Underutilisation of Victorian in-patient palliative care consultation services? Results of an exploratory study.

Abstract

The recent Australian Institute of Health and Welfare (AIHW) report on Australian palliative care services highlighted several important issues, including increasing demand for palliative care services and differences in provision across health care settings.1 In response to this report, the peak national organisation, Palliative Care Australia, raised concerns around access, suggesting that the majority of Australians with a need for palliative care services were not currently receiving them.2 The AIHW report addressed many aspects of Australian palliative care service provision; however, limited specific attention was paid to the role of palliative care consultation services (PCCS) for in-patients of acute hospitals. The role of PCCS are worthy of consideration because 51% of all deaths in Australia in 2011-12 occurred in hospital and, of these, more than 60% were not specifically palliative care patients.1There is increasing evidence showing the benefits of PCCS. Improvements have been demonstrated in symptom control, satisfaction with care, patient-clinician communication and end-of-life care.3,4 Important reductions have also been reported in healthcare costs and resource utilisation.5 Attempts have been madetoquantifythepalliativecareneeds ofhospitalin-patients in several international settings. Recent data from the UK, Australia and New Zealand identified between 20% and 36% of in-patients as having palliative care needs.6-8 For the majority of patients, these needs will be met by generalist rather than specialist palliative care services;7 however, the ideal referral rate to PCCS remains unspecified. A recent US report into palliative care utilisation suggested that between 5% and 10% of all hospital admissions should receive a specialist palliative consultation.9 In response to this report, we investigated referral rates from an Australian viewpoint by using the Victorian Admitted Episodes Database (VAED) and the Victorian Integrated Non-Admitted Health (VINAH) dataset to assess PCCS utilisation across Victorian metropolitan public hospital networks. Each network consists of a varying number of separate in-patient facilities and collection and submission of clinical data to these datasets is mandatory for all Victorian health services and Health Department-funded PCCS. No specific paediatric hospitals were included in our analysis and only multiday acute admitted episodes were analysed.Using palliative care consultancy episodes as a numerator and total acute multiday admitted episodes as a denominator we calculated a percentage that approximated PCCS uptake for individual Victorian metropolitan public hospital networks. For 2012-13, across the eight networks with 500 or greater annual palliative care consultancy episodes, this percentage ranged from 2.1% to 18.1%. The 18.1% was from a solely cancer tertiary hospital and, when this was excluded, the range was 2.1%-4.2%. The median of 3.1% is in keeping with US data, suggesting that currently between 2% and 4% of admitted patients receive a palliative care consultation.Many in-patients will never require involvement from specialist palliative care services; however, determining when referral is appropriate can be difficult. Factors influencing this decision include differing goals of care, prognostic uncertainty, variations in clinician recognition of care needs, patient and/or family belief systems, particularly around death and dying, palliative care workforce limitations and concerns around deskilling generalist staff. …