Higher Palliative Care Research Articles

Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer.

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use. A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life. Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52). Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

The Association of Unmet Palliative Care Needs and Physical Frailty With Clinical Outcomes: A Prospective Study of Adults With Heart Failure.

People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality. In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months). We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes. In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants. Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.

Racial/ethnic disparities in inpatient palliative care utilization and hospitalization outcomes among patients with colorectal cancer.

Research has shown that racial/ethnic disparities exist in outcomes for colorectal cancer (CRC) patients, but there are no studies assessing inpatient palliative care utilization and hospitalization outcomes in this population. We examined racial/ethnic disparities in palliative care utilization and hospitalization outcomes among CRC and early-onset CRC patients. Using National Inpatient Sample (NIS) data collected between 2016 and 2018, cross-sectional analyses were performed. Descriptive analyses were done, stratified by race/ethnicity. Multivariable logistic and linear regression models were used to examine racial/ethnic differences in palliative care utilization, inpatient mortality, chemotherapy/radiotherapy use, length of stay and total hospital charges among hospitalized patients with CRC and early-onset CRC. Blacks had higher odds (AOR: 1.09; 95% CI: 1.03-1.16) of receiving palliative care consultation while Hispanics had lower odds (AOR: 0.90; 95% CI: 0.84-0.96) compared to Whites. Blacks had 1.1 times higher odds (95% CI: 1.01-1.18) of inpatient mortality relative to Whites while Hispanics had 16% (AOR: 0.84; 95% CI: 0.76-0.93) lower odds of inpatient mortality. Compared to Whites, Blacks (AOR: 1.99; 95% CI: 1.64-2.41), Hispanics (AOR: 2.49; 95% CI: 1.94-3.19) and colorectal cancer patients in the other category (AOR: 1.72; 95% CI: 1.35-2.18) were more likely to receive inpatient treatment with chemotherapy/radiotherapy. Furthermore, Black patients were 1.1 times (95% CI: 1.06-1.14) more likely to have a length of stay more than 5 days. Blacks (𝛃: $3,096.7; 95% CI: $1,207.0-$4,986.5) Hispanic (𝛃: $10,237.5; 95% CI: $7,558.2-$12,916.8) and other patients (𝛃: $6,332.0; 95% CI: $2,830.9-$9, 833.2) had higher hospital charges relative to their White counterparts. Among patients with early onset CRC, Blacks had higher palliative care use (AOR: 1.29; 95% CI: 1.10-1.51) and inpatient mortality (AOR: 1.38; 95% CI: 1.06-1.79) while Hispanics reported $5,589.7 (95% CI: $683.2-$10,496.2) higher total hospital charges and were more likely to receive inpatient chemotherapy/radiotherapy (AOR: 2.48; 95% CI: 1.70-3.63). Further research is needed to explore specific cultural, socioeconomic, and political factors that explain these disparities and identify ways to narrow the gap. Meanwhile, the healthcare sector will need to assess what strategies might be helpful in addressing these disparities in outcomes in the context of other socioeconomic and cultural factors that may be affecting the patients.

Palliative Care Needs of Physically Frail Community-Dwelling Older Adults With Heart Failure.

Physical frailty is emerging as a potential "trigger" for palliative care (PC) consultation, but the PC needs of physically frail persons with heart failure (HF) in the outpatient setting have not been well described. This study describes the PC needs of community dwelling, physically frail persons with HF. We included persons with HF ≥50 years old who experienced ≥1 hospitalization in the prior year and excluded those with moderate/severe cognitive impairment, hospice patients, or non-English speaking persons. Measures included the FRAIL scale (0-5: 0=robust, 1-2=prefrail, 3-5=frail) and the Integrated Palliative Outcome Scale (IPOS) (17 items, score 0-68; higher score=higher PC needs). Multiple linear regression tested the association between frailty group and palliative care needs. Participants (N=286) had a mean age of 68 (range 50-92) were majority male (63%) and White (68%) and averaged two hospitalizations annually. Most were physically frail (44%) or prefrail (41%). Mean PC needs (IPOS) score was 19.7 (range 0-58). On average, participants reported 5.86 (SD 4.28) PC needs affecting them moderately, severely, or overwhelmingly in the last week. Patient-perceived family/friend anxiety (58%) weakness/lack of energy (58%), and shortness of breath (47%) were the most prevalent needs. Frail participants had higher mean PC needs score (26) than prefrail (16, P < 0.001) or robust participants (11, P < 0.001). Frail participants experienced an average of 8.32 (SD 3.72) moderate/severe/overwhelming needs compared to prefrail (4.56, SD 3.77) and robust (2.39, SD 2.91) participants (P < 0.001). Frail participants reported higher prevalence of weakness/lack of energy (83%), shortness of breath (66%), and family/friend anxiety (69%) than prefrail (48%, 39%, 54%) or robust (13%, 14%, 35%) participants (P < 0.001). Physically frail people with HF have higher unmet PC needs than those who are nonfrail. Implementing PC needs and frailty assessments may help identify vulnerable patients with unmet needs requiring further assessment and follow-up.

Racial and socioeconomic factors associated with palliative care utilization in pancreatic cancer: An analysis of National Inpatient Sample.

e16296 Background: Palliative care (PC) has been validated as a crucial component in end-of-life quality. Despite the higher PC utilization in cancer patients than other conditions, some studies have raised concern of systemic inequality in PC utilization. PC has a significant role in the care of pancreatic cancer, especially due to the poor prognosis. Here, we investigate the sociodemographic factors associated with the recent trend of PC utilization in pancreatic cancer. Methods: We used the Healthcare Cost and Utilization Project National Inpatient Sample database, all-payer inpatient care database in the United States, with data years 2016-2019. The end-of-life hospitalizations were defined as adult patients (age at least 18 years old) who were hospitalized at least three days and passed away. The cases were identified with International Classification of Diseases (ICD) 10th edition for pancreatic cancer (C25.0-25.9) within the top three diagnoses. Prevalence of PC consultation could be estimated with the billable code Z51.5. The factors that were statistically associated with PC utilization in univariable analysis would be included in the final multivariable logistic regression model. Charlson Comorbidity Index was used to adjust for comorbidities. Hospital factors such as size and base (rural, urban, urban teaching) were included in the analysis. Results: Among 339,318 adult patients who were hospitalized at least three days and passed away, 2,011 cases had pancreatic cancer within top three diagnosis codes. 1576 (78.4%) patients were at least age 60 or above. 1,275 (63.4%) of them had PC consult at their end-of-life. There was a significant yearly trend of increasing PC utilization (Cochran-Armitage test p-value &lt; 0.05). Male, African American, lower income, and rural area were significantly associated with less PC consult in multivariable regression model. The adjusted odds ratio (aOR) of PC consult was 0.66 (p &lt; 0.005) in African American. There was significantly more PC utilization in the top 25% income group (vs the bottom 25% counterpart, aOR 1.35; p &lt; 0.05) and in urban hospitals (vs rural hospitals, aOR 1.80 in nonteaching; aOR 1.88 in teaching; p &lt; 0.001). Conclusions: There was a trend of increasing PC utilization in pancreatic cancer. Nevertheless, racial and socioeconomic factors were still significantly associated with the PC utilization. Further study and systemic policy approach are required to investigate and address such disparities and promote the PC utilization.

Sociodemographic factors associated with end-of-life palliative care utilization in female breast cancer: A national inpatient database analysis.

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.

Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals.

There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization. Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.

Prevalence of Cancer Patients Requiring Palliative Care in Outpatient Clinics in a Tertiary Hospital in Southern Thailand

Objective: To estimate the prevalence of patients requiring palliative care in outpatient clinics and associated factors.Materials and Methods: A cross-sectional study was conducted by retrospectively reviewing the electronic medical records of cancer patients visiting the outpatient clinics in the major tertiary care institution in southern Thailand during 1 January– 31 December 2018 from the Hospital Information System. The Supportive and Palliative Care Indicators Tool in Low Income Settings (SPICT-LISTM) was used to determine if the patients would benefit from palliative care. Forward stepwise multiple logistic regression was used to assess associations between potential factors and the need for palliative care.Results: Nine thousand nine hundred and ninety medical records were reviewed. 3,628 (36.3%) patients were male and 6,324 (63.3%) were female with a median age of 58.7 years. The prevalence of cancer patients requiring palliative care according to the SPICT-LISTM criteria was 7.8%. Age was the main factor associated with palliative care need [odds ratio (OR)=1.03, 95% confidence interval (CI)=1.02-1.04]. Muslim patients had a significantly higher requirement for palliative care compared with Buddhist patients (OR=1.62, 95% CI=1.09-2.37). Although not statistically significant, malignant neoplasms of bone and articular cartilage were associated with higher palliative care need than lip, oral cavity and pharynx cancers (OR=5.35, 95% CI=0.69-29.40).Conclusion: Muslim religion and having malignant neoplasms of bone and articular cartilage were associated with the highest palliative care need. Future studies should focus on more in-depth examination of the reasons these groups have higher needs for palliative care.

Inpatient Palliative Care Use Among Critically III Brain Metastasis Patients in the United States.

The objective of this study was to understand the trends and characteristics of palliative care delivery among critically ill brain metastasis patients using a nationally representative database. This study was a retrospective analysis of Nationwide Inpatient Sample data collected during 2005 to 2014. This study included critically ill patients, 18 years and above, diagnosed with brain metastasis, identified using International Classification of Diseases-Ninth Revision-Clinical Modification diagnosis and procedure codes. Multivariable logistic regression models were used for predicting factors associated with inpatient palliative care use. Among 18,309 critically ill patients with brain metastasis, 3298 (18.0%) received inpatient palliative care. The rate of inpatient palliative care use among these patients increased from 3.2% to 28.5%, during 2005 to 2014 (P<0.001). Regression analysis showed that hospital teaching status (odds ratio [ORs], 1.45; 95% confidence interval [CI], 1.14-1.84), primaries located in head and neck (OR, 1.42; 95% CI, 1.21-2.05) or lung (OR, 1.32; 95% CI, 1.22-1.44), and primary diagnosis of pneumonia (OR, 1.42; 95% CI, 1.22-1.97) or septicemia (OR, 1.59; 95% CI, 1.30-1.97), were associated with higher palliative care use. Hispanic ethnicity (OR, 0.86; 95% CI, 0.67-0.96), and hospital location in Northeast (OR, 0.73; 95% CI, 0.54-0.96), Midwest (OR, 0.63; 95% CI, 0.45-0.87), or South (OR, 0.64; 95% CI, 0.48-0.86) were associated with lower palliative care use. Inpatient palliative care use increased significantly among critically ill patients with brain metastases, though overall rate was low. There were geographical and racial disparities among these patients. Health care providers and policy makers should focus on decreasing these disparities. In addition, hospitals should focus on adopting more palliative care services.

Comparison of Integrated Outpatient Palliative Care With Standard Care in Patients With Parkinson Disease and Related Disorders

Parkinson disease and related disorders (PDRD) have consequences for quality of life (QoL) and are the 14th leading cause of death in the United States. Despite growing interest in palliative care (PC) for persons with PDRD, few studies are available supporting its effectiveness. To determine if outpatient PC is associated with improvements in patient-centered outcomes compared with standard care among patients with PDRD and their caregivers. This randomized clinical trial enrolled participants at 3 academic tertiary care centers between November 1, 2015, and September 30, 2017, and followed them up for 1 year. A total of 584 persons with PDRD were referred to the study. Of those, 351 persons were excluded by phone and 23 were excluded during in-person screenings. Patients were eligible to participate if they had PDRD and moderate to high PC needs. Patients were excluded if they had urgent PC needs, another diagnosis meriting PC, were already receiving PC, or were unable or unwilling to follow the study protocol. Enrolled participants were assigned to receive standard care plus outpatient integrated PC or standard care alone. Data were analyzed between November 1, 2018, and December 9, 2019. Outpatient integrated PC administered by a neurologist, social worker, chaplain, and nurse using PC checklists, with guidance and selective involvement from a palliative medicine specialist. Standard care was provided by a neurologist and a primary care practitioner. The primary outcomes were the differences in patient quality of life (QoL; measured by the Quality of Life in Alzheimer Disease scale) and caregiver burden (measured by the Zarit Burden Interview) between the PC intervention and standard care groups at 6 months. A total of 210 patients with PDRD (135 men [64.3%]; mean [SD] age, 70.1 [8.2] years) and 175 caregivers (128 women [73.1%]; mean [SD] age, 66.1 [11.1] years) were enrolled in the study; 193 participants (91.9%) were white and non-Hispanic. Compared with participants receiving standard care alone at 6 months, participants receiving the PC intervention had better QoL (mean [SD], 0.66 [5.5] improvement vs 0.84 [4.2] worsening; treatment effect estimate, 1.87; 95% CI, 0.47-3.27; P = .009). No significant difference was observed in caregiver burden (mean [SD], 2.3 [5.0] improvement vs 1.2 [5.6] improvement in the standard care group; treatment effect estimate, -1.62; 95% CI, -3.32 to 0.09; P = .06). Other significant differences favoring the PC intervention included nonmotor symptom burden, motor symptom severity, completion of advance directives, caregiver anxiety, and caregiver burden at 12 months. No outcomes favored standard care alone. Secondary analyses suggested that benefits were greater for persons with higher PC needs. Outpatient PC is associated with benefits among patients with PDRD compared with standard care alone. This study supports efforts to integrate PC into PDRD care. The lack of diversity and implementation of PC at experienced centers suggests a need for implementation research in other populations and care settings. ClinicalTrials.gov Identifier: NCT02533921.

Abstract WP363: Trends and Disparities in Utilization of Palliative Care for Ischemic Stroke Patients Undergoing Thrombolytic Therapies: 10-Year Analysis of Nationwide Data

Introduction: We characterize 10-year nationwide trends in utilization of palliative care (PC) for ischemic stroke (IS) patients and describe in-hospital outcomes and costs for IS patients receiving PC, particularly those with acute thrombolytic therapy (TT) i.e. IV tPA and endovascular thrombectomy (EVT). Methods: We analyzed the National Inpatient Sample (90% US hospitalizations) from 2006 - 2015 and identified adult (age ≥18) IS patients, with or without TT and PC using validated ICD-9 codes. We used survey design methods to report nationally representative adjusted odds ratios (aOR) of PC utilization across five 2-year time periods. Results: Of 4,249,201 IS encounters, 4% were coded for PC utilization. PC utilization increased over time (aOR 4.80, 95% CI 4.15 - 5.55), regardless of acute treatment type (Figure 1a). Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity and comorbidity burden, and discharge from teaching hospitals in non-Northeastern regions were independently associated with receiving PC. In the fully adjusted model, treatment with IV tPA and EVT respectively confer a 5% and 10% greater likelihood of receiving PC. Overall, PC utilization is associated with higher mortality (aOR 15.14, 95% CI 14.36 - 15.96). However, 10-year outcome trends demonstrate a significant decline in in-hospital mortality compared to all other dispositions (aOR 0.46, 95% CI 0.38 - 0.56) with an increasing proportion of PC patients receiving long-term care and home health/hospice (aOR 2.42, 95% CI 2.03 - 2.88) (Figure 1b). Despite longer length of stay, PC hospitalizations incurred 16% lower adjusted costs. Conclusions: Though PC utilization has increased in IS patients, considerable disparities exist. Acute TT is associated with higher PC utilization and outcome trends indicate lower in-hospital mortality with higher long-term care and home health/hospice. Protocolized PC for IS patients may optimize outcomes and costs.

Progress and trends in the utilization and adoption of palliative care in patients with terminal gynecologic cancer in the United States: A study of 4,264 women.

11606 Background: To determine the factors associated with the utilization of palliative care (PC) in patients with metastatic gynecologic cancer who died while hospitalized. Methods: Data were extracted from the National Inpatient Sample (NIS) database for patients with cervical, uterine, and ovarian cancers from 2005 to 2011. Chi-squared and logistic regression models were employed for statistical analyses. Results: Of 4264 women with gynecologic cancer, 983 (23.0%) utilized PC (median age: 66 years). 2633 (61.8%), 1034 (24.3%), and 597 (14.0%) patients had ovarian, uterine, and cervical cancer, respectively. The majority were white (57.9%), and the remainder were black (12.6%), Hispanic (7.8%), and Asian (3.1%). 24.9, 23.9, 23.6, and 25.2% were low, low-middle, middle-high, and high with respect to median income. Medicare, Medicaid, and private insurance was found in 46.7, 10.8, and 37.6% of patients. 36.9, 21.0, 18.0, and 24.1% of patients were treated in hospitals in the South, West, Midwest, and Northeast. 11.3, 23.9, and 64.2% of patients were treated in small, medium, and large hospitals, designated as teaching (53.1%) and nonteaching (46.3%) institutions. The utilization of PC increased from 5.2% in 2005 to 30.4% in 2011. Older age (OR: 1.34; 95% CI: 1.10-1.64; P = 0.01), high SES (OR: 1.37; 95% CI: 1.09-1.72; P = 0.01), privately insured (OR: 1.81; 95% CI: 1.46-2.24; P &lt; 0.001), treatment at Western (OR: 1.94; 95% CI: 1.56-2.41; P &lt; 0.001) and Midwestern hospitals (OR: 1.43; 95% CI: 1.15-1.77; P = 0.001), and depression (OR: 1.34; 95% CI: 1.00-1.80; P = 0.05) were associated with higher PC use. However, race, cancer type, hospital teaching status, and hospital location were not associated with PC use. Conclusions: The use of inpatient palliative care has increased significantly over the study period. The lower utilization of palliative care for terminal illness associated with younger, lower socioeconomic status, Southern and smaller volume hospitals warrants further attention.

Incidence, Trends, and Predictors of Palliative Care Consultation After Aortic Valve Replacement in the United States.

Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have become a reasonably safe procedure with acceptable morbidity and mortality rate. However, little is known regarding the incidence, trends, and predictors of palliative care (PC) consult in aortic valve replacement (AVR) patients. The main purpose of this analysis was to assess the incidence, trends, and predictors of PC consultation in AVR recipients using the Nationwide Inpatient Sample (NIS) database. We queried the NIS database from 2005 to September 2015 to identify those who underwent TAVR or SAVR and had PC referral during the index hospitalization. Adjusted odds ratio (aOR) was calculated to identify patient demographic, social and hospital characteristics, and procedural characteristics associated with PC consult using multivariable regression analysis. We also reported the trends of PC referral in AVR recipients. A total of 522 765 admissions (mean age: 75.3 ± 7.8 years, 40.3% female) who had TAVR (1.7% transapical and 9.2% endovascular approach) and SAVR (89.2%) were identified. Inpatient mortality was 3.96%, and 0.5% patients of the total admissions had PC consultation. The PC referral for SAVR increased from 0.90 to 7.2 per 1000 SAVR from 2005 to 2015 ( P = .011), while it remained stable ranging from 9.30 to 13.3 PC consults per 1000 TAVR ( P = .86). Age 80 to 89 (aOR: 1.93), age ≥90 years (aOR: 2.57), female sex (aOR: 1.36), electrolyte derangement (aOR: 1.90), weight loss (aOR: 1.88), and do not resuscitate status (aOR: 44.4) were associated with PC consult. West region (aOR: 1.46) and Medicaid (aOR: 3.05) were independently associated with PC consult. Endovascular (aOR: 1.88) and transapical TAVR (aOR: 2.80) had higher PC referral rates compared with SAVR. There was an increase in trends for utilization of PC service in SAVR admissions while it remained unchanged in TAVR cohort, but the overall PC referral rate was low in AVR recipients during the index hospitalization.