Evaluation of an Emergency Department-based Palliative Care Extender Program on Hospital and Patient Outcomes.

BACKGROUND: Boston Medical Center (BMC), a safety-net hospital, treated a substantial portion of the Boston cohort that was sick with COVID-19. Unfortunately, these patients experienced high rates of morbidity and mortality given the significant health disparities that many of BMC's patients face. Boston Medical Center launched a palliative care extender program to help address the needs of critically ill ED patients under crisis conditions. In this program evaluation our goal was to assess outcomes between those who received palliative care in the emergency department (ED) vs those who received palliative care as an inpatient or were admitted to an intensive care unit (ICU). METHODS: We used a matched retrospective cohort study design to assess the difference in outcomes between the two groups. RESULTS: A total of 82 patients received palliative care services in the ED, and 317 patients received palliative care services as an inpatient. After controlling for demographics, patients who received palliative care services in the ED were less likely to have a change in level of care (P<0.001) or be admitted to an ICU (P<0.001). Cases had an average length of stay of 5.2 days compared to controls who stayed 9.9 days (P<0.001). CONCLUSION: Within a busy ED environment, initiating palliative care discussions by ED staff can be challenging. This study demonstrates that consulting palliative care specialists early in the course of the patient's ED stay can benefit patients and families and improve resource utilization.

Racial equity in linkage to inpatient opioid use disorder treatment in patients that received emergency care.

OBJECTIVES: Opioid use disorder (OUD) is a national epidemic, and Black and Hispanic patients are less likely to receive treatment when compared to white patients. In this study, race was used as a proxy to assess potential effects of racism on the referral process for OUD treatment. Our primary aim was to examine whether Black or Hispanic patients experienced increased barriers to inpatient OUD detoxification (detox) placement at a community-integrated, substance use disorder support program based in an emergency department (ED). Our secondary aim was to determine if Black and Hispanic patients were more likely to have >3 referrals. METHODS: This retrospective cohort study was conducted at a large urban safety-net hospital and included patients seen in the ED from July 2018 to September 2019 with ICD-10 codes for an opioid-related visit and who sought placement to inpatient detox. A generalized linear mixed model controlling for multiple visits, age, sex, insurance, time, day of week, and time of year was used to assess the association between race/ethnicity and hypothesized barriers to placement. The proportion of patients with >3 visits for referral to inpatient detox was compared between Black and Hispanic patients and white patients using a chi-squared test. RESULTS: We identified 1733 encounters from 782 unique patients seeking connection to inpatient detox for OUD. Of the 1733 encounters, 45% were among Black and Hispanic patients. Hispanic and Black men had significantly lower odds of having a barrier to inpatient OUD detox than white men (OR = 0.734, 95% CI 0.542-0.995). No significant difference was found for Hispanic and Black women (OR = 1.212, 95% CI 0.705-2.082). More Black and Hispanic patients experienced >3 referrals to inpatient detox compared to white patients (19.2% vs 12.9%, p = 0.016). CONCLUSIONS: This study suggests in the context of near-universal health insurance coverage, an ED-based OUD support program staffed by diverse community members can mitigate inequities in access to inpatient detox. However, the increased number of ED visits for OUD detox placement by Black and Hispanic patients suggests racial inequities in OUD treatment exist after linkage to care. Additional research should explore the causes, specifically structural and interpersonal racism, and determine solutions to address racial inequities in detox placement as well as maintenance in treatment programs.