To examine the associations between palliative care types and hospital outcomes for patients who have or do not have advance directives.
Method:
Using administrative claims and clinical data for critically ill older adults (n = 1291), multivariable regressions examined the associations between palliative care types and hospital outcomes by advance directive status.
Results:
Integrative palliative care was associated with lower hospital costs, lower adjusted probability of in-hospital deaths, and higher adjusted probability of hospice discharges. There was no difference in hospital outcomes by palliative care types in those with advance directives.
Conclusion:
Significantly lower hospital costs and in-hospital deaths with higher hospice discharges were observed in integrative palliative care compared to consultative palliative care, but these findings were diminished with the presence of advance directives.
ManfrediPLMorrisonRSMorrisJGoldhirschSLCarterJMMeierDE. Palliative care consultations: how do they impact the care of hospitalized patients?J Pain Symptom Manage. 2000;20(3):166–173.
2.
CieminsELBlumLNunleyMLasherANewmanJM. The economic clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med. 2007;10(6):1347–1355.
3.
MorrisonRSPenrodJDCasselJB; Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783–1790.
4.
PenrodJDDebPDellenbaughC. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973–979.
5.
CasselJBKerrKPantilatSSmithTJ. Palliative care consultation and hospital length of stay. J Palliat Med. 2010;13(6):761–767.
6.
WeissmanDESpragensLH. Disruptive innovation: leveraging palliative care for the cost/quality sweet spot. 18th Annual Health Forum and the American Hospital Association leadership summit on July 24, 2010, San Diego, CA.
7.
MeierDESpragensLH. The impact of palliative care programs on quality and cost. 2011 Congress on Healthcare Leadership of American College of Healthcare Executives on March 22, 2011, Chicago, IL.
8.
SmithTJCasselJB. Cost and non-clinical outcomes of palliative care. J Pain Symptom Manage. 2009;38(1):32–44.
9.
HanksGChernyNIChristakisNA. Oxford Textbook of Palliative Medicine. 4th ed. Oxford, UK: Oxford University Press; 2009.
10.
NelsonJEBassettRBossR; Improve Palliative Care in the Intensive Care Unit Project. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med. 2010;38(9):1765–1772.
11.
O’MahonySMcHenryJBlankAE. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med. 2010;24(2):154–165.
12.
AhrensTYanceyVKollerM. Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use. Am J Crit Care. 2003;12(4):317–323.
13.
CurtisJR. Caring for patients with critical illness and their families: the value of the integrated clinical team. Respir Care. 2008;53(4):480–487.
14.
NortonSAHoganLAHollowayRGTemkin-GreenerHBuckleyMJQuillET. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med. 2007;35(6):1530–1535.
15.
NicholasLHKennethKMIwashynaTJWeirDR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306(13):1446–1453.
16.
SilveiraMJKimSYLangaKM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–1218.
17.
TenoJMLynnJPhillipsRS. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill patients?J Clin Ethics. 1994;5(1):23–30.
18.
TenoJMLicksSLynnJ. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. J Am Geriatr Soc. 1997;45(4):508–512.
19.
FerrucciLGuralnikJMPahorMCortiMCHavikRJ. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA. 1997;277(9):728–734.
20.
FriedLPFerrucciLDarerJAndersonG. Untangling the concepts of disability, frailty and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255–263.
21.
Bureau of Labor Statistics, Department of Labor. Consumer Price Index, US urban annual report. http://www.bls.gov/cpi/cpid06av.pdf. Accessed May 25, 2011.
22.
LagmanRLWalshDDavisMPYoungB. All patient refined-diagnostic related group and case mix index in acute care palliative medicine. J Support Oncol. 2007;5(3):145–149.
23.
ShenY. Applying the 3M all patient refined diagnosis related groups grouper to measure inpatient severity in the VA. Med Care. 2003;41(6 suppl):II103–II110.
24.
ManningWGBasuAMullahyJ. Generalized modeling approaches to risk adjustment of skewed outcomes data. J Health Econ. 2005;24(3):465–488.
25.
StokesMEDavisCSKochGG. Categorical Data Analysis Using the SAS System. 2nd ed. Cary, NC: SAS; 2009.
The SUPPORT principal investigators. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995;274(20):1591–1598.
28.
TenoJLynnJWengerN. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatment. J Am Geriatr Soc. 1997;45(4):500–507.
29.
CasarettDvan NessPHO’LearyJRFriedTR. Are patient preferences for life-sustaining treatment really a barrier to hospice enrollment for older adults with serious illness?J Am Geriatric Soc. 2006;54(3):472–478.
30.
PotetzLCubanskiJNeumanT. Medicare Spending and Financing: A Primer 2011. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2011. Report No. 7731-03.
31.
Medicare Payment Advisory Commission report to Congress [MedPAC]. Hospital inpatient and outpatient services: Assessing payment adequacy and updating payments. http://www.medpac.gov/chapters/mar11_ch03.pdf. Accessed May 25, 2011.
Agency for Healthcare Research and Quality. Department of Health and Human Services. a. AHRQ quality indicators. Guide to inpatient quality indicators: Quality of care in hospitals-volume, mortality, and utilization, version 3.1. Rockville, MD: AHRQ; 2007. http://www.qualityindicators.ahrq.gov/iqi_download.htm.
