University of North Carolina at Chapel Hill Graduate School
Doi
Abstract
The overall objectives of this research were to: (1) determine whether triggered palliative care consultation (TPCC) could achieve effective consult implementation in oncology and (2) examine the effect of inpatient palliative care consults on health resource use (i.e., hospice discharge and 30-day readmissions). We used a mixed-methods research design of two distinct inpatient oncology services at UNC Hospital. Data sources included qualitative interviews and secondary data using the UNC Palliative Care Clinical Research Database linked to electronic medical record data from 2010 to 2016. The first study used a two-case study design of palliative care consult implementation in the medical oncology and gynecologic oncology services. Qualitative data were collected through in-person interviews with clinicians. Quantitative data on consult uptake were used to complement the qualitative findings. The study provided an in-depth understanding of organizational contextual factors associated with effective palliative care consult implementation and suggested refinements to organizational theory. The second study used difference-in-difference regression models to longitudinally examine the impact of two TPCC approaches on palliative care consult uptake and timeliness. TPCC supported by a single strategy was associated with greater consult uptake compared to usual care (aRR 1.45, p<.05), and TPCC supported by multiple strategies was associated with greater consult uptake compared to a single strategy (aRR 2.34, p<.001). TPCC did not significantly impact time to consult. The third study used multivariate regression with propensity score matching to examine associations among inpatient palliative care consultation, hospice use (discharge), and 30-day unplanned readmissions. The likelihood of having a 30-day readmission did not significantly differ between the palliative care consult and usual care groups. However, the palliative care consult group was significantly more likely than usual care to have a hospice discharge (aRR = 4.09, p<.001). The predicted probability of readmission was lower when palliative care consultation was combined with hospice discharge compared to consultation with discharge to non-hospice post-acute care or usual care (p<.001). In sum, TPCC improved consult implementation in oncology, and inpatient palliative care consults leading to hospice discharge resulted in reduced 30-day readmissions. Health care systems should consider the organizational context for implementation to identify optimal strategies for integrating palliative care consults into oncology and improving outcomes for cancer patients.Doctor of Philosoph
