Care Consultation For Patients Research Articles

Palliative care consultation in patients hospitalized with out-of-hospital cardiac arrest: Impact on invasive procedures, do-not-resuscitate orders, and healthcare costs

BackgroundThe impact of palliative care consultation on the management and outcomes of patients hospitalized with out-of-hospital cardiac arrest (OHCA) remains poorly understood. This study examined associations between palliative care consultation and in-hospital outcomes of patients hospitalized with OHCA, stratified by survival status. MethodThis cross-sectional study used data from the National Inpatient Sample (2016–2021). Adult patients hospitalized with OHCA who received cardiopulmonary resuscitation were included. Multivariable analyses assessed associations between palliative care consultation and outcomes in non-terminal and terminal OHCA hospitalizations, adjusting for demographics, hospital characteristics, and comorbidities. ResultsAmong 488,700 OHCA hospitalizations, palliative care consultation was associated with lower odds of invasive procedures in non-terminal hospitalizations, including percutaneous coronary intervention (PCI) (aOR 0.30, 95 % CI 0.25–0.36), mechanical circulatory support (aOR 0.54, 95 % CI 0.44–0.68), permanent pacemaker (aOR 0.27, 95 % CI 0.20–0.37) and implantable cardioverter defibrillator insertion (aOR 0.22, 95 % CI 0.16–0.31), and cardioversion (aOR 0.62, 95 % CI 0.55–0.70). In terminal hospitalizations, palliative care was associated with lower odds of PCI (aOR 0.78, 95 % CI 0.70–0.87) and cardioversion (aOR 0.91, 95 % CI 0.85–0.97), but higher odds of therapeutic hypothermia (aOR 3.12, 95 % CI 2.72–3.59), gastrostomy (aOR 1.22, 95 % CI 1.05–1.41), and renal replacement therapy (aOR 1.19, 95 % CI 1.12–1.26). Palliative care was associated with higher DNR utilization in both subgroups and lower hospital costs in non-terminal hospitalizations but higher costs in terminal hospitalizations. ConclusionPalliative care consultation in OHCA is associated with differences in invasive procedures, DNR utilization, and hospital costs, varying by survival status.

Pain trajectories over 12 months following conservative care consultation in patients with lumbar spinal stenosis

ObjectiveTo investigate symptom trajectories in chiropractic patients with lumbar spinal stenosis (LSS).MethodsPatients diagnosed with LSS were recruited from chiropractic clinics and self-reported questionnaires were collected at baseline and 1-year follow-up. Patients received weekly text messages about low back pain (LBP) and leg symptoms for 1 year. Group-based trajectory modelling was performed to identify symptom trajectory groups. The groups were compared based on patient characteristics, LBP and leg pain intensity, Oswestry Disability Index (ODI) and Zurich Claudication Questionnaire (ZCQ).ResultsA total of 90 patients were included in the analysis. A three-group trajectory model was chosen: ‘improving’ (16%), ‘fluctuating/improving’ (30%), and ‘persistent’ (54%). The ‘persistent’ group had a higher proportion of women [71% (95% CI 57–82%)] than the ‘improving’ group 29% (95% CI 11–56%), and a higher ODI score at both baseline [34.2 (95% CI 29.7–38.8) vs. 22.8 (16.4–29.1)] and 1-year follow-up [28.1 (95% CI 23.2–33.0) vs. 4.8 (0.1–9.4)]. Similar differences were observed for ZCQ symptom and function scores.ConclusionsPain symptoms in people with LSS followed distinctly different trajectories. Half of the sample had a pattern of consistently severe symptoms over a year, while the other half either improved rapidly or experienced fluctuating symptoms with some improvement.

S1380 Examination of Timing of Palliative Care Consultation in Patients With Grade 3 Acute on Chronic Liver Failure at a Large Academic Transplant Center

S1380 Examination of Timing of Palliative Care Consultation in Patients With Grade 3 Acute on Chronic Liver Failure at a Large Academic Transplant Center

Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors

In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes. A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (<Postoperative day 7) versus late (≥Postoperative day 7) consultation. Of 363 patients undergoing surgery for spinal metastasis, 62 (17.0%) patients received palliative care consultation during the same hospitalization, 11 (17.7%) were preoperative, and 51 (82.2%) were postoperative. Among same-stay consultations, 32 (51.6%) were early and 30 (48.4%) were late. Palliative care consultation recipients had worse preoperative Karnofsky Performance Scale (KPS) score (P < 0.001), were more likely to have other organ metastases (P= 0.005) or cord compression (P= 0.026), had longer hospitalization (P < 0.001), and were less likely to be discharged home (P < 0.001). Patients presenting with mechanical pain were more likely to receive preoperative consults compared with postoperative (P= 0.029), and earlier compared with later consultations (P= 0.046). Regarding long-term outcomes, patients with same-stay palliative care consultation had significantly shorter overall survival (log-rank; P < 0.001), worse KPS postoperatively (P= 0.017), and worse KPS and Modified McCormick Scale at the last follow-up (P < 0.001). Only 1 in 6 patients received palliative care consultation. Patients receiving same-stay palliative care consultation had more advanced local and systemic disease burden. Increased utilization of palliative care consultation in patients with spine metastasis is needed.

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care.

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation. Retrospective, Observational cohort study. Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019. Adult patients that electively underwent 1 of 19 major procedures. None. The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 (n = 2,103,836) and PostM: 2016-2019 (n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts. We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Integration of palliative care consultation into the management of patients with chronic limb-threatening ischemia

ObjectiveWe assessed the feasibility of integrating palliative care consultation into the routine management of patients with chronic limb-threatening ischemia (CLTI). Additionally, we sought to describe patient-reported outcomes from the palliative care and vascular literature in patients with CLTI receiving a palliative care consultation at our institution. MethodsThis was a single-institution, prospective, observational study that aimed to assess feasibility of incorporating palliative care consultation into the management of patients admitted to our tertiary academic medical center with CLTI by looking at utilization of palliative care before and after implementation of a protocol-based palliative care referral system. A survey comprised of patient-reported outcomes from the palliative care literature was administered to patients before and after palliative consultation. Length of stay and mortality were compared between our study cohort and a historic cohort of patients admitted with CLTI. ResultsOver a 14-month enrollment period, 44% of patients (n = 39) with CLTI (rest pain, 36%; tissue loss, 64%) admitted to the vascular service received palliative care consultation, compared with 5% of patients (n = 4) who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69 years, 23% were female, 92% were white, and 49% were able to ambulate independently. Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). Additional procedures included minor amputation or wound debridement (26%) and major amputation (15%). No patients received medical management alone. After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (P = .03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (P = .002). Fewer patients reported being unsure of the purpose of their medical care after palliative care consultation (8%) vs before (18%), although this was not statistically significant (P = .10). Median length of stay was longer in the study group compared with the historic cohort (8 vs 7 days; P = .02). There was no difference in 30-day mortality (3% vs 8%; P = .42) between the study group and the historic cohort (n = 77). ConclusionsIntegrating inpatient palliative care consultation into the routine management of patients with CLTI is feasible and may improve emotional domains of health-related quality of life. This study laid the foundation for future studies on longer term outcomes of patients with CLTI undergoing palliative care consultation as well as the benefit of outpatient palliative care consultation in patients with CLTI.

Outcomes of Palliative Care Consultation in Patients With CKD Hospitalized With Acute Stroke

Outcomes of Palliative Care Consultation in Patients With CKD Hospitalized With Acute Stroke

Consultation rates in people with type 2 diabetes with and without vascular complications: a retrospective analysis of 141,328 adults in England

ObjectiveTo assess trends in primary and specialist care consultation rates and average length of consultation by cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), or cardiometabolic multimorbidity exposure status.MethodsObservational, retrospective cohort study used linked Clinical Practice Research Datalink primary care data from 01/01/2000 to 31/12/2018 to assess consultation rates in 141,328 adults with newly diagnosed T2DM, with or without CVD. Patients who entered the study with either a diagnosis of T2DM or CVD and later developed the second condition during the study are classified as the cardiometabolic multimorbidity group. Face to face primary and specialist care consultations, with either a nurse or general practitioner, were assessed over time in subjects with T2DM, CVD, or cardiometabolic multimorbidity. Changes in the average length of consultation in each group were investigated.Results696,255 (mean 4.9 years [95% CI, 2.02–7.66]) person years of follow up time, there were 10,221,798 primary and specialist care consultations. The crude rate of primary and specialist care consultations in patients with cardiometabolic multimorbidity (N = 11,881) was 18.5 (95% CI, 18.47–18.55) per person years, 13.5 (13.50, 13.52) in patients with T2DM only (N = 83,094) and 13.2 (13.18, 13.21) in those with CVD (N = 57,974). Patients with cardiometabolic multimorbidity had 28% (IRR 1.28; 95% CI: 1.27, 1.31) more consultations than those with only T2DM. Patients with cardiometabolic multimorbidity had primary care consultation rates decrease by 50.1% compared to a 45.0% decrease in consultations for those with T2DM from 2000 to 2018. Specialist care consultation rates in both groups increased from 2003 to 2018 by 33.3% and 54.4% in patients with cardiometabolic multimorbidity and T2DM, respectively. For patients with T2DM the average consultation duration increased by 36.0%, in patients with CVD it increased by 74.3%, and in those with cardiometabolic multimorbidity it increased by 37.3%.ConclusionsAnnual primary care consultation rates for individuals with T2DM, CVD, or cardiometabolic multimorbidity have fallen since 2000, while specialist care consultations and average consultation length have both increased. Individuals with cardiometabolic multimorbidity have significantly more consultations than individuals with T2DM or CVD alone. Service redesign of health care delivery needs to be considered for people with cardiometabolic multimorbidity to reduce the burden and health care costs.

Palliative Care Consultations in Patients with Severe Traumatic Brain Injury: Who Receives Palliative Care Consultations and What Does that Mean for Utilization?

Palliative care has the potential to improve goal-concordant care in severe traumatic brain injury (sTBI). Our primary objective was to illuminate the demographic profiles of patients with sTBI who receive palliative care encounters (PCEs), with an emphasis on the role of race. Secondary objectives were to analyze PCE usage over time and compare health care resource utilization between patients with or without PCEs. The National Inpatient Sample database was queried for patients age ≥ 18 who had a diagnosis of sTBI, defined by using International Classification of Diseases, 9th Revision codes. PCEs were defined by using International Classification of Diseases, 9th Revision code V66.7 and trended from 2001 to 2015. To assess factors associated with PCE in patients with sTBI, we performed unweighted generalized estimating equations regression. PCE association with decision making was modeled via its effect on rate of percutaneous endoscopic gastrostomy (PEG) tube placement. To quantify differences in PCE-related decisions by race, race was modeled as an effect modifier. From 2001 to 2015, the proportion of palliative care usage in patients with sTBI increased from 1.5 to 36.3%, with 41.6% White, 22.3% Black, and 25% Hispanic patients with sTBI having a palliative care consultation in 2015, respectively. From 2008 to 2015, we identified 17,673 sTBI admissions. White and affluent patients were more likely to have a PCE than Black, Hispanic, and low socioeconomic status patients. Across all races, patients receiving a PCE resulted in a lower rate of PEG tube placement; however, White patients exhibited a larger reduction of PEG tube placement than Black patients. Patients using palliative care had lower total hospital costs (median $16,368 vs. $26,442, respectively). Palliative care usage for sTBI has increased dramatically this century and it reduces resource utilization. This is true across races, however, its usage rate and associated effect on decision making are race-dependent, with White patients receiving more PCE and being more likely to decline the use of a PEG tube if they have had a PCE.

An Internal Review of Rates of Palliative Medicine Referral for Patients With Advanced Pancreatic Cancer.

BackgroundThe American Society of Clinical Oncology recommends that patients with advanced cancer receive palliative care services in concurrence with active treatment. While the benefits of palliative care are clear, integration of palliative care can be challenging. We aim to review rates of palliative care consultation in patients with advanced pancreatic cancer at our institution, intending to improve these rates.MethodsWe retrospectively reviewed the electronic records of all patients with pancreatic cancer treated at Allegheny General Hospital diagnosed between 2009-2020. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data.ResultsOf the 171 patients reviewed, 121 completed all treatment and evaluation within our health network (Pittsburgh, United States). The median age was 63 years (IQR 40-91 years); 55 patients (45%) were male; the majority were white (107 patients, 88%). At the time of diagnosis, 28% of our patients had stage IV disease (34 patients), and 19.8% of patients who developed stage IV disease had palliative care referrals.ConclusionsPalliative care is an integral part of usual care for advanced pancreatic cancer. Our analysis showed that palliative care is underutilized in our hospital. We aim to improve palliative care integration in our patients’ care by adding a hard stop to electronic medical records to remind physicians to offer palliative care to our patients with pancreatic cancer and to arrange lecture series to emphasize the importance of palliative care in this setting.

Improving consultations for persistent musculoskeletal low back pain in orthopaedic spine settings: an intervention development

BackgroundThere is a need to improve consultations between patients with persistent musculoskeletal low back pain and orthopaedic spine clinicians when surgery is not indicated. Poor communication and lack of education about self- management in these consultations have been shown to be associated with increased distress and higher subsequent health care seeking.AimTo develop a standardised intervention to improve spine care consultations for patients for whom surgery is not beneficial.MethodThe intervention was developed in six stages. The first three stages included: interviews with patients, an interactive workshop with clinicians from a mix of disciplines, and interviews with spine clinicians about their perspective of the recommendations, their perceived difficulties and potential improvements. Information from these stages was synthesised by an expert panel, creating a draft intervention structure and content. The main features of the intervention and the materials developed were then reviewed by patients and spine clinicians. Finally, the research team incorporated the recommended amendments to produce the intervention.ResultsIn total, 36 patients and 79 clinicians contributed to the development of the intervention. The final intervention includes three components: a pre-consultation letter with information suggesting that surgery is one possible intervention amongst many, introducing the staff, and alerting patients to bring with them a potted history of interventions tried previously. The intervention includes short online training sessions to improve clinicians’ communication skills, during the consultation, in reference to listening skills, validation of patients’ pain, and use of appropriate language. Clinicians are also supplied with a list of evidence-based sources for advice and further information to share with patients. Finally, post consultation, a follow up letter includes a short summary of the patients’ clinical journey, the results of their examination and tests, and a reminder of recommendations for self-management.ConclusionThe intervention includes aspects around patient education and enhanced clinician skills. It was developed with input from a multitude of stakeholders and is based on patients’ perceptions of what they would find reassuring and empowering when surgery is excluded. The intervention has the potential to improve the patients care journey and might lead to changes in practice in spine clinicians.

An internal review of rates of palliative medicine referral for patients with advanced pancreatic cancer.

e16245 Background: Patients diagnosed with advanced pancreatic cancer face many challenges in addition to symptom burden including psychological stressors and often the need for supportive care at home. In recent years, both clinical trials and retrospective reviews have confirmed the benefits of early integration of palliative care services such as improved quality of life and reduced symptom intensity. The American College of Clinical Oncology recommends patients with advanced cancer receive directed palliative care services early after diagnosis and in concurrence with active treatment. While the benefit of palliative care services is clear, the best way to integrate palliative services has not been determined. Our project aims to review the rates of palliative care consultation in patients with advanced pancreatic cancer intending to improve patient outcomes. Methods: We retrospectively reviewed the electronic medical records of all patients diagnosed with pancreatic cancer at Allegheny General Hospital diagnosed between 2009-2020. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Results: Of the 171 patients reviewed, 121 competed all treatment and evaluation within our health network. Median age was 63 years (IQR 40-91 years); 55 patients (45%) were male. The majority were white (88%). At the time of diagnosis, 28% of our patients had stage IV disease and 19.8% of patients with stage IV disease had documented palliative care referrals. Eight patients had pain documented at diagnosis, six patients underwent celiac plexus neurolysis, 31 underwent palliative radiation and 43 patients had documented opiate use. Of the 6 patients who underwent celiac plexus neurolysis, only 4 documented pain at 6-month follow-up. Of the 31 patients who underwent palliative radiation, 6 documented pain at 6-month follow-up. Conclusions: Palliative care is an integral part of usual care for pancreatic cancer. Our analysis showed that palliative care is underutilized in our hospital with only 19.8% of patients having documented palliative care visits. While patients may refuse palliative care consult, other contributing factors are likely the lack of access or lack of early involvement of palliative care team members. Integration of palliative care has been proven repeatedly to improve quality of life in patients diagnosed with advanced pancreatic cancer. We aim to improve palliative care integration in out patients’ care by adding a hard stop to electronic medical records to remind physicians to offer palliaitive care to the patients, in addition to arranging medical grand rounds and various lectures to increase awareness of the importance of palliative care in this setting.

Outcomes of palliative care consultation inpatients with ESRD who received cardiopulmonary resuscitation.

The majority of dialysis patients receive aggressive burdensome treatment near the end of life. Currently, we lack interventions to improve end-of-life care (EoLC) for these patients. We examined the association of palliative care consultation with improving EoLC for critically ill patients with end-stage renal disease (ESRD) who received cardiopulmonary resuscitation (CPR). In this retrospective study, we included patients with ESRD admitted to a large academic center who received CPR either prior to or during their hospital stay. Over 8 years, 17 out of 403 patients received palliative care consultation during their hospital stay; consultations were not standardized in their content. Main outcomes of interest to operationalize better EoLC were: (1) change in code status from full code to do not resuscitate (DNR) and (2) withdrawal from intensive care. Of the patients studied, 60.5% were African-American and 43.2% were female. Demographic differences between those with palliative care consultation and those with usual care were not statistically significant. Palliative care consultation was associated with higher odds of change in code status to DNR (odds ratio 8.10, 95% confidence interval 2.19 - 29.94) and withdrawal from intensive care (odds ratio 8.82, 95% confidence interval 2.69 - 28.91) in patients with ESRD who had received CPR. Palliative care consultation was not associated with any change in in-hospital mortality. Palliative care consultation needs to be considered for hospitalized ESRD patients with limited expected prognoses as it may reduce aggressive and burdensome therapies at the end of life. Furthermore, primary palliative care skills such as communication and decision-making should be taught to nephrologists to improve EoLC for dialysis patients.

Palliative care consultation in patients with Staphylococcus aureus bacteremia

Background: Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality. Aim: To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States. Design: A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality. Setting/subjects: All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12). Measurements: Palliative care consultation was identified using ICD-9-CM code V66.7. Patients’ baseline characteristics and outcomes were compared between those with and without palliative care consult. Results: A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001). Conclusions: Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.

In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support

Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.

Standardized Triggers for Palliative Care Consultation in Patients with End-Stage Liver Disease Improves Utilization and Outcomes (SCI909)

Standardized Triggers for Palliative Care Consultation in Patients with End-Stage Liver Disease Improves Utilization and Outcomes (SCI909)

A Retrospective Analysis of Factors Affecting Palliative Care Consults in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

PurposeThis study was conducted to determine factors that influence palliative care (PC) consultation in patients receiving cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC).Patient and methodsWe queried our Electronic Medical Record EPIC for a list of patients who underwent cytoreductive surgery with HIPEC or hyperthermic intrathoracic chemotherapy (HITEC) in the hospital from April 2016-April 2019. Data was manually extracted and patients who did not meet our criteria were excluded. Patients were divided on the basis of palliative care consults and differences between the groups were analyzed. Odds ratios (OR) with p-value of 0.05 and confidence interval of (CI) 95% were calculated.ResultsWe identified 55 patients of whom 34 met our inclusion criteria: 11 males and 23 females with an average age of 56 years at the time of diagnosis. Eight patients (23%) had PC, with six having commercial insurance, seven married, and six with more than one comorbid medical issue. Comorbidities >1 (OR: 0.12; CI: 0.02-0.76; p: 0.02) and age >40 (OR: 0.015; CI: 0.0007-0.3029; P: 0.006) were associated with a higher likelihood of PC. Gender, insurance type, and marital status did not have a significant association with PC. Mean age between PC consulted patients versus non-PC consulted patients was 58.5 vs. 55.9 and median age between the two groups was 60.5 vs. 60 which also showed a trend towards higher rates of PC in the older population.ConclusionApproximately one quarter of patients who underwent CRS with HIPEC had a concurrent PC consult. Though this is better than the national average of 11-16%, it continues to be a very small number. Efforts must be made to engage PC early in the course of treatment and recognize it as an integral part of cancer care. PC is not only an end-of-life service, in fact, studies have shown that early consultations lead to higher patient satisfaction, improved quality of life, and better communication.

Abstract 15170: In-hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support

Introduction: Hospitalizations associated with advanced heart failure (HF) requiring mechanical circulatory support (MCS) are usually associated with a high morbidity, mortality and a protracted hospital course. Prior studies have shown that the early inclusion of palliative care specialist is associated with better end-of-life experiences. Methods: The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes to identify patients above 18 years with advanced HF admitted with cardiogenic shock requiring MCS. Baseline characteristics and in-hospital outcomes were compared among patients evaluated by palliative care and those who were not. A p-value of &lt;0.001 was considered statistically significant. Results: There were 748,360 patients hospitalized for advanced HF complicated by cardiogenic shock requiring MCS, of these a palliative care consult was placed in 118,015 (15.8%) patients. Patients evaluated by palliative care were older (70.6±14.9 vs. 64.9±16.3 years old, p&lt;0.001) and had a higher prevalence of atrial fibrillation (39.3 vs. 35.1%,p&lt;0.001) and chronic kidney disease (40.4 vs. 33.3, p&lt;0.001), however had lower hypertension (57.4 vs. 59.7%, p&lt;0.001), diabetes (35.4 vs. 36.5%, p&lt;0.001), coronary artery disease (51.2 vs. 58.4%, p&lt;0.001) and acute coronary syndromes (39.2 vs. 45.0%, p&lt;0.001). Consulting palliative care was associated with a shorter length of stay (8.8±12.0 vs. 11.9±15.5 days, p&lt;0.001), lower total hospital cost ($161,972±265,156 vs. $219,114±318,387, p&lt;0.001) and higher Do Not Resuscitate (DNR) orders (30.8 vs. 5.8%, p&lt;0.001). Mortality rates were higher in the palliative care cohort (73.4 vs. 29.4%, p&lt;0.001). Conclusions: Despite the high morbidity and mortality associated with advanced HF patients with cardiogenic shock requiring MCS, the overall prevalence of palliative care consultation is exceedingly low. DNR orders were more prevalent in patients seen by the palliative care service. This study highlights the underutilization of palliative care services in this patient population, precluding any perceived benefit in end of life experiences.

Frequency, Timing, and Predictors of Palliative Care Consultation in Patients with Advanced Cancer at a Tertiary Cancer Center: Secondary Analysis of Routinely Collected Health Data.

Early integration of palliative care (PC) with oncological care is associated with improved outcomes in patients with advanced cancer. Limited information exists on the frequency, timing, and predictors of PC consultation in patients receiving oncological care. The Cross Cancer Institute (CCI) is the sole tertiary cancer center serving the northern half of the Canadian province of Alberta, located in the city of Edmonton. The objectives of this study were to estimate the proportion of patients with advanced cancer at the CCI who received consultation by the CCI PC program and the comprehensive integrated PC program in Edmonton, and to determine the timing and predictors of consultation. In this secondary analysis of routinely collected health data, adult patients who died between April 2013 and March 2014, and had advanced disease while under the care of a CCI oncologist, were eligible. Data from the Alberta Cancer Registry, electronic medical records, and Edmonton PC program database were linked. Of 2,253 eligible patients, 810 (36%) received CCI PC consultation. Median time between consultation and death was 2 months (range, 1.1-5.4). In multivariable logistic regression analysis, age, residence, income, cancer type, and interval from advanced cancer diagnosis to death influenced odds of receiving consultation. Among 1,439 patients residing in Edmonton, 1,121 (78%) were referred to the Edmonton PC program. A minority of patients with advanced cancer received PC consultation at the tertiary cancer center, occurring late in the disease trajectory. Frequency and timing of PC consultation varied significantly, according to multiple factors. Clinical and demographic factors are associated with variations in frequency and timing of palliative care consultation at a cancer center and may, in some cases, reflect barriers to access that warrant attention.

Palliative Care Consultation Reduces 30-Day Readmission Rates for Hospitalized Patients with End-Stage Chronic Obstructive Pulmonary Disease (FR440C)

•List the rates and causes for hospital readmission in patients with end-stage chronic obstructive disease, with and without palliative care services.•Provide the outcomes in end-stage chronic obstructive disease patients, with and without palliative care consultation. End-stage chronic obstructive disease (COPD) has a high level of symptom burden, requirement for long-term oxygen therapy and frequent exacerbations that require hospitalization. Research to date is limited regarding the delivery and impact of palliative care services in patients with end-stage COPD. Determine the relationship between in-hospital palliative consultation on hospital readmission in patients with end-stage COPD in the United States. A retrospective study was conducted using the AHRQ-HCUP Nationwide Readmission Database for 2014. Adults (≥ 18 years) with a diagnosis of end-stage COPD that received an in-hospital palliative consultation were identified using ICD-9 codes described in literature. The primary outcome was rate of readmission within 30-days of discharge. Secondary outcomes were reasons for readmission, and mortality and morbidity rates. Propensity score (PS) using the next neighbor method without replacement with 1:1 matching was utilized to adjust for confounders. Independent risk factors for readmission were identified using Cox's proportional hazards model. In total, 233,184 hospital admissions with a diagnosis of end-stage COPD were identified, of which 6.87% (16,038) received in-hospital palliative care consultation. PS matching was performed based on age, gender, hospital status, and Charlson comorbidity score. The overall 30-day rate of readmission in patients with end-stage COPD was 16.9%. Palliative care consultation was an independent predictor associated with a lower risk of readmission (Hazard Ratio 0.521, CI 0.398-0.682, p <0.001). The most common cause for readmission was sepsis (8.46%), followed by COPD (7.29%). Those readmitted had a significantly higher rate of death in hospital than those for index admissions (8.44% vs 5.52 %, p < 0.001). In-hospital palliative care consultation in patients with end-stage COPD reduces hospital readmission.