Outcomes and Cost of Patients With Terminal Cancer Admitted to Acute Care in the Final 2 Weeks of Life: A Retrospective Chart Review.

BACKGROUND: Patients with terminal conditions are often admitted to the emergency department (ED) for acute medical services, but studies have suggested that multiple ED admissions may negatively impact end-of-life (EOL) care. Research have shown that incorporating palliative care (PC) is integral to optimal EOL care, but it is an aspect of medical practice that is often neglected. The current study sought to provide an overview of health outcomes and hospital costs of patients with cancer admitted to The Ottawa Hospital and/or received acute medical services during their final 2 weeks of life. Cost comparisons and estimates were made between hospital and hospice expenditures. METHODS: We conducted a retrospective chart review of palliative patients who died at The Ottawa Hospital in 2012. A total of 130 patients who visited the ED within 2 weeks of death were included in the analyses. RESULTS: In this cohort of patients, 71% of admitted patients did not have advanced care directives and 85% experienced a metastasis, but only 18% had a PC medical doctor. Patients were hospitalized, on average, for 7 days and hospitalization costs exceeded the estimated hospice cost by approximately 2.5 times (Can$1 041 170.00 at Can$8009.00/patient vs Can$401 570.00 at Can$3089.00/patient, respectively). CONCLUSION: Our study highlighted the importance of PC integration in high-risk patients, such as those in oncology. Patients in our sample had minimal PC involvement, low advanced care directives, and accrued high costs. Based on our analyses, we concluded that these patients would have likely benefited more from hospice care rather than hospitalization.

Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injury Update.

In 2012, we published a study in this journal exploring the emergence of unique skin changes in end-of-life patients admitted to a palliative care unit. The purpose of the study was to describe the skin changes and identify the relationship between these changes and time of death. In the above study of 80 patients, the skin changes were found to be unique and different from Kennedy terminal ulcers and deep tissue injuries. Median time from identification of skin changes and death was 36 hours. The phenomenon was named as Trombley-Brennan terminal tissue injury. The current article presents findings that include the study of additional 86 patients. The results further validate the phenomenon and its relationship with time of death.

Implications of Palliative Care Consultation Timing among a Cohort of Hospice Decedents.

Background: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation. Objective: Comparison of health care utilization for hospice decedents who received early versus late palliative care. Design: A retrospective cohort study utilizing hospital and hospice administrative databases. Setting/Subjects: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice. Measurements: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS). Results: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days). Conclusions: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.

Costs of Care and Location of Death in Community-Based Pediatric Palliative Care.

Background: Children with complex chronic conditions (CCCs) are dying at home with increased frequency, yet the number of studies on the financial feasibility of community-based pediatric palliative care is limited. Objective: The objectives of this study were to (1) describe characteristics of patients who died in a community-based palliative care program and (2) evaluate cost differences associated with participant characteristics and location of death. Design: A retrospective cohort analysis of administrative and electronic medical record data was employed. Setting/Subjects: Children enrolled in the community-based pediatric palliative care program, CompassionNet, who died between 2008 and 2015 were included (N = 224). Measurements: Demographic data, program expense, and paid claims were extracted from an insurance provider database and clinical data from the electronic medical record. Results: Sixty-six (29%) of the children were <1 year old at death; 80 (36%) were 1-9 years old, and 78 (35%) were 10-22 years old. Malignancy was the most common primary CCC diagnosis for the 158 children/adolescents (n = 89, 56%), whereas neuromuscular conditions (n = 20, 30%) were most frequent for infants. Death at home occurred 21% of the time for infants, 48% for children of ages 1-9 years, and 46% for children of ages 10-22 years. The mean total cost in the final year of life for pediatric patients was significantly related to location of death, a malignancy diagnosis, and participation in Medicaid. The largest estimated difference was between costs of care associated with death at home ($121,111) versus death in the hospital ($200,050). Conclusions: Multidisciplinary community-based pediatric palliative care teams provide the opportunity for a home death to be realized as desired. Significant cost differences associated with location of death may support program replication and sustainability.

Is palliative care cost-effective in low-income and middle-income countries? A mixed-methods systematic review.

INTRODUCTION: Of the 40 million people globally in need of palliative care (PC), just 14% receive it, predominantly in high-income countries. Within fragile health systems that lack PC, incurable illness is often marked by pain and suffering, as well as burdensome costs. In high-income settings, PC decreases healthcare utilisation, thus enhancing value. Similar cost-effectiveness models are lacking in low-income and middle-income countries and with them, the impetus and funding to expand PC delivery. METHODS: We conducted a systematic search of seven databases to gather evidence of the cost-effectiveness of PC in low-income and middle-income countries. We extracted and synthesised palliative outcomes and economic data from original research studies occurring in low-income and middle-income countries. This review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and includes a quality appraisal. RESULTS: Our search identified 10 eligible papers that included palliative and economic outcomes in low-income and middle-income countries. Four provided true cost-effectiveness analyses in comparing the costs of PC versus alternative care, with PC offering cost savings, favourable palliative outcomes and positive patient-reported and family-reported outcomes. CONCLUSIONS: Despite the small number of included studies, wide variety of study types and lack of high-quality studies, several patterns emerged: (1) low-cost PC delivery in low-income and middle-income countries is possible, (2) patient-reported outcomes are favourable and (3) PC is less costly than the alternative. This review highlights the extraordinary need for robust cost-effectiveness analysis of PC in low-income and middle-income countries in order to develop health economic models for the delivery of PC, direct resource allocation and guide healthcare policy for PC delivery in low-income and middle-income countries.

Palliative Care Program Development in a Low- to Middle-Income Country: Delivery of Care by a Nongovernmental Organization in India.

PURPOSE: Limited data describe the delivery of palliative care services in low- and middle-income countries. We describe delivery of care by the Trivandrum Institute of Palliative Sciences (TIPS) in Trivandrum, India. METHODS: Administrative records were used to describe case volumes, setting of care, and organizational expenditures. An estimate of cost per clinical encounter was derived by dividing 2016 monthly clinical expenditures by the number of patient visits. Costs are reported in US dollars and are corrected for Organization for Economic Co-operation and Development purchasing power parity (PPP). RESULTS: A total of 11,620 new patients were seen at TIPS during 2007 to 2016; 59% had cancer. The average annual growth rate in case volumes was 18% (480 new patients in 2007 and 1,882 in 2016). The proportion of patients with cancer increased over time from 56% in 2014 to 66% in 2016 ( P < .001). During 2014 to 2016, outpatient visits increased 26% (from 8,524 to 10,732), inpatient days increased 49% (from 1,763 to 2,625), inpatient visits at other hospitals increased 41% (from 248 to 417), and home visits increased 57% (from 3,951 to 6,186). Total clinical expenditures in 2016 were $288,489 (PPP corrected, $5.1 million). Between 2014 and 2016, the cost of delivering care increased by 74%. The mean cost per clinical encounter in 2016 was $15 (PPP corrected, $263). CONCLUSION: Demand for palliative care services has increased substantially, with an increasing proportion related to cancer. The organization of clinical services by TIPS may serve as a model for the development of other palliative care programs in low- and middle-income countries.

Economic outcomes in palliative and end-of-life care: current state of affairs.

The status of economic research in palliative care is evaluated. Significant limitations are observed in research to date. Recommendations are made for broadening the scope of economic enquiry in palliative care.

Economic Impact of Early Inpatient Palliative Care Intervention in a Community Hospital Setting.

BACKGROUND: Inpatient palliative care programs have demonstrated financial benefit for the hospital and improved quality of care for patients with advanced disease. Previous studies on this subject have focused on comparisons between palliative and traditional care. The financial and clinical effects of early versus late palliative care intervention are less well documented. OBJECTIVE: The aims of this study are to review the financial and quality outcomes that early palliative care intervention has on appropriate inpatients in the community hospital setting. MATERIALS AND METHODS: This retrospective study analyzed 449 palliative care patients. The independent variable was days to palliative care consultation, characterized as early palliative care (≤3 days) and late palliative care (>3 days). Dependent variables included length of stay (LOS) and financial considerations. The two groups were further stratified according to case mix index, medical versus surgical, as well as certain disease groups, such as sepsis, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) exacerbation. The patient's functional status, measured by the Victoria Palliative Performance Scale (PPSv2) was calculated to determine if this variable independently influenced the timing of consultation. RESULTS: Patients in the early intervention group realized a reduction in LOS and a significant cost reduction. In the analysis of the entire group, the average LOS with early intervention was 6.09 days versus 16.5 days with late intervention (p < 0.001). The early intervention group demonstrated an earlier transition to comfort care, earlier referral to outpatient hospice, and did not have a negative effect on mortality. The patient's PPSv2 score did not influence the timing of intervention (p 0.25). CONCLUSION: Early intervention with inpatient palliative care consultation correlated with financial benefit as well as earlier referral to more appropriate levels of care. These effects were achieved with minimal expense in a medium-sized community hospital.

A team approach to recruitment in hospice research: engaging patients, close people and health professionals.

Research is vital to the future development of hospice care. However, research in hospice settings is very challenging. This paper describes a case study of a successful multidisciplinary research team approach (MDRT) to the recruitment of participants (hospice patients, family members and health professionals) for a study in a hospice setting on the economic evaluation of end-of-life care. A successful recruitment plan includes three key strategies: identifying key members of the MDRT early in the research process; having a clear and constant communication stream; and creating an environment where all team members have a shared commitment to the research, all voices are heard and valued, and everyone contributes to the research aims. An MDRT approach will be helpful to guide the development of successful recruitment plans for academic-community research partnerships in the hospice setting.

The effect of pediatric knowledge on hospice care costs.

The cost of hospice care is rising. Although providing care for children at end of life may be costly for hospices, it is unclear whether or not gaining pediatric knowledge and even establishing a pediatric program may be done cost effectively. The purpose of our study was to examine the effect of possessing pediatric knowledge (i.e., pediatric program, pediatric experience) on core hospice care costs. Using 2002 to 2008 California hospice data, the findings of the regression analysis suggest that having pediatric knowledge does not significantly increase nursing, physician, and medical social service costs. Having a pediatric program was related to increased counseling costs. Our findings shed important light on the minimal costs incurred when hospices decide to develop pediatric knowledge.

Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay.

Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53-105 days before death. Using data from the Health and Retirement Study, 2002-08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53-105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1-7, 8-14, and 15-30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.