Verification of administrative data to measure palliative care at terminal hospital stays.

BACKGROUND: Administrative data and clinician documentation have not been directly compared for reporting palliative care, despite concerns about under-reporting. OBJECTIVE: The aim of this study was to verify the use of routinely collected administrative data for reporting in-hospital palliation and to examine factors associated with coded palliative care in hospital administrative data. METHOD: Hospital administrative data and inpatient palliative care activity documented in medical records were compared for patients dying in hospital between 1 July 2017 and 31 December 2017. Coding of palliative care in administrative data is based on hospital care type coded as "palliative care" and/or assignment of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) palliative care diagnosis code Z51.5. Medical records were searched for specified keywords, which, read in context, indicated a palliative approach to care. The list of keywords (palliative, end of life, comfort care, cease observations, crisis medications, comfort medications, syringe driver, pain or symptom management, no cardiopulmonary resuscitation, advance medical plan/resuscitation plan, deteriorating, agitation, restless and delirium) was developed in consultation with seven local clinicians specialising in palliative care or geriatric medicine. RESULTS: Of the 576 patients who died in hospital, 246 were coded as having received palliative care, either solely by the ICD-10-AM diagnosis code Z51.5 (42%) or in combination with a "palliative care" care type (58%). Just over one-third of dying patients had a palliative care specialist involved in their hospital care. Involvement of a palliative care specialist and a cancer diagnosis substantially increased the odds of a Z51.5 code (odds ratio = 11 and 4, respectively). The majority of patients with a "syringe driver" or identified as being at the "end of life" were assigned a Z51.5 code (73.5% and 70.5%, respectively), compared to 53.8% and 54.7%, respectively, for "palliative" or "comfort care." For each keyword indicating a palliative approach to care, the Z51.5 code was more likely to be assigned if the patient had specialist palliative care input or if they had cancer. CONCLUSION: Our results suggest administrative data under-represented in-hospital palliative care, at least partly due to medical record documentation that failed to meet ICD-10-AM coding criteria. Collaboration between clinicians and coders can enhance the quality of records and, consequently, administrative data.

Specialist Palliative Care Activity at an Acute Care Tertiary Hospital and Its Representation in Administrative Data.

OBJECTIVE: To quantify and examine specialist palliative care (SPC) in-hospital activity and compare it to routinely collected administrative data on palliative care (PC). METHODS: All patients discharged from a large acute care tertiary hospital in New South Wales, Australia, between July 1 and December 31, 2017, were identified from the hospital's data warehouse. Administrative data were supplemented with information from the electronic medical record for hospital stays which were assigned the PC additional diagnosis code (Z51.5); had a "palliative care" care type; or included SPC consultation. RESULTS: Of 34 653 hospital stays, 524 were coded as receiving PC-based on care type (43%) and/or diagnosis code Z51.5 (100%). Specialist palliative care provided 1717 consultations over 507 hospital stays. Patients had 2 (median; interquartile range: 1-4) consultations during an average stay of 15.3 days (SD 15.78; median 10); the first occurred 7.0 days (SD 12.13; median 3) after admission. Of patient stays with an SPC consultation, 70% were assigned the PC Z51.5 code; 60% were referred for symptom management; 68% had cancer. One hundred forty-one patients were under a palliative specialist-either from initial hospital admission (49.6%) or later in their stay. CONCLUSIONS: Palliative care specialists provide expert input into patient management, benefitting patients and other clinicians. Administrative data inadequately capture their involvement in patient care, especially consultations, and are therefore inappropriate for reporting SPC activity. Exclusion of information related to SPC activity results in an incomplete and distorted representation of PC services and fails to acknowledge the valuable contribution made by SPC.

Variation in Hospital Use at the End of Life Among New South Wales Residents Who Died in Hospital or Soon After Discharge.

Objective: Hospital use increases in the last 3 months of life. We aimed to examine its association with where people live and its variation across a large health jurisdiction. Methods: We studied a number of emergency department presentations and days spent in hospital, and in-hospital deaths among decedents who were hospitalized within 30 days of death across 153 areas in New South Wales (NSW), Australia, during 2010-2015. Results: Decedents' demographics and health status were associated with hospital use. Primary care and aged care supply had no or minimal influence, as opposed to the varying effects of areal factors-socioeconomic status, remoteness, and distance to hospital last admitted. Overall, there was an approximate 20% difference in hospital use by decedents across areas. In all, 18% to 57% of areas had hospital use that differed from the average. Discussion: The observed disparity can inform targeted local efforts to strengthen the use of community care services and reduce the burden of end-of-life care on hospitals.

Comparing the Montreal Cognitive Assessment and Rowland Universal Dementia Assessment Scale in a multicultural rehabilitation setting.

In Australia it is recommended that all older people undergoing rehabilitation have a cognitive screen. We performed a longitudinal study comparing the correlation of two cognitive screening tools - the Rowland Universal Dementia Assessment Scale (RUDAS) and Montreal Cognitive Assessment (MoCA) with discharge outcomes in a geriatric inpatient setting. The RUDAS cut-off (<23/30) was associated with discharge to a nursing home (sensitivity 52%, specificity 70%). This was also noted with a MoCA cut-off <18/30 (sensitivity 57%, specificity 69%). Furthermore the association between the RUDAS and discharge destination was independent of its association with the Functional Independence Measure (r = 0.116; P = 0.275) and had a shorter administration time. Both RUDAS and MoCA scores could be used as predictors of discharge destination in a multicultural population.

Variation in out-of-hospital death among palliative care inpatients across public hospitals in New South Wales, Australia.

BACKGROUND: Place of death is an important indicator in palliative care, as out-of-hospital death is often preferred by patients and is less costly for the healthcare system. AIM: To examine variation and contributing factors in out-of-hospital death after receiving palliative care in hospital to inform improvement in transition of care between hospitals and communities. METHODS: Using hospital linked data (July 2010, June 2015) we followed individuals aged 50 or older who received palliative care in hospital and within 3 months to death who were last admitted to a public acute-care hospital in New South Wales, Australia (73 hospitals). RESULTS: Among 25 359 palliative care inpatients, 3677 (14%) died out of hospital. The out-of-hospital death rate was lower for younger patients, males and those living in the most deprived areas; it was higher for cancer patients and those who received palliative care before their last admission. Hospital size, location and availability of hospice care unit were not influential. Across hospitals, the median crude rate of out-of-hospital death was 14% (interquartile range 10-19%). The contributing factors explained 19% of the variation, resulting in a rate difference of 44% between hospitals with high versus low rates; 25% of hospitals had a higher and 14% had a lower than average adjusted out-of-hospital death rate. CONCLUSION: The majority of patients who received palliative care in hospital stayed in hospital until death. The variation in out-of-hospital death across hospitals was considerable and mostly remained unexplained. This variability warrants investigation into transition of palliative care between hospitals and communities to inform interventions.