Inpatient Palliative Care Consultation Team Research Articles

Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study.

Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.

Transitioning From Hospital to Palliative Care at Home: Patient and Caregiver Perceptions of Continuity of Care

ContextContinuity of care is important at improving the patient experience and reducing unnecessary hospitalizations when transitioning across care settings, especially at the end of life. ObjectiveTo explore patient and caregiver understanding and valuation of “continuity of care” while transitioning from an in-hospital to a home-based palliative care team. MethodsLongitudinal qualitative design using semistructured interviews conducted with patients and their caregivers before and after transitioning from hospital to palliative care at home. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis within a postpositivist framework. Thirty-nine participants (18 patients, seven caregivers, and seven patient-caregiver dyads) were recruited from two acute care hospitals, wherein they received care from an inpatient palliative care consultation team and transitioned to home-based palliative care. ResultsPatients had a mean age of 68 years, 60% were female and 60% had a diagnosis of cancer. Caregivers had a mean age of 62 years and 50% were female. Participants perceived continuity of care to occur in three ways, depending on which stage they were at in their hospital-to-home transition. In hospital, continuity of care was experienced, as consistency of information exchanged between providers. During the transition from hospital to home, continuity of care was experienced as consistency of treatments. When receiving home-based palliative care, continuity of care was experienced as having consistent providers. ConclusionPatients' and their caregivers’ valuation of continuity of care was dependent on their stage of the hospital-to-home transition. Optimizing continuity of care requires an integrated network of providers with reliable information transfer and communication.

Accuracy of the Palliative Prognostic Score With or Without Clinicians' Prediction of Survival in Patients With Far Advanced Cancer

ContextPrevious studies suggest that clinicians' prediction of survival (CPS) may have reduced the accuracy of objective indicators for prognostication in palliative care. ObjectivesWe aimed to examine the accuracy of CPS alone, compared to the original Palliative Prognostic Score (PaP), and five clinical/laboratory variables of the PaP in patients with far advanced cancer. MethodsWe compared the discriminative accuracy of three prediction models (the PaP-CPS [the score of the categorical CPS of PaP], PaP without CPS [sum of the scores of only the objective variables of PaP], and PaP total score) across 3 settings: inpatient palliative care consultation team, palliative care unit, and home palliative care. We computed the area under receiver operating characteristic curve (AUROC) for 30-day survival and concordance index (C-index) to compare the discriminative accuracy of these three models. ResultsWe included a total of 1534 subjects with median survival of 34.0 days. The AUROC and C-index in the three settings were 0.816–0.896 and 0.732–0.799 for the PaP total score, 0.808–0.884 and 0.713–0.782 for the PaP-CPS, and 0.726–0.815 and 0.672–0.728 for the PaP without CPS, respectively. The PaP total score and PaP-CPS showed similar AUROCs and C-indices across the three settings. The PaP total score had significantly higher AUROCs and C-indices than the PaP without CPS across the three settings. ConclusionOverall, the PaP total score, PaP-CPS, and PaP without CPS showed good discriminative performances. However, the PaP total score and PaP-CPS were significantly more accurate than the PaP without CPS.

Timing of palliative care access and outcomes of advanced cancer patients referred to an inpatient palliative care consultation team in Brazil.

Little is known about the outcomes of cancer patients referred to palliative care (PC) teams in developing countries. Our aim was to examine the timing of PC access and outcomes of patients with advanced cancer referred to an inpatient PC consultation team in Brazil. Retrospective study of consecutive patients with advanced cancer admitted to a tertiary care general hospital (April 2015-December 2016) and referred for the first time to an inpatient PC consultation team. Patients' demographics, clinical features, time from first consult to death or discharge, and outcomes on medication use, clinical interventions, and end-of-life preferences were retrieved. An analysis was performed before and after PC. One hundred eleven patients were included. Median age was 68; 72% had an Eastern Cooperative Oncology Group performance status ≥3. The median timing of PC access was 9 days (first interquartile = 3, third interquartile = 19). The use of analgesics (from 75% to 85%, p = 0.001) and opioids (from 50% to 73%, p < .001) increased. A lower proportion was receiving antibiotics (68% vs 48%, p < 0.001), thromboprophylaxis (44% vs 26%, p < 0.001), antihypertensives (28% vs 15%, p = 0.001), and antiemetic agents (64% vs 54%, p = 0.027). Chemotherapy use was lower (39-25%, p < 0.001). More patients had an end-of-life preference (39% to 25%, p < 0.001) and were not willing to receive intubation (32% vs 60%, p < 0.001), intensive care treatment (30% vs 55%, p < 0.001), cardiopulmonary resuscitation (35% vs 62%, p < 0.001), and artificial nutrition (22% vs 34%, p < 0.001). Although PC referrals occurred exceedingly late during the cancer disease trajectory, positive changes were observed in medication profiles, clinical interventions use, and end-of-life preferences of patients with advanced cancer referred to a specialized inpatient PC consultation team in Brazil. Further efforts are needed to improve early palliative cancer care in developing countries.

Care Planning for Inpatients Referred for Palliative Care Consultation

Care planning is a critical function of palliative care teams, but the impact of advance care planning and goals of care discussions by palliative care teams has not been well characterized. To describe the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, the care planning activities that occur, and the results of these activities. This was a prospective cohort study conducted between January 1, 2013, and December 31, 2016. Seventy-eight inpatient palliative care teams from diverse US hospitals in the Palliative Care Quality Network, a national quality improvement collaborative. Standardized data were submitted for 73 145 patients. Inpatient palliative care consultation. Overall, 52 571 of 73 145 patients (71.9%) referred to inpatient palliative care were referred for care planning (range among teams, 27.5%-99.4% of patients). Patients referred for care planning were older (73.3 vs 67.9 years; F statistic, 1546.0; P < .001), less likely to have cancer (30.0% vs 41.1%; P < .001), and slightly more often had a clinical order of full code at the time of referral (54.6% vs 52.1%; P < .001). Palliative care teams identified care planning needs in 52 825 of 73 145 patients (72.2%) overall, including 42 467 of 49 713 patients (85.4%) referred for care planning and in 10 054 of 17 475 patients (57.5%) referred for other reasons. Through care planning conversations, surrogates were identified for 10 571 of 11 149 patients (94.8%) and 9026 patients (37.4%) elected to change their code status. Substantially more patients indicated that a status of do not resuscitate/do not intubate was consistent with their goals (7006 [32.1%] preconsultation to 13 773 [63.1%] postconsultation). However, an advance directive was completed for just 2160 of 67 955 patients (3.2%) and a Physicians Orders for Life-Sustaining Treatment form was completed for 8359 of 67 955 patients (12.3%) seen by palliative care teams. Care planning was the most common reason for inpatient palliative care consultation, and care planning needs were often found even when the consultation was for other reasons. Surrogates were consistently identified, and patients' preferences regarding life-sustaining treatments were frequently updated. However, a minority of patients completed legal forms to document their care preferences, highlighting an area in need of improvement.

Economic Evaluation of Specialist Inpatient Palliative Care Consultation Teams: Treatment Effect Varies by Patient Complexity (TH306-C)

•Understand that patient-level factors determine a high level of cost in many health economics studies and that previous economic evaluations of in-hospital palliative care consultation teams have not addressed patient-level factors.•Understand that palliative care consult treatment effect on cost varies according to individual patient complexity.•Understand the implications of these findings for clinical practice and for future palliative care research. Patient-level factors may determine a high proportion of hospital costs in providing care to patients with serious illness. For example, economic evaluations taking into account individual complexity may offer new and valuable information for understanding variations in cost. Studies of specialist inpatient palliative care consultation teams (PCCTs) have yet to attempt this. To compare how treatment effect of PCCT on hospital cost varies according to patient complexity. Using a prospective, observational design, data were collected on patients admitted with an advanced cancer diagnosis at four hospitals in a 4-year period (n=1,023). Treatment was defined as seeing a PCCT within 3 weeks of hospital admission (n=271); all other patients were put into the control arm (n=762). Overlapping subsamples were created according to number of comorbidities on the Elixhauser Index at baseline: (a) All Patients (n=1023); (b) 3< = Elixhauser total (n=680); (c) 4< = Elixhauser total (n=489); (d) 5< = Elixhauser total (n=300). Generalized linear models (GLMs) with a gamma distribution and a log link were used to regress daily and total cost of hospital stay against each treatment variable, 33 baseline socioeconomic and clinical covariates, and dummy variables for each site. Subsample specific propensity scores were calculated to balance the intervention and control arms on the basis of observed covariates. Treatment effect was cost reducing for all subsamples. The estimated $ treatment effect and statistical significance were greatest for (d), then (c), then (b), then (a). Individual patient complexity influences the economic impact of PCCTs. Higher patient comorbidities are associated with larger treatment effect.

Economic Evaluation of Specialist Inpatient Palliative Care Consultation Teams: Cost Effect Estimates Vary by Treatment Timeliness (TH306-A)

Objectives Understand that previous economic evaluations of in-hospital palliative care consultation teams have defined treatment as a consult at any time during hospitalization. Understand the variance in timeliness of in-hospital palliative care consultation. Understand that timeliness of consult has a major impact on treatment effect on cost; earlier consult is associated with greater cost reduction. Original Research Background: Economic evaluations of specialist inpatient palliative care consultation teams (PCCTs) have consistently defined treatment as binary (seeing a PCCT at any time during hospitalization). However, consults at any time during

Changes in medication profile among patients with advanced cancer admitted to an acute palliative care unit.

The decision-making process for medication use in the last weeks of life is complex because of patient frailty and poor prognosis. Limited literature is available on medication use in the palliative care setting, particularly in acute palliative care units (APCUs). We examined the changes in medication profile among hospitalized patients with advanced cancer before their palliative care inpatient consultation team referral, after palliative care consultation, at the time of APCU admission, and at APCU discharge or death. We included consecutive patients with advanced cancer who were first seen by our inpatient palliative care consultation team and subsequently admitted to the APCU. We retrieved data on all scheduled medications at the prespecified time points. Among the 100 patients, the median duration of hospitalization was 10.5 days (interquartile range 8-15 days), and the median APCU stay was 5 days (interquartile range 3-7 days). The average number of medications before palliative care inpatient consultation team referral, after palliative care consultation, at APCU admission and at APCU discharge/death was 9.2 (standard deviation [SD] 4.5), 9.9 (SD 4.2), 10.3 (SD 3.8), and 10.1 (SD 3.8), respectively (P = 0.03). An increasing proportion of patients received medications for symptom control over their course of hospitalization, including systemic corticosteroids, laxatives, neuroleptics, and antiulcer agents (P < 0.05). In contrast, the frequency of several classes of medications such as antihypertensives, antilipemics, and anticonvulsants decreased over time (P < 0.05). Palliative care involvement was associated with an increase in symptom control medications and decrease in medications for comorbid conditions over time.

A Month in an Acute Palliative Care Unit

Few cancer centers have developed acute palliative care units (APCUs). The purpose of this study is to highlight clinical interventions and financial outcomes during a typical 1-month period on an APCU. We evaluated consecutive patients admitted to our APCU from February 1 to 28, 2009, regarding demographic information, sources of and reasons for admissions, resuscitation status, clinical interventions, disposition, and reimbursement data. Forty-two patients were admitted during a 1-month period. Of these, 30 (71%) were referred from the inpatient palliative care consultation team. In all, 10 (24%) patients had a full code status on admission, and 8 had their status changed to do not resuscitate (DNR) prior to discharge. A total of 11 (26%) patients were discharged home with hospice care, 12 (29%) died on the APCU, and 10 (24%) were discharged home with outpatient follow-up visits. All patients received intravenous medications and the majority received intravenous antibiotics. All patients met acute care criteria for hospitalization, and financial reimbursement was satisfactory and comparable to that of other oncology patients. The APCU model is designed for the care of very complex advanced cancer patients. Palliative interventions are given simultaneously with other medical interventions. The APCU is labor intensive and well reimbursed.

Availability and integration of palliative care at US cancer centers.

The current state of palliative care in cancer centers is not known. To determine the availability and degree of integration of palliative care services and to compare between National Cancer Institute (NCI) and non-NCI cancer centers in the United States. A survey of 71 NCI-designated cancer centers and a random sample of 71 non-NCI cancer centers of both executives and palliative care clinical program leaders, where applicable, regarding their palliative care services between June and October 2009. Survey questions were generated after a comprehensive literature search, review of guidelines from the National Quality Forum, and discussions among 7 physicians with research interest in palliative oncology. Executives were also asked about their attitudes toward palliative care. Availability of palliative care services in the cancer center, defined as the presence of at least 1 palliative care physician. A total of 142 and 120 surveys were sent to executives and program leaders, with response rates of 71% and 82%, respectively. National Cancer Institute cancer centers were significantly more likely to have a palliative care program (50/51 [98%] vs 39/50 [78%]; P = .002), at least 1 palliative care physician (46/50 [92%] vs 28/38 [74%]; P = .04), an inpatient palliative care consultation team (47/51 [92%] vs 28/50 [56%]; P < .001), and an outpatient palliative care clinic (30/51 [59%] vs 11/50 [22%]; P < .001). Few centers had dedicated palliative care beds (23/101 [23%]) or an institution-operated hospice (37/101 [37%]). The median (interquartile range) reported durations from referral to death were 7 (4-16), 7 (5-10), and 90 (30-120) days for inpatient consultation teams, inpatient units, and outpatient clinics, respectively. Research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon. Executives were supportive of stronger integration and increasing palliative care resources. Most cancer centers reported a palliative care program, although the scope of services and the degree of integration varied widely.