Inpatient Palliative Care and Post-operative Healthcare Utilization Among Older Surgical Patients.

Background: National guidelines recommend palliative care (PC) alongside life-sustaining treatment for older adults with severe trauma. However, outcomes associated with PC for these patients are not well-defined. Objectives: To determine frequency of inpatient PC process documentation in older adults with severe trauma and test associations with postdischarge health care utilization. Design: Retrospective cohort study using electronic health record data linked to Medicare claims. Setting/Subjects: We included adults ≥66 years old admitted to a large, regional U.S. health care system with severe trauma (2016-2018) using consensus criteria for serious illness in trauma. Measurements: Natural language processing was used to measure documentation of five inpatient PC processes: code status limitations, goals-of-care (GOC) conversations, hospice discussions, PC consultations, and health care proxy designations. Associations between PC processes and postdischarge health care utilization were tested using multivariable regression. Results: Among 1267 admissions, the median age was 82 years (interquartile range [IQR] 75-88), and median injury severity score (0-75, higher is worse) was 16 (IQR 9-21); ≥1 PC process was documented in 81%. Among those surviving hospitalization (87%), one-year mortality was 26%. Documentation of ≥1 PC process was not significantly associated with differences in mean hospital days (16 vs. 19), home days (306 vs. 307), emergency department visits (2.3 vs. 2.2), or intensive care unit days (0.6 vs. 0.9) at one year. PC processes were significantly associated with subsequent hospice enrollment (p < 0.01). Conclusions: PC was not associated with reduced health care utilization in older adults after trauma but was associated with one-year hospice enrollment. GOC conversations, specialty PC, and inpatient hospice discussions had low utilization, highlighting target areas for improvements in care delivery.

489 Background: There has been an increase in Palliative care utilization in cancer patients. We examined trends of palliative care and intensive care utilization in pancreatic cancer patients in an urban setting safety net hospital. Methods: This is a retrospective analysis of pancreatic cancer patients seen at the Parkland Health and Hospital System between January 1999 and September 2016. Cancer cases and receipt of palliative care were identified from prospectively maintained registries. Health care utilization including intensive care unit (ICU) was reviewed. All statistical analysis was done using IBM SPSS version 24. Results: We identified 455 new diagnoses of pancreatic cancer, mean age 61 years, 227 (50%) female and 228 (50%) white. Of these, 277 (61%) received palliative care ever. Patient who received palliative care were more likely to be younger (mean age, 59.3+-12 vs 62.8 +- 12 years) and have stage 4 disease vs stage 1-3 disease (p 0.006, and p 0.003 respectively). There was no statistically significant difference in palliative care utilization between gender and ethnicity groups. 140 patients had a DNR order and 29 required ICU admission at any point. A first contact with palliative care consult was obtained &lt; = 7 days before death for 29 (10%) patients, &lt; = 30 days before death for 86 (31%) patients, 30-60 days before death for 50 (18%) and more than 60 days before death for 141 (51%) patients. Patients receiving palliative care were more likely to have a DNR status (p &lt; 0.001) but had no difference in ICU use within the last 30 days of life (p 0.285). Conclusions: The rate of palliative care in patients with pancreatic cancer in this cohort from a safety net hospital is higher than nationally reported studies. Most patients received palliative care &gt; 30 days before death. While patients received early palliative care, it did not result in reduced ICU care. Factors influencing ICU care utilization near the end of life need further study.

Abstracts from Center to Advance Palliative Care National Seminar Palliative Care Everywhere: Bridging the Gaps November 12-14, 2015 San Antonio, TX.

Feedback on Missed and Delayed Diagnosis: Differential Diagnosis of Communication Dilemmas

Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit

Background Disparities have been found in the utilization of palliative care (PC). However, a limitation of existing research is that it co-mingles factors affecting whether a patient is offered PC with factors affecting whether a patient accepts/refuses PC. Our objective is to identify the determinants and disparities of neurosurgery patients accepting/refusing inpatient PC after a provider recommends an inpatient PC consult. Methodology In this single-center retrospective cohort study, the last 750 consecutive neurosurgery patient medical records were screened. Inclusion criteria were as follows: (1) the patient was seen by the neurosurgery service during their hospitalization and (2) the patient had a documented inpatient PC consult ordered or the patient had at least one progress note documenting PC in the plan of care. Excluded were patients not seen by the neurosurgery service during the hospitalization in which the PC consult order or plan was documented. Analysis was performed using multivariate logistic regression with backward stepwise variable selection. Candidate variables included age, gender, race, ethnicity, language, marital status, insurance type, surrogate decision-maker (SDM) relationship to patient, advanced directive, Charlson Comorbidity Index (CCI), ambulation, activities of daily living (ADL) dependence, primary diagnosis category, Glasgow Coma Scale (GCS) at the time of admission, GCS at the time of PC consult, GCS at the time of discharge, duration of hospitalization, and hospitalization mortality. Results Of the last 750 neurosurgery patients, this study included 144 patients (33.3% female; mean age 57.53±19.89 years). Among these patients, 109 patients (75.7%) accepted PC and 35 patients (24.3%) refused PC. Univariate analysis showed that patients refusing PC tended to be older (p=0.003) and have a shorter duration of hospitalization (p=0.023). Chi-squared analysis found associations between PC acceptance/refusal and preferred language (p=0.026), religion (p<0.001), and SDM relationship to patient (p=0.004). Multivariate logistic regression found that predictors of PC refusal were older age (OR=0.965, p=0.049), non-English (OR=0.219, p=0.004), adult child SDM (OR=0.246, p=0.023), and other relative/friend SDM (OR=0.208, p=0.011). Religious patients were more likely to accept PC (OR=7.132, p<0.001). Race and ethnicity factors were not found to be significant predictors of PC refusal: Black (p=0.649), other race (p=0.189), and Hispanic (p=0.525). Conclusion Nearly one-quarter of neurosurgery patients offered PC refused this care. Predictors of PC refusal were older age, non-English, adult child SDM, and other relative/friend SDM. Religious patients were more likely to accept PC. Race and ethnicity were not found to be significant predictors of accepting/refusing PC, which may suggest these previously identified disparities stem from minority patients being offered less PC. Additional research is needed to replicate these findings among different patient populations. Because PC is compatible with life-prolonging therapies and aims to provide additional emotional and spiritual support to the patient and family, the finding that nearly one-quarter of patients refused PC may demonstrate a pervasive misconception and need for patient education.

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

Palliative care consultation reduces hospital costs and length of stay among decedents with hematologic malignancies: A propensity score matched analysis from the national inpatient sample, 2016-2022

12031 Background: While palliative care integration into oncology represents a quality metric, its relationship with mortality outcomes and cost implications remains incompletely characterized. This study evaluates the association between palliative care consultation and healthcare utilization across major cancer types. Methods: We conducted a retrospective analysis using the National Inpatient Sample (2018-2022). Eligible patients included adults with primary diagnoses of lung, breast, prostate, or colon cancer. Palliative care utilization was identified (ICD-10 code Z51.5). Primary endpoints included in-hospital mortality, length of stay (LOS), and total charges. Propensity score matching (1:1 nearest neighbor, caliper 0.2) was used to account for selection bias. Confounding variables included age, race, insurance status, hospital characteristics, and comorbidity burden. Missing data were handled using complete case analysis. Temporal trends were assessed using Cochran-Armitage test. Results: Among 1,104,888 eligible hospitalizations (469,831 lung, 203,857 breast, 204,837 colon, 226,065 prostate), 70,863 in-hospital deaths occurred. Palliative care consultation was associated with reduced LOS (adjusted mean difference: -1.2 days; 95% CI: -1.4 to -1.0; p&lt;0.001) and lower total charges (adjusted mean difference: -$31,947; 95% CI: -$34,521 tor o -$29,373; p&lt;0.001) among deceased patients. Cancer-specific mortality rates with without were: lung (31.26% vs 4.16%, p&lt;0.001), breast (26.72% vs 2.16%, p&lt;0.001), colon (25.60% vs 2.27%, p&lt;0.001), and prostate (27.07% vs 1.98%, p&lt;0.001). Overall palliative care utilization increased from 13.50% to 15.91% (2018-2022; APC: +0.68%; p-trend&lt;0.001). DNR status strongly predicted palliative care utilization (adjusted OR: 4.50; 95% CI: 4.41-4.60; p&lt;0.001). Conclusions: In this large nationwide analysis, palliative care consultation was associated with significant reductions in healthcare utilization and costs among deceased cancer patients. Universal implementation could potentially save 27,744 hospital days and $996.4 million annually, suggesting substantial opportunities for healthcare system optimization. Healthcare utilization outcomes by cancer type and palliative care status. Cancer Type Deaths (N) PC Rate (%) Adjusted Cost Difference* ($) Adjusted LOS Difference* (Days) Lung 41,808 61.45 -32,655 (-35,124, -30,186) -0.94 (-1.12, -0.76) Breast 9,981 60.80 -31,382 (-34,276, -28,488) -0.97 (-1.18, -0.76) Colon 9,667 56.95 -47,079 (-50,612, -43,546) -1.32 (-1.56, -1.08) Prostate 9,407 56.61 -37,099 (-40,388, -33,810) -0.81 (-1.02, -0.60) *Values represent adjusted differences (95% CI) between palliative care and non-palliative care groups. PC = Palliative Care; LOS = Length of Stay.

79 Background: Despite rigorous evidence of improved quality of life and longer survival, disparities in the utilization and quality of palliative and hospice care persist for racial and ethnic minority (Black and Latinx) patients with advanced lung cancer. To better understand drivers of palliative care and hospice inequities, this study evaluated the impact of psychosocial factors (e.g., lung cancer beliefs) on palliative and hospice care utilization among minority patients with cancer. Methods: This was a prospective cohort study of 99 patients with advanced lung cancer recruited at the Mount Sinai Hospital. At enrollment, minority and non-minority patients were asked questions about their sociodemographic, clinical, and the following psychosocial factors: medical mistrust, lung cancer beliefs, palliative care and hospice beliefs. Palliative care and hospice care utilization was abstracted from patients’ medical records. Bivariate analysis examined the association between independent factors (e.g., sociodemographic, lung cancer beliefs) and outcomes of palliative care consult and hospice care use (yes vs. no). Results: Of the 99 enrolled participants, 55 (55%) were minorities with a mean age of 65 years. 42% completed a palliative care consult and 26% utilized hospice care (26%). Palliative care utilization was associated with more favorable beliefs toward palliative care (p = 0.022) and hospice (p = 0.005) and lower levels of medical mistrust (p = 0.007). Majority of the sample was not refered to palliative (50%) or hospice care (61%); however patients refered were more likely to utilize care (p &lt; 0.001). Minority patients were more likely to receive a referral and schedule a palliative care consultation compared to non-minorities (p &lt; 0.001). Self-reported minority status did not predict differences in hospice care use. Conclusions: Minority patients with lung cancer were more likely to receive a palliative care referral and specialty level consultation when compared to non-minority patients. Higher levels of mistrust were a driver of not receiving palliative care. Patient referrals appear to be an important leverage point to help mitigate disparities in palliative and hospice care use. Future work to understand factors associated with palliative care use and the impact on minority patients is needed.

12035 Background: Palliative care (PC) has been shown to improve end-of-life quality in cancer patients. Nevertheless, several studies suggest that PC utilization is associated with socioeconomic factors. Patients with breast cancer, the most common neoplasm in women in the U.S., has lower PC utilization than those with other malignancies. We aim to investigate any sociodemographic barriers that are associated with the inpatient PC utilization in female breast cancer in the U.S. at the end of life. Methods: We used the National Inpatient Sample database of Healthcare Cost and Utilization Project, an all-payer inpatient care database in the United States, with data years 2014-2019. The end-of-life case was defined as hospitalized at least three days and passed away. We included all adult women (age at least 18 years old and female gender in electronic health records). The breast cancer cases were identified with International Classification of Diseases (ICD) 9th or 10th edition within the top three diagnoses. PC consultation could be identified with the ICD procedure code. Comorbidities were controlled with Charlson Comorbidity Index. After univariable analysis, the factors that were statistically associated with PC utilization would subsequently be added to the multivariable logistic regression model. Results: Between the year 2014 to 2019, we identified a total of 2,226 adult female patients who had breast cancer as their top three diagnoses and were hospitalized at least three days before death. 217 (9.7%) cases were 40-49 years old; 441 (19.8%) cases were 50-59 years old; and 1,455 (65.4%) patients were at least age 60 or above. The top three racial groups were Caucasian 1,420 (63.8%), African American 418 (18.8%), and Hispanic 166 (7.5%). 1,267 (56.9%) of all the cases had PC consult. African American (adjusted odds ratio [aOR]: 0.75; p &lt; 0.005) and Hispanic (aOR: 0.62; p &lt; 0.05) were significantly associated with less PC utilization than the Caucasian reference group in multivariable regression model. Lower PC prevalence was also observed at rural hospitals and Midwest region. Higher income group and private insurance no longer showed statistically significant higher PC utilization after adjusted for other variables. Conclusions: In end-of-life hospitalization with breast cancer as primary diagnosis, racial and hospital resource factors were significantly associated with the PC utilization. Cultural difference could be associated with the lower PC prevalence since adjusting income and insurance types could not explain the disparities in PC utilization among different racial groups. Future study should investigate and address the disparities of PC utilization in female terminal breast cancer.

Using the Evidence for Palliative Care to Improve Outcomes for Patients With Heart Failure.

152 Background: Palliative care’s role in oncology has expanded, but its impact on aggressiveness of care at the end of life has not been characterized at the population level. Methods: This matched retrospective cohort study examined the effect of an encounter with palliative care on healthcare utilization at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared healthcare utilization before and after palliative care consultation to a matched non-palliative care cohort. Results: The palliative care cohort had higher rates of healthcare utilization in the 30 days prior to palliative care consult compared to the non-palliative cohort, with higher rates of hospitalization (risk ratio [RR] 3.33; 95% CI 2.87-3.85), invasive procedures (RR 1.75; 95% CI 1.62-1.88), and chemotherapy administration (RR 1.61; 95% CI 1.45-1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lower rates of hospitalization (RR 0.53; 95% CI 0.44-0.65), invasive procedures (RR 0.52; 95% CI 0.45-0.59), and chemotherapy administration (RR 0.46; 95% CI 0.39-0.53). Patients with early palliative care consultation had larger absolute reductions in healthcare utilization compared to those with palliative care consultation closer to the end of life. Conclusions: This population-based study found that palliative care substantially decreased healthcare utilization among Medicare beneficiaries with advanced cancer. Given the increasing number of elderly patients with advanced cancer, this study emphasizes the importance of early integration of palliative care alongside standard oncologic care.

e24074 Background: Early integration of palliative care (PC) into advanced cancer care has been shown to improve quality of life and prognostic understanding. However, there is a paucity of data on utilization of inpatient PC consultation and survival outcomes in patients (pts) receiving inpatient chemotherapy (IC). Methods: A retrospective review was performed at a single academic center of pts receiving IC between Jan 2016 and Dec 2017. We evaluated utilization of PC services, reasons for consult, code status, disposition, and 60-day mortality. Descriptive statistics and odds ratios (OR) were estimated from logistic regression models with mixed-effect, taking into account correlations from multiple admissions per patient. Cumulative incidence plot and Cox proportional hazard regression models were used to assess the association between mortality and study covariates. Results: Of 880 admissions, 733 (83%) were hematologic malignancies (HM) and 147 (17%) were solid tumors (ST). PC consults were more likely in ST than HM (OR 3.19, 95% CI 1.85 - 5.50) and for KPS ≤50% (OR 22.20, 95% CI 11.51- 42.79). Of 159 PC consults, 91 (57%) were for pain and 25 (16%) for goals of care. 66 pts (10%) who received IC died within 60 days of admission, 44 (67%) HM and 22 (33%) ST (p = 0.002). In pts who died within 60 days, 63% had PC consult. Median time from admission to PC consult was 2 days for ST and 9 for HM. Of those with PC consult, 40% had a change from full code to DNR/DNI and were more likely to have a health care proxy (HCP) assigned (OR 7.31, p = 0.001). PC consults were also associated with significantly higher odds of discharge to hospice (OR 10.52, 95% CI: 4.3-25.6; p = &lt; 0.0001; Table). Mortality risk was higher in those admitted for symptoms/complications related to their disease or with progression (HR 3.24, 95% CI (2.50-4.19), p &lt; 0.001) and in those with advanced stage disease: Stage 3 (p = 0.033); Stage 4 (p = 0.0003). Of the pts who died within 60 days, 33 (50%) died during the admission and 24 (36%) in hospice. Conclusions: Significant 60-day mortality after receiving IC is consistent with aggressive end-of-life care. Pts with ST and those with poor performance status more frequently utilized inpatient PC services; however, there is opportunity to increase utilization amongst pts with HM and introduce PC earlier in the inpatient clinical course. PC consultations improve advanced care planning with appropriate transitions in code status, HCP assignments, and discharge to hospice.[Table: see text]

Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review