Sage Journals: Discover world-class research

Abstract

Objective

To evaluate a new intervention intended to increase referral rates from the emergency department (ED) to the palliative medicine service (PMS) in acute hospitals.

Methods

We conducted a quasi-experimental evaluation in an urban teaching hospital in Dublin, Ireland. Data were collected over two eight-week periods in November/December 2013 and May/June 2015, with the PALliative Medicine in the Emergency Department (PAL.M.ED.™) intervention implemented in the intervening period. All adults who were admitted to the hospital via the ED during the two time periods and who received a palliative care consultation during their hospital stay were included in the study. Our primary analysis evaluated the impact of PAL.M.ED.™ on PMS referral in the ED. Our secondary analysis evaluated the impact of PMS referral in the ED on length of stay (LOS) and utilization, compared to PMS referral later in the admission. We controlled for observed confounding between groups using propensity scores.

Results

PAL.M.ED.™ was associated with an increase in PMS referral in the ED (p < 0.005; odds ratio: 10.5 (95%CI: 3.8 to 28.7)). PMS referral in the ED was associated with shorter hospital LOS (p < 0.005; −10.9 days (95%CI: −17.7 to −4.1)).

Conclusions

Low PMS referral rates in the ED, and the poor outcomes for patients and hospitals that arise from admissions of those with serious illness, may be mitigated by a proactive intervention to identify appropriate patients at admission.

Keywords

emergency department length of stay palliative care

Get full access to this article

View all access options for this article.

References

Organisation for Economic Co-operation and development. Avoidable hospital admissions. Health at a Glance, www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017/avoidable-hospital-admissions_health_glance-2017-31-en (2017, accessed 9 March 2019).

Fingar

Barrett

Elixhauser

et al.

Trends in potentially preventable inpatient hospital admissions and emergency department visits. Rockville, MD: H-CUP/AHRQ, 2015.

Lehnert

Heider

Leicht

et al . Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev 2011; 68: 387–420.

Latham

Ackroyd-Stolarz

Emergency department utilization by older adults: a descriptive study. Canad Geriatr J 2014; 17: 118–125.

Mierendorf

Gidvani

Palliative care in the emergency department. Perm J 2014; 18: 77–85.

Centeno

Lynch

Donea

et al.

EAPC atlas of palliative care in Europe. Milan: European Association of Palliative Care, 2013.

Morrison

RS.

Models of palliative care delivery in the United States. Curr Opin Support Palliat Care 2013; 7: 201–206.

El-Jawahri

Greer

Temel

JS.

Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. J Support Oncol 2011; 9: 87–94.

May

Normand

Cassel

et al . Economics of palliative care for hospitalized adults with serious illness: a meta-analysis. JAMA Intern Med 2018; 178: 820–829.

10.

Delgado-Guay

Rodriguez-Nunez

Shin

SHC

et al . Characteristics and outcomes of patients with advanced cancer evaluated by a palliative care team at an emergency center. A retrospective study. Support Care Cancer 2016; 24: 2287–2295.

11.

May

Garrido

Cassel

et al . Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol 2015; 33: 2745–2752.

12.

May

Normand

Analyzing the impact of palliative care interventions on cost of hospitalization: practical guidance for choice of dependent variable. J Pain Symptom Manage 2016; 52: 100–106.

13.

Kistler

Sean Morrison

Richardson

et al . Emergency department-triggered palliative care in advanced cancer: proof of concept. Acad Emerg Med 2015; 22: 237–239.

14.

Quest

Asplin

Cairns

et al . Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med 2011; 18: e70–e76.

15.

Elsayem

Elzubeir

Brock

et al . Integrating palliative care in oncologic emergency departments: challenges and opportunities. World J Clin Oncol 2016; 7: 227–233.

16.

Grudzen

Hwang

Cohen

et al . Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med 2012; 15: 396–399.

17.

Health Service Executive. Report of the national acute medicine programme. Dublin: HSE, 2010.

18.

National Advisory Committee on Palliative Care. The report of the National Advisory Committee on Palliative Care. Dublin: Department of Health and Children, Author, 2001.

19.

Kane

Daveson

Ryan

et al . The need for palliative care in Ireland: a population-based estimate of palliative care using routine mortality data, inclusive of nonmalignant conditions. J Pain Symptom Manage 2015; 49(4): 726–733.e1.

20.

Wallace

Tiernan

Referral patterns of nonmalignant patients to an Irish specialist palliative medicine service. Am J Hosp Palliat Care 2013; 30: 399–402.

21.

Meier

Beresford

Fast response is key to partnering with the emergency department. J Palliat Med 2007; 10: 641–645.

22.

Osta

Palmer

Paraskevopoulos

et al . Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center. J Palliat Med 2008; 11: 51–57.

23.

George

Phillips

Zaurova

et al . Palliative care screening and assessment in the emergency department: a systematic review. J Pain Symptom Manage 2016; 51: 108–119.e2.

24.

Richards

Gisondi

Chang

et al . Palliative care symptom assessment for patients with cancer in the emergency department: validation of the Screen for Palliative and End-of-life care needs in the Emergency Department instrument. J Palliat Med 2011; 14: 757–764.

25.

The Joint Commission. Facts about the advanced certification program for palliative care. Washington, DC, www.jointcommission.org/facts_about_palliative_care/ (2016, accessed 9 March 2019).

26.

Charlson

Pompei

Ales

et al . A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383.

27.

Quan

Sundararajan

Halfon

et al . Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130–1139.

28.

Department of Health. Health in Ireland: Key Trends in 2015. Dublin. Available at: https://health.gov.ie/wp-content/uploads/2015/12/Health_in_Ireland_KeyTrends2015.pdf (accessed 20 June 2019).

29.

Rubin

DB.

The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Statist Med 2007; 26: 20–36.

30.

Garrido

MM.

Propensity scores: a practical method for assessing treatment effects in pain and symptom management research. J Pain Symptom Manage 2014; 48: 711–718.

31.

Austin

PC.

Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Statist Med 2009; 28: 3083–3107.

32.

Jones

AM.

Models for health care. York: Health Economics and Data Group, University of York, 2010.

33.

Brooks

Ohsfeldt

RL.

Squeezing the balloon: propensity scores and unmeasured covariate balance. Health Serv Res 2013; 48: 1487–1507.

34.

Jones

Rice

Bago d'Uva

et al.

Applied health economics. 2nd ed. Oxford: Routledge, 2013.

35.

Newman

Lasher

et al . Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med 2013; 16: 1362–1367.

36.

Lukin

Douglas

O'Connor

Palliative care in the emergency department: an oxymoron or just good medicine?

Emerg Med Austral 2012; 24: 102–104.

37.

Higginson

Evans

CJ.

What is the evidence that palliative care teams improve outcomes for cancer patients and their families?

Cancer J 2010; 16: 423–435.

38.

May

Garrido

Aldridge

et al . Prospective cohort study of hospitalized adults with advanced cancer: associations between complications, comorbidity, and utilization. J Hosp Med 2017; 12: 407–413.

39.

Johnston

Normand

May

Economics of palliative care: measuring the full value of an intervention. J Palliat Med 2017; 20: 222–224.

40.

May

Garrido

Cassel

et al . Using length of stay to control for unobserved heterogeneity when estimating treatment effect on hospital costs with observational data: issues of reliability, robustness and usefulness. Health Serv Res 2016; 51: 2020–2043.

41.

Gardiner

Gott

Ingleton

et al . Extent of palliative care need in the acute hospital setting: a survey of two acute hospitals in the UK. Palliat Med 2013; 27: 76–83.

42.

May

Cassel

JB.

Economic outcomes in palliative and end-of-life care: current state of affairs. Ann Palliat Med 2018; 7: S244–S2S8.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.13 MB

A quasi-experimental evaluation of an intervention to increase palliative medicine referral in the emergency department

Abstract

Objective

Methods

Results

Conclusions

Keywords

Get full access to this article

References

Supplementary Material