Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

Context There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). Objective To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. Methods In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to “do not resuscitate” (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. Results In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR—adjusted odds ratio (AOR) = 7.5; 95% CI 5.6–9.9) and hospice referrals—(AOR = 7.6; 95% CI 5.0–11.7). They had slightly lower 30-day readmissions—(AOR = 0.7; 95% CI 0.5–1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation—by Day 4 of admission—was associated with reductions in LOS (1.7 days [95% CI −3.1, −1.2]) and average direct variable costs (−$1815 [95$3322, −$803]) compared to those who received no PCC. Conclusion Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered

Emergency Care Use and the Medicare Hospice Benefit for Individuals with Cancer with a Poor Prognosis

ObjectivesTo compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not.DesignMatched case-control study.SettingNationally representative sample of Medicare fee-for-service beneficiaries with cancer with a poor prognosis who died in 2011.ParticipantsBeneficiaries in hospice matched to individuals not in hospice on time from diagnosis of cancer with a poor prognosis to death, region, age, and sex.MeasurementsComparison of ED use and inpatient admission rates before and after hospice enrollment for beneficiaries in hospice and controls.ResultsOf 272,832 matched beneficiaries, 81% visited the ED in the last 6 months of life. At baseline, daily ED use and admission rates were not significantly different between beneficiaries in and not in hospice. By the week before death, nonhospice controls averaged 69.6 ED visits/1,000 beneficiary-days, versus 7.6 for beneficiaries in hospice (rate ratio (RR) = 9.7, 95% confidence interval (CI) = 9.3-10.0). Inpatient admission rates in the last week of life were 63% for nonhospice controls and 42% for beneficiaries in hospice (RR = 1.51, 95% CI = 1.45-1.57). Of all beneficiaries in hospice, 28% enrolled during inpatient stays originating in EDs; they accounted for 35.7% (95% CI = 35.4-36.0%) of all hospice stays of less than 1 month and 13.9% (95% CI = 13.6-14.2%) of stays longer than 1 month.ConclusionMost Medicare beneficiaries with cancer with a poor prognosis visited EDs at the end of life. Hospice enrollment was associated with lower ED use and admission rates. Many individuals enrolled in hospice during inpatient stays that followed ED visits, a phenomenon linked to shorter hospice stays. These findings must be interpreted carefully given potential unmeasured confounders in matching