The impact of community-based palliative care on acute hospital use in the last year of life is modified by time to death, age and underlying cause of death. A population-based retrospective cohort study.

Katrina Spilsbury,Lorna Rosenwax,James B Semmens,Glenn Arendts,Antony Bayer

doi:10.1371/journal.pone.0185275

Abstract

ObjectiveCommunity-based palliative care is known to be associated with reduced acute care health service use. Our objective was to investigate how reduced acute care hospital use in the last year of life varied temporally and by patient factors.MethodsA retrospective cohort study of the last year of life of 12,763 Western Australians who died from cancer or one of seven non-cancer conditions. Outcome measures were rates of hospital admissions and mean length of hospital stays. Multivariate analyses involved time-to-event and population averaged log-link gamma models.ResultsThere were 28,939 acute care overnight hospital admissions recorded in the last year of life, an average of 2.3 (SD 2.2) per decedent and a mean length of stay of 9.2 (SD 10.3) days. Overall, the rate of hospital admissions was reduced 34% (95%CI 1–66) and the mean length of stay reduced 6% (95%CI 2–10) during periods of time decedents received community-based palliative care compared to periods of time not receiving this care. Decedents aged <70 years receiving community-based palliative care showed a reduced rate of hospital admission around five months before death, whereas for older decedents the reduction in hospital admissions was apparent a year before death. All decedents who were receiving community-based palliative care tended towards shorter hospital stays in the last month of life. Decedents with neoplasms had a mean length of stay three weeks prior to death while not receiving community-based palliative care of 9.6 (95%CI 9.3–9.9) days compared to 8.2 (95% CI 7.9–8.7) days when receiving community-based palliative care.ConclusionRates of hospital admission during periods of receiving community-based palliative care were reduced with benefits evident five months before death and even earlier for older decedents. The mean length of hospital stay was also reduced while receiving community-based palliative care, mostly in the last month of life.

Highlights

The rate of hospital admissions was reduced 34% (95%CI 1–66) and the mean length of stay reduced 6% (95%CI 2–10) during periods of time decedents received community-based palliative care compared to periods of time not receiving this care
All decedents who were receiving community-based palliative care tended towards shorter hospital stays in the last month of life
Rates of hospital admission during periods of receiving community-based palliative care were reduced with benefits evident five months before death and even earlier for older decedents

Summary

Introduction

Community-based palliative care, sometimes called home-based palliative care, has consistently been shown to be associated with reduced acute care health service use and improved patient wellbeing in a variety of different settings.[1,2,3,4,5,6] Historically palliative care research has focussed on patients with advanced cancers, it is clear that specialist palliative care, home-based or hospital-based, benefits people with non-cancer chronic and life-limiting conditions. [7,8,9,10] Despite this, access to specialist palliative care for non-cancer conditions is generally considered sub-optimal [11,12,13,14] there are signs that this is improving.[14, 15]The effectiveness of community-based palliative care in reducing use of acute care health services is not uniform and has been shown to vary by type of service, patient and temporal factors. Community-based palliative care, sometimes called home-based palliative care, has consistently been shown to be associated with reduced acute care health service use and improved patient wellbeing in a variety of different settings.[1,2,3,4,5,6] Historically palliative care research has focussed on patients with advanced cancers, it is clear that specialist palliative care, home-based or hospital-based, benefits people with non-cancer chronic and life-limiting conditions. [5] An Italian study reported that the intensity of specialist home-based palliative care delivered to a cohort of patients with non-cancer chronic disease was associated with reduced hospital stays. A study of hospital outpatient early palliative care in end-stage liver disease found improvements in patient mood scores[21] and the effect of early hospital-based palliative care intervention in chronic obstructive pulmonary disease (COPD) is being investigated in a randomised controlled trial setting. [22] There have been few studies that have directly compared rates of hospital use in the last year of life between cancer and individual non-cancer conditions amenable to palliative care and how this is modified by accessing community-based palliative care in the last year of life

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Conclusion