been on mechanical ventilation for over 21 days, were 18 years or older between 2009 to 2017, and had undergone hospice palliative care. The control group was obtained by 1:1 matching using propensity scoring after excluding patients who had participated in palliative care for less than 15 or more than 181 days. Furthermore, we used conditional logistic regression analysis to explore intensive care unit readmission, emergency department presentation, and cardiopulmonary resuscitation incidents, 14 days prior to death.Results: A total of 186,533 new PMV patients aged ≥ 18 years with terminal diseases were admitted between 2009 and 2017. Additionally, the number of patients receiving palliative care increased annually, from 0.6% in 2009 to 41.33% in 2017. The number of prolonged mechanical ventilation during emergency visits (odds ratio [OR]=0.68, 95%CI: 0.63-0.74), intensive care unit hospitalisation (OR=0.59, 95%CI: 0.53-0.46), cardiopulmonary resuscitation (OR=0.40, 95%CI: 0.35-0.46), and total hospitalisation cost (USD 1319.9.57 ± 1821.67 vs. 1544.37 ± 2309.27) was lower in the palliative care group.Conclusion: Patients undergoing PMV whilst in hospice palliative care can significantly reduce total hospitalisation cost, intensive care unit admittance, cardiopulmonary resuscitation utilisation, and medical expenses at ≤14 days prior to death.

Development and implementation of a cardiac resynchronisation therapy care pathway: improved process and reduced resource use

BackgroundCardiac resynchronisation therapy (CRT) requires intensive, complex and multidisciplinary care to maximize the clinical benefit. In current practice this is typically a task for highly specialised physicians. We report on a novel multidisciplinary, standardised CRT care pathway (CRT-CPW). Experienced clinicians developed a CPW with simple and broadly applicable aids based on clinical evidence and identified shortcomings in the current CRT care. The resulting CPW was implemented at the Maastricht University Medical Center, aiming at a transfer from heterogeneous physician-led care to standardized nurse-led care.MethodsTwo CRT patient cohorts were compared in this analysis. The benchmarked usual care cohort (2012–2014, 122 patients) was compared with the CRT-CPW cohort (2015–2017, 115 patients). The primary outcomes were process-related: number of physician consultations, nurse consultations, length of stay (LOS) at implantation and total hospitalisation days during 1-year follow-up, and referral-to-treatment time. Clinical outcomes were assessed to adress non-inferiority of quality of care.ResultsPatients in the CRT-CPW cohort consulted nurses and technicians significantly more often than patients in the usual care cohort (2.4±1.5 vs 1.7±2.0, p<0.0001 and 4.3±2.5 vs 3.7±1.5, p=0.063, respectively). Patients with CRT-CPW consulted physicians significantly less often (1.7±1.4 vs 2.6±2.1, p<0.001). Referral to treatment time was significantly reduced in the CRT-CPW group (23.6±18.4 vs 37.0±26.3 days, p=0.002). LOS at implantation and total hospitalisation days were significantly reduced in the CRT-CPW group (1.1±1.2 vs 1.5±0.7 days, p<0.0001 and 2.4±4.8 vs 4.8±9.3, p<0.0001, respectively). Clinical outcome analyses showed no significant difference in 12-month all-cause mortality and heart failure hospitalisations.ConclusionThe introduction of a novel CRT-CPW resulted in a successful transition of physician-led to nurse-led care, with a significantly reduced resource use and equal clinical outcomes. Future evaluations will focus on impact on outcomes versus costs, to evaluate cost-effectiveness of the CRT-CPW.