Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis

Abstract

Objective To determine the pooled effect of exposure to one of 11 specialist palliative care teams providing services in patients' homes.Design Pooled analysis of a retrospective cohort study.Setting Ontario, Canada.Participants 3109 patients who received care from specialist palliative care teams in 2009-11 (exposed) matched by propensity score to 3109 patients who received usual care (unexposed). InterventionThe palliative care teams studied served different geographies and varied in team composition and size but had the same core team members and role: a core group of palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes. The teams' role was to manage symptoms, provide education and care, coordinate services, and be available without interruption regardless of time or day.Main outcome measures Patients (a) being in hospital in the last two weeks of life; (b) having an emergency department visit in the last two weeks of life; or (c) dying in hospital.Results In both exposed and unexposed groups, about 80% had cancer and 78% received end of life homecare services for the same average duration. Across all palliative care teams, 970 (31.2%) of the exposed group were in hospital and 896 (28.9%) had an emergency department visit in the last two weeks of life respectively, compared with 1219 (39.3%) and 1070 (34.5%) of the unexposed group (P<0.001). The pooled relative risks of being in hospital and having an emergency department visit in late life comparing exposed versus unexposed were 0.68 (95% confidence interval 0.61 to 0.76) and 0.77 (0.69 to 0.86) respectively. Fewer exposed than unexposed patients died in hospital (503 (16.2%) v 887 (28.6%), P<0.001), and the pooled relative risk of dying in hospital was 0.46 (0.40 to 0.52).Conclusions Community based specialist palliative care teams, despite variation in team composition and geographies, were effective at reducing acute care use and hospital deaths at the end of life. IntroductionHome based palliative care teams are meant to help patients manage symptoms, improve quality of life, and prevent avoidable hospitalisations, which are documented issues at end of life.1-3 Moreover, policy makers internationally want to deliver integrated palliative care in the home and community, since many patients prefer to be cared for at home, community care is often less expensive than hospital care, and acute care hospitals are overwhelmed.4 5 However, policy makers are unsure of optimal models of care delivery based on interdisciplinary teams. Although studies have evaluated specialist palliative care teams in hospitals, 6-8 only nine randomised controlled trials specifically investigated specialist teams in the community. [9][10][11][12][13][14][15][16][17] The community based teams studied in these trials involved a core group of interdisciplinary team members, specifically palliative care physicians, nurses, and family physicians who provide integrated palliative care to patients in their homes...

Identification of the physician workforce providing palliative care in Ontario using administrative claims data

“…5 A recent study showed that different community-based team models in Ontario reduced hospital admissions and emergency department visits, provided certain key elements were present. 17 About 40% of the GP/FPs in our study did not use a single palliative care fee code. If the intention is to increase the capacity of primary palliative care, this may represent a target group or metric.…”

NCCN Guidelines Insights: Palliative Care, Version 2.2017

“…39 Palliative care consultations for patients with advanced cancer have also been shown to reduce the quantity and intensity of life-prolonging care received toward the EOL. [40][41][42][43][44] Conversely, the lack of palliative care team consultation has been shown to be a predisposing factor for futile life-sustaining treatments at EOL. 45 An observational study suggested that inpatient palliative care led to fewer or no transitions in care settings at EOL.…”

“…These services have been associated with a reduced need for EOL emergency department visits, reduced length and frequency of hospitalization, and fewer intensive care unit (ICU) admissions and in-hospital deaths. [40][41][42][43][44] Palliative care has been shown to reduce symptom burden, improve QOL, and increase the odds of dying at home. Similarly, a 2013 Cochrane Database systematic review that analyzed home palliative care in patients with advanced illness demonstrated a reliable reduction of symptom burden and an increased likelihood of dying at home without a negative impact on caregiver grief.…”

Perfil Dos Pacientes Oncológicos Atendidos Em Uma Unidade De Emergência

“…Os autores enfatizam a importância do atendimento domiciliar a estes pacientes visando a redução utilização de cuidados intensivos e óbitos hospitalares no final da vida (15).…”