Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre.

BACKGROUND: Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. AIMS: This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. METHODS: One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. RESULTS: During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. CONCLUSIONS: The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.

Working in value-discrepant environments inhibits clinicians' ability to provide compassion and reduces well-being: A cross-sectional study.

BACKGROUND: The practice of compassion in healthcare leads to better patient and clinician outcomes. However, compassion in healthcare is increasingly lacking, and the rates of professional burnout are high. Most research to date has focused on individual-level predictors of compassion and burnout. Little is known regarding how organizational factors might impact clinicians' ability to express compassion and well-being. The main study objective was to describe the association between personal and organizational value discrepancies and compassion ability, burnout, job satisfaction, absenteeism and consideration of early retirement among healthcare professionals. METHODS: More than 1000 practising healthcare professionals (doctors, nurses and allied health professionals) were recruited in Aotearoa/New Zealand. The study was conducted via an online cross-sectional survey and was preregistered on AsPredicted (75407). The main outcome measures were compassionate ability and competence, burnout, job satisfaction and measures of absenteeism and consideration of early retirement. RESULTS: Perceived discrepancies between personal and organizational values predicted lower compassion ability (B = -0.006, 95% CI [-0.01, -0.00], p < 0.001 and f 2  = 0.05) but not competence (p = 0.24), lower job satisfaction (B = -0.20, 95% CI [-0.23, -0.17], p < 0.001 and f 2  = 0.14), higher burnout (B = 0.02, 95% CI [0.01, 0.03], p < 0.001 and f 2  = 0.06), absenteeism (B = 0.004, 95% CI [0.00, 0.01], p = 0.01 and f 2  = 0.01) and greater consideration of early retirement (B = 0.02, 95% CI [0.00, 0.03], p = 0.04 and f 2  = 0.004). CONCLUSIONS: Working in value-discrepant environments predicts a range of poorer outcomes among healthcare professionals, including hindering the ability to be compassionate. Scalable organizational and systems-level interventions that address operational processes and practices that lead to the experience of value discrepancies are recommended to improve clinician performance and well-being outcomes.

Predictors of Medical Students' Compassion and Related Constructs: A Systematic Review.

Phenomenon: Compassion, and related constructs such as empathy, are core values in healthcare, with known benefits for both patients and staff. Yet research on the factors that affect compassion and compassion-related constructs remains scattered. This review systematizes and synthesizes studies investigating the predictors of compassion and related constructs among medical students, allowing for a better understanding of the factors that both positively and negatively contribute to the development of compassionate future physicians. Approach: A systematic review of 12 databases for studies from database inception up until April 2020 was conducted. Non-peer-reviewed literature and studies in which >50% of the sample were non-medical students were excluded. Intervention studies were also out of the scope of this review. We assessed risk of bias and confidence in the findings using standardized tools. Data were categorized within the Transactional Model of Physician Compassion, a framework in which compassion is influenced by personal (student), environmental, patient/family, and clinical factors. Findings: Of 14,060 retrieved articles, 222 studies were included. Of these, 95% studied student factors, but only 25% studied environmental, 9% studied patient, and 6% studied clinical factors. Predictors of greater compassion included maturity; work and life experiences; personality traits of openness to experience and agreeableness; skills such as perspective taking, reflection, and mindfulness; and positive role modeling. Conversely, negative attitudes/emotions, burnout, stress, detachment, operating in cultures prioritizing knowledge and efficiency over humanistic care, negative role models, time constraints, and heavy workloads predicted lower compassion. Patient-related factors included "difficult" and "noncompliant" patients or those perceived as responsible for their illness. Overall, 60% of studies had a serious risk of bias, particularly confounding and participant selection biases. Insights: Medical student compassion is predicted by a wide range of factors relating to the student, their training environment, their patients, and the clinical situation. However, existing research has largely focused on student factors (e.g., sociodemographic and dispositional traits), many of which are not amenable to intervention. Skills such as perspective taking, reflection, and mindfulness are associated with higher compassion and may present opportunities for intervention. There is also strong evidence that environmental factors shape students' compassion. Researchers and educators should continue to explore the impact of patient and clinical factors on students' compassion. Studies remain at high risk of bias.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review.

BACKGROUND: Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC). METHODS: A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach. RESULTS: One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC. DISCUSSION: The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

Providing a liminal space: Threshold concepts for learning in palliative medicine.

Introduction: Experience in palliative medicine provides a beneficial learning opportunity for doctors-in-training. There is, however, a gap in understanding which aspects of learning are most useful, which are problematic and how learning can best be facilitated. This study addresses that gap using the 'threshold concepts' framework. Threshold concepts are critical points of learning, often unique to a discipline. The learning occurs within a transitional or 'liminal' space and has specific characteristics including being 'troublesome' and 'transformative.'Methods: A qualitative, exploratory study was carried using the threshold concept framework. Semi-structured focus group interviews were held with doctors-in-training who had undertaken a 6-month palliative medicine attachment. Data were analysed using a content analysis approach with deductive and inductive phases, in order to identify threshold concepts.Results: Five threshold concepts were identified. Two of these, 'emotional engagement' and 'communication management,' displayed all the typical characteristics of threshold concepts. This learning was highly valued by participants, had not occurred elsewhere in training and continued to influence practice.Conclusions: Specific threshold concepts were identified for doctors undertaking a palliative medicine placement. These highlights where specific supports are required for learning and can be used to inform curriculum design.

Deathbed Confession: When a Dying Patient Confesses to Murder: Clinical, Ethical, and Legal Implications.

During an initial palliative care assessment, a dying man discloses that he had killed several people whilst a young man. The junior doctor, to whom he revealed his story, consulted with senior palliative care colleagues. It was agreed that legal advice would be sought on the issue of breaching the man's confidentiality. Two legal opinions conflicted with each other. A decision was made by the clinical team not to inform the police. In this article the junior doctor, the palliative medicine specialist, a medical ethicist, and a lawyer consider the case from their various perspectives.

Reigniting compassion in healthcare: Manaakitia Reflective Rounds.

BACKGROUND: The reported levels of staff stress and burnout at all levels of training and disciplines is significant and recognised to impact on the care of patients and families. We present an initiative to support staff at Auckland City Hospital based on the Schwartz Center Rounds. AIM: To evaluate the efficacy of monthly case-based, staff support reflective rounds to discuss complex emotional and psychosocial issues that arise in caring for patients and families. METHODS: At Auckland City Hospital, a pilot programme called Manaakitia Reflective Rounds was conducted between April 2014 and September 2015. These were facilitated 1-h, monthly, case-based, staff support groups to discuss complex emotional and psychosocial issues in caring for patients. Staff evaluations and feedback were collated. RESULTS: A total of 12 rounds was conducted exploring a range of challenging issues, from difficulty in achieving a patient's wish to die at home to coping with the 'heart sink' patient. There were 276 attendees in total, with an average attendance of 23 participants per round. A total of 218 evaluations was returned (79%) with rounds being rated as either exceptional or excellent by 87.5% of participants. Attendees reported positive benefits, such as gaining knowledge to help them care for patients (94%), working better with colleagues (87%) and gaining insight into how others think and feel in caring for patients (97%). Attendees reported a sense of having a 'shared experience' with better understanding of each other's professional perspectives and acknowledgement of the limitations (practical and human) in caring for patients and families. CONCLUSION: Evaluations of the rounds indicate a need for staff to have a safe and supportive space to explore the emotional aspects of their work. Staff particularly appeared to value having a 'shared understanding' with the recognition that they are 'not alone' when managing challenging situations.

Can we predict which hospitalised patients are in their last year of life? A prospective cross-sectional study of the Gold Standards Framework Prognostic Indicator Guidance as a screening tool in the acute hospital setting.

BACKGROUND: Screening to identify hospital inpatients with a short life expectancy may be a way to improve care towards the end of life. The Gold Standards Framework Prognostic Indicator Guidance is a screening tool that has recently been advocated for use in the hospital setting. AIM: To assess the clinical utility of the Gold Standards Framework Prognostic Indicator Guidance as a screening tool in an acute hospital setting. MAIN OUTCOME MEASURES: Mortality at 6 and 12 months and sensitivity, specificity and predictive value of the Gold Standards Framework Prognostic Indicator Guidance at 1 year. DESIGN, SETTING AND PARTICIPANTS: Prospective cross-sectional study of 501 adult inpatients in a tertiary New Zealand teaching hospital screened utilising the Gold Standards Framework Prognostic Indicator Guidance. RESULTS: A total of 99 patients were identified as meeting at least one of the Gold Standards Framework Prognostic Indicator Guidance triggers. In this group, 6-month mortality was 56.6% and 12-month mortality was 67.7% compared with 5.2% and 10%, respectively, for those not identified as meeting the criteria. The sensitivity and specificity of the Gold Standards Framework Prognostic Indicator Guidance at 1 year were 62.6% and 91.9%, respectively, with a positive predictive value of 67.7% and a negative predictive value of 90.0%. CONCLUSION: The sensitivity, specificity and predictive values of the Gold Standards Framework Prognostic Indicator Guidance in this study are comparable to, or better than, results of studies identifying patients with a limited life expectancy in particular disease states (e.g. heart failure and renal failure). Screening utilising the Gold Standards Framework Prognostic Indicator Guidance in the acute setting could be the first step towards implementing a more systematic way of addressing patient need--both current unrecognised and future anticipated--thereby improving outcomes for this population.

Do I care for you more when you really need help? An experimental test of the effect of clinical urgency on compassion in health care.

OBJECTIVES: To experimentally investigate whether more urgent patient presentations elicit greater compassion from health care professionals than less urgent, facilitating future research and thinking to address systemic barriers to compassion in health care. DESIGN: This is a pre-registered online study with an experimental, within-subjects repeated-measure study design. Two clinical vignettes that systematically varied the urgency of patient presentation were utilized. Both vignettes depicted a patient with difficult behaviours typically associated with lower compassion. METHODS: Health care professionals (doctors, nurses and allied health practitioners) recruited from all 20 District Health Boards across Aotearoa/New Zealand completed two vignettes in a counterbalanced order. Paired-sample t-tests were used to test the effect of the presentation urgency on indices of compassion. RESULTS: A total of 939 participants completed the vignettes (20% doctors, 47%, nurses and 33% allied health professionals). As expected, participants reported greater care and motivation to help the more urgent patient. However, the more urgent patient was also perceived as less difficult, and exploratory analyses showed that perceived patient difficulty was associated with lower caring and motivation to help, particularly in the less urgent patient. CONCLUSIONS: This is the first work to experimentally test the relationship between the urgency of patient presentation and compassion in health care. Although the association between urgency and difficulty is complex, our findings are consonant with evolutionary views in which urgent distress elicits greater compassion. A system-wide orientation towards efficiency and urgency may exacerbate this 'bias' which must be addressed to ensure more equitable compassion in health care.

Defective Visceral Adipose Tissue Adaptation in Gestational Diabetes Mellitus.

CONTEXT: Gestational diabetes mellitus (GDM) is a complex obstetric condition affecting localized glucose metabolism, resulting in systemic metabolic dysfunction. OBJECTIVE: This cross-sectional study aimed to explore visceral adipose tissue (VAT) as an integral contributor to GDM, focusing on elucidating the specific contribution of obesity and GDM pathology to maternal outcomes. METHODS: Fifty-six nulliparous pregnant women were recruited, including normal glucose tolerant (NGT) (n = 30) and GDM (n = 26) participants. Participants were subgrouped as nonobese (BMI <30 kg/m2) or obese (BMI ≥30 kg/m2). Metabolic markers in circulation, VAT, and placenta were determined. Morphological analysis of VAT and immunoblotting of the insulin signaling cascade were performed. RESULTS: GDM participants demonstrated hyperinsulinemia and elevated homeostatic model assessment for insulin resistance (HOMA-IR) scores relative to NGT participants. The GDM-obese subgroup had significant VAT adipocyte hypoplasia relative to NGT-nonobese tissue. GDM-obese VAT had significantly lower insulin receptor substrate (IRS)-2 expression, with elevated ser312 phosphorylation of IRS-1, relative to NGT-nonobese. GDM-obese participants had significantly elevated circulating leptin levels and placental adipsin secretion, while GDM-nonobese participants had elevated circulating adipsin levels with reduced placental adiponectin secretion. CONCLUSION: These findings suggest that GDM-obese pregnancy is specifically characterized by inadequate VAT remodeling and dysfunctional molecular signaling, which contribute to insulin resistance and hinder metabolic health.

The nature of, and reasons for, 'inappropriate' hospitalisations among patients with palliative care needs: a qualitative exploration of the views of generalist palliative care providers.

BACKGROUND: Recent studies have concluded that there is significant potential to reduce the extent of 'inappropriate' hospitalisations among patients with palliative care needs. However, the nature of, and reasons for, inappropriate hospitalisations within a palliative care context is under-explored. AIM: To explore the opinions of 'generalist' palliative care providers regarding the nature of, and reasons for, inappropriate admissions among hospital inpatients with palliative care needs. DESIGN: Qualitative study with data collected via individual interviews and focus groups. SETTING/PARTICIPANTS: Participants (n = 41) comprised 'generalist' palliative care providers working in acute hospital and community settings. SETTING: One District Health Board in an urban area of New Zealand. RESULTS: The majority of participants discussed 'appropriateness' in relation to their own understanding of a good death, which typically involved care being delivered in a 'homely' environment, from known people. Differing attitudes among cultural groups were also evident. The following reasons for inappropriate admissions were identified: family carers being unable to cope, the 'rescue culture' of modern medicine, the financing and availability of community services and practice within aged residential care. CONCLUSIONS: On the basis of our findings, we recommend a shift to the term 'potentially avoidable' admission rather than 'inappropriate admission'. We also identify an urgent need for debate regarding the role of the acute hospital within a palliative care context. Interventions to reduce hospital admissions within this population must target societal understandings of death and dying within the context of medicalisation, as well as take into account cultural and ethnic diversity in attitudes, if they are to be successful.

Emotional congruence in learning and health encounters in medicine: addressing an aspect of the hidden curriculum.

This paper aims to draw attention to and provide insights into an area that is of educational significance for clinical teachers, namely the need to acknowledge and respond appropriately to the emotional context of both learning and health encounters in order to improve the outcomes of both. This need has been highlighted by recent calls for more attention to be paid to the role of emotion within medical education and within health care provision. What is already known about the role of emotion in learner-teacher encounters and in patient-doctor encounters will be used to develop the concept of emotional congruence within these two types of encounter as a challenge to clinical teachers to examine their own practice. The reasons why emotional congruence is not always apparent in the learning environment of the teaching hospital will be discussed using the model of the 'hidden curriculum'. It will be suggested that explicit strategies to counteract the hidden curriculum in relation to emotion can bring about transformative change in individual practice and the health care environment that has the potential to improve both learning and health outcomes.

Palliative care need and management in the acute hospital setting: a census of one New Zealand Hospital.

BACKGROUND: Improving palliative care management in acute hospital settings has been identified as a priority internationally. The aim of this study was to establish the proportion of inpatients within one acute hospital in New Zealand who meet prognostic criteria for palliative care need and explore key aspects of their management. METHODS: A prospective survey of adult hospital inpatients (n = 501) was undertaken. Case notes were examined for evidence that the patient might be in their last year of life according to Gold Standards Framework (GSF) prognostic indicator criteria. For patients who met GSF criteria, clinical and socio-demographic information were recorded. RESULTS: Ninety-nine inpatients met GSF criteria, representing 19.8% of the total census population. The patients' average age was 70 years; 47% had a primary diagnosis of cancer. Two thirds had died within 6 months of their admission. Seventy-eight of the 99 cases demonstrated evidence that a palliative approach to care had been adopted; however documentation of discussion about goals of care was very limited and only one patient had evidence of an advance care plan. CONCLUSION: One fifth of hospital inpatients met criteria for palliative care need, the majority of whom were aged >70 years. Whilst over three quarters were concluded to be receiving care in line with a palliative care approach, very little documented evidence of discussion with patients and families regarding end of life issues was evident. Future research needs to explore how best to support 'generalist' palliative care providers in initiating, and appropriately recording, such discussions.

Medical students' evaluation of a suicide prevention multimedia resource: A focus group study.

AIMS: A series of podcasts and videos was created to assist medical students with learning about suicide prevention. The aim of this research was to explore medical students experiences of using a suicide prevention learning resource. METHODS: A multimedia repository of learning resources for suicide prevention was designed and created for use across all years of the medical programme at The University of Auckland. Emphasis was placed on ensuring that the resource was culturally safe. The impact of the learning resource was evaluated with a qualitative approach using focus group methodology. Two focus groups were audio-recorded, transcribed and a thematic analysis was conducted employing three cycles of coding. RESULTS: Three themes were identified: perceiving that suicide is complex and sensitive; tailoring knowledge to match students' developmental stage and context; and elements that facilitated interaction with the resource. CONCLUSIONS: Suicide is unsurprisingly a challenging topic for medical students. The students in this study actively engaged with this resource on suicide prevention, which supplemented their core learning of the topic. Early access to resources developed in a culturally safe way within a spiral curriculum empowers students to understand that they have an important contribution to make in preventing suicide. This may prepare them for encountering suicide with peers, family members and in clinical practice.

Happiness at the End of Life: A Qualitative Study.

BACKGROUND: Happiness is a core ingredient of health and well-being, yet relatively little is known about what happiness means for individuals near the end of life, and whether perceptions of happiness change as individuals approach the end of their lives. AIM: The aim of this study was to explore, through interviews, how individuals experiencing hospice care understood and conceptualized happiness. DESIGN: Qualitative interviews with hospice patients were analyzed thematically. SETTING/PARTICIPANTS: Adult patients (n = 20) in a New Zealand hospice who were receiving palliative care and who could give their informed consent were invited by hospice nurse coordinators to an interview. RESULTS: Four themes emerged from analysis of the transcribed interviews. Participants defined happiness most frequently and in most depth in relation to connection with others. They identified being in the present moment, particularly in relation to nature, and that happiness had become less associated with money, status, or possessions. They had an attitude of determination to focus on what mattered now. CONCLUSION: Patients receiving palliative care were generally happy with their lives, appreciated the simpler aspects of life away from the material. There was a common exhortation to young people to avoid focusing too much on acquisition and the internet and to prioritize instead social connection and engagement with the natural world.

Factors Associated With Terminally Ill People Who Want to Die.

CONTEXT: The decision to request and proceed with euthanasia or physician-assisted dying is complex, and predictors of such decisions are heterogeneous with regard to physical health, psychological, and social factors. Local research is therefore needed. OBJECTIVES: To examine the interplay of demographic, clinical, and psychosocial factors routinely collected by a standardized clinical instrument, the interRAI Resident Assessment Instrument for Palliative Care (interRAI-PC), in people with a prognosis of less than 12 months who wanted to die. METHODS: All New Zealanders who had an interRAI-PC in 2018 were included. The outcome variable was the single item Wants to die now. Independent variables included biopsychosocial factors and health index scales generated by interRAI-PC. A binary logistic regression was used to determine the predictive factors of Wants to die now (yes vs. no). RESULTS: There were 771 individuals included (mean age 76.0 years; SD 11.6; female 50.1%); 9.3% of whom reported yes to Wants to die now, 59.8% no, and for 30.9%, the assessor was unable to determine. The factors with the largest odds ratios (ORs) were awareness of terminal prognosis (OR 4.8; 95% CI 2.2-10.3), high level of depression (OR 4.6; 95% CI 1.7-12.6), not finding meaning in day-to-day life (OR 3.8; 95% CI 1.8-8.1), and pain (less than severe: OR 3.7; 95% CI 1.3-10.4 and severe to excruciating: OR 3.5; 95% CI 1.1-10.7). CONCLUSION: Addressing the significant factors we identified should form part of a multidisciplinary assessment when terminally ill patients express a wish to die, to ensure their physical, psychological, and existential needs are adequately met.

Performativity, identity formation and professionalism: Ethnographic research to explore student experiences of clinical simulation training.

Developing professional identity is a vital part of health professionals' education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.

A comparative study of self-perceived public health competencies: practice teachers and qualifying SCPHNs.

There is evidence to suggest that population-focused public health nursing is more rhetoric than reality. This quantitative study compares the self-perceived public health competence of qualifying student specialist community public health nurses (SCPHNs) (n = 35) with those of the practice teachers (PTs) facilitating their practice learning (n = 31). Findings suggest that PTs felt more competent than qualifying students on leadership and management for public health, working with communities, and communication skills. However, the qualifying students self-rated higher than the PTs on principles and practice of public health, suggesting that the PTs in this study felt less competent than their qualifying students in key public health skills, such as epidemiology, population health needs assessment, research and evidence-based decision-making. It is recommended that the triennial review of PTs should address not only educational skills but knowledge and skills in contemporary public health practice, a continuing professional development framework for SCPHNs should be developed and funded, providers should assist PTs in keeping up with contemporary public health, and the role of the PT should be recognised and given appropriate support and remuneration.

The extent and cost of potentially avoidable admissions in hospital inpatients with palliative care needs: a cross-sectional study.

OBJECTIVE: More than 90% of people spend time in hospital in the last year of life and, in many developed countries, hospitals are the setting in which most people will die. Previous research indicates that a proportion of these hospital admissions could have been avoided. The objective of this study was to establish the extent and cost of potentially avoidable hospital admissions among patients with palliative care needs. METHODS: A prospective survey of hospital inpatients was undertaken to identify patients who met clinical criteria indicating palliative care need. Case notes were reviewed by two expert palliative care clinicians to determine if the hospital admission was potentially avoidable. An analysis of the cost of potentially avoidable admissions compared to all other admissions for those patients identified as being in the last year of life was carried out using the statistical analysis software R V.2.15.1. Logistic regression was performed using the logit (log of OR) link. The binary outcome of the logistic regression model was a potentially avoidable admission. RESULTS: Of the 99 patients who met the criteria for palliative care need, 22 were deemed to have experienced a potentially avoidable admission. Those living in a residential aged care facility were more at risk of experiencing such admissions. The mean total cost of hospital care for those with palliative care needs was lower for those whose admission was deemed potentially avoidable. CONCLUSIONS: A significant proportion of patients with palliative care needs experience a potentially avoidable admission. Although these admissions are relatively short compared to those whose admissions are unavoidable, any hospital admission impacts on the experiences of patients and families and may contribute to unnecessary hospital expenditure.