Palliative Care and Resource Utilization at the End-of-Life in Advanced Liver Disease

Abstract

Introduction: There has been increased attention paid to improving end-of-life care quality in patients with advanced liver disease, though care experiences during terminal hospitalizations remain largely undescribed. The purpose of this study is to use a large national database to understand palliative care and resource utilization in patients with advanced liver disease. Methods: This is a cross-sectional, observational study that examines terminal hospitalizations of adults with decompensated cirrhosis using the National Inpatient Sample (NIS) database, 2009-2013. Patients of age less than 18 years and length of stay less than 3 days were excluded. The main outcomes of interest were receipt of palliative care consultation and total hospital costs. Covariates included demographics, hospital factors, and clinical characteristics. Multivariate regression was used to determine predictors of palliative care consultation and whether consultation was associated with lower costs. Survey weights were applied to obtain national estimates. Multiple imputation was used for missing data. Results: During 59,687 terminal hospitalizations of adults with decompensated cirrhosis from 2009 to 2013, 29.1% received palliative care consultation and the mean cost per hospitalization was $47,454 (SE: $1,116). Palliative care use (p < 0.05) and hospital costs (p < 0.05) increased from 2009 to 2013. African Americans (OR: 0.74, 95% CI: 0.62-0.88), Hispanics (OR: 0.79, 95% CI: 0.68-0.93), Asians (OR: 0.73, 95% CI: 0.54-0.99), and liver transplant candidates (OR: 0.66, 95% CI: 0.48-0.92) were less likely to receive palliative care, whereas care in large (OR:1.48, 95% CI: 1.17-1.88) and urban/teaching (OR: 1.37, 95% CI: 1.07-1.77) hospitals was associated with higher odds of receiving palliative care. Adjusting for other variables, palliative care was significantly associated with lower costs of hospitalization (-$8,670, 95% CI: -$11,288, -$6,052). Conclusion: Despite an increase in palliative care consultation between 2009 and 2013, the cost of end-of-life care has also increased. There are significant barriers to palliative care consultation for patients with advanced liver disease that need to be systematically addressed in future studies. Palliative care consultation during terminal hospitalizations of patients with decompensated cirrhosis is associated with lower costs. Future research should evaluate timing and impact of palliative care on quality of end-of-life care in this population.