Search

Background: Hospice care frequently includes hands-on care from hospice aides, but the need for hospice aide care may vary in residential settings (e.g., assisted livings and nursing homes). Objectives: The objective of this study is to compare hospice aide use and factors associated with use across residential settings. Design: This longitudinal cohort study used data from Medicare beneficiaries in the United States enrolled in the Medicare Current Beneficiary Survey (MCBS) who died between 2010 and 2019 and had hospice claims and available residential setting data in MCBS (n = 1,915). Analysis: Decedent hospice aide use was compared by residential settings; multivariable models controlling for sociodemographic, clinical/functional, and hospice characteristics examined factors associated with hospice aide care in different residential settings. Results: Hospice aide visits were least common in the community setting (64.4% vs. 76.6% vs. 72.6% with any hospice aide visits in community, assisted living, and nursing home, respectively, p = 0.001). In adjusted models, factors associated with hospice aide visits did not significantly differ by residential settings. Conclusions: Despite staff providing hands-on support in assisted livings and nursing homes, hospice aide visits were more common in residential as opposed to community settings, and factors associated with hospice aide visits were similar among settings. To maximize the potentially positive impact of hospice aides on overall care, additional work is needed to understand when hospice aides are used and how hospice aides collaborate with families and care teams. This will help to ensure that hospice care is appropriately tailored to individual care needs in all residential settings. [ABSTRACT FROM AUTHOR]

The article discusses the growing influence of the financial sector, particularly private equity, in the home health and hospice industries in the U.S. Topics discussed include the shift from nonprofit to for-profit ownership, the potential conflict between profit motives and patient care quality, and the implications for care outcomes and Medicare costs.

Background: The evidence base to support palliative care clinical practice is inadequate and opportunities to improve the evidence base remain despite the field's rapid growth. Objective: The aim of this study was to examine current National Institutes of Health (NIH) funding of palliative medicine research and trends over time. Design: We sought to identify NIH funding of palliative medicine (2016–2020) in two stages: (1) we searched the NIH grant database, RePORTER, for grants with the keywords, "palliative care," "end-of-life care," "hospice," and "end of life," and (2) identified palliative care researchers likely to have secured NIH funding using three strategies. Methods: We abstracted (1) the first and last authors' names from original investigations published in major palliative medicine journals from 2016 to 2018; (2) names from a PubMed-generated list of original articles published in major medicine, nursing, and subspecialty journals using the above keywords; and (3) palliative medicine journal editorial board members and members of key palliative medicine initiatives. We cross-matched the pooled names against NIH grants funded from 2016 to 2021. Results: A crosswalk analysis of the author search and NIH RePORTER search identified 1658 grants. Of those, 541 were categorized as relevant to palliative medicine, which represented 419 unique principal investigators (mean of 1.34 grants per investigator). Compared with 2011–2015, the number of NIH-funded grants increased by 25%, NIH dollars increased by 35%, and the distribution of grant types remained stable. Conclusions: Despite the challenging NIH funding climate, the number of NIH grants and funding to palliative care have increased. Given the increased funding allocation toward Alzheimer's dementia and related dementia research at the congressional level, this increase in funding reflects this funding allocation and does not represent overall growth. Dedicated federal funding for palliative care research remains critical to grow the evidence base for persons living with serious illnesses and their families. [ABSTRACT FROM AUTHOR]

Background: In order to improve early access to palliative care, strategies for monitoring referral practices in real-time are needed. Objective: To evaluate how Australia-Modified Karnofsky Performance Status (AKPS) at the time of initial palliative care consult differs between serious illnesses and could be used to identify opportunities for earlier referral. Methods: We retrospectively evaluated data from an inpatient palliative care consult registry. Serious illnesses were classified using ICD-10 codes. AKPS was assessed by palliative care clinicians during consult. Results: The AKPS distribution varied substantially between the different serious illnesses (p < 0.001). While patients with cancer and heart disease often had preserved functional status, the majority of patients with dementia, neurological, lung, liver, and renal disease were already completely bedbound at the time of initial palliative care consult. Conclusion: Measuring functional status at the time of palliative care referral could be helpful for monitoring referral practices and identifying opportunities for earlier referral. [ABSTRACT FROM AUTHOR]

Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1–June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities. [ABSTRACT FROM AUTHOR]

Background: Meeting the needs of seriously ill SARS-CoV-2 (COVID-19) patients requires novel models of deploying health social workers (SWs) to expand the palliative care workforce. To inform such expansion, understanding the current state of health SWs' core palliative care skills is necessary. Methods: Following minimal training, health SWs in one New York City hospital were surveyed about their frequency, competence, and confidence in using core palliative care skills. Results: Of the 170 health SWs surveyed, 46 (27%) responded, of whom 21 (46%) and 24 (52%) had palliative care training before and during the COVID-19 surge, respectively. Health SWs reported a "moderate improvement" in the use of three skills: "identify a medical decision maker," "assess prognostic understanding," and "coordinate care." There was "minimal decrease" to "no improvement" to "minimal improvement" in competence and confidence of skill use. Conclusion: Our findings suggest that educational initiatives can improve health SWs' use of core palliative care skills. [ABSTRACT FROM AUTHOR]

Background: In the United States, the percentage of hospitals over 50 beds with palliative care programs has risen substantially from 7% of hospitals in 2001 to 72% in 2017. Yet the dynamic nature of program adoption and closure over time is not known. Objective: To examine the rate of palliative care program adoption and closure and associated hospital and geographic characteristics in a national sample of U.S. hospitals. Design: Adoption and closure rates were calculated for 3696 U.S. hospitals between 2009 and 2017. We used multivariable logistic regression models to examine the association between adoption and closure status and hospital, geographic, and community characteristics. Setting/Subjects: All nonfederal general medical and surgical, cancer, heart, and obstetric or gynecological hospitals, of all sizes, in the United States in operation in both 2009 and 2017. Results: By 2017, 34.9% (812/2327) of the hospitals without palliative care in 2009 had adopted palliative care programs, and 15.0% (205/1369) of the hospitals with programs had closed them. In multivariable models, hospitals in metropolitan areas, nonprofit and public hospitals (compared to for-profit hospitals), and those with residency training approval by the Accreditation Council for Graduate Medical Education were significantly more likely to adopt and significantly less likely to close palliative care programs during the study period. Conclusions: This study indicates that palliative care is not equitably adopted nor sustained by hospitals in the United States. Federal and state interventions may be required to ensure that high-quality care is available to our nation's sickest patients. [ABSTRACT FROM AUTHOR]

Background: Implantable cardioverter-defibrillators (ICDs) reduce the incidence of sudden cardiac death for high-risk patients with heart failure (HF), but shocks from these devices can also cause pain and anxiety at the end of life. Although professional society recommendations encourage proactive discussions about ICD deactivation, clinicians lack training in conducting these conversations, and they occur infrequently. Methods: As part of a six-center randomized controlled trial, we evaluated the educational component of a multicomponent intervention shown to increase conversations about ICD deactivation by clinicians who care for a subset of patients with advanced HF. This consisted of a 90-minute training workshop designed to improve the quality and frequency of conversations about ICD management. To characterize its utility as an isolated intervention, we compared HF clinicians' pre- and postworkshop scores (on a 5-point Likert scale) assessing self-reported confidence and skills in specific practices of advance care planning, ICD deactivation discussions, and empathic communication. Results: Forty intervention-group HF clinicians completed both pre- and postworkshop surveys. Preworkshop scores showed high baseline levels of confidence (4.36, standard deviation [SD] = 0.70) and skill (4.08, SD = 0.72), whereas comparisons of pre- and postworkshop scores showed nonsignificant decreases in confidence (−1.16, p = 0.252) and skill (−0.20, p = 0.843) after the training session. Conclusions: Our findings showed no significant changes in self-assessment ratings immediately after the educational intervention. However, our data did demonstrate that HF clinicians had high baseline self-perceptions of their skills in advance care planning conversations and appear to be well-primed for further professional development to improve communication in the setting of advanced HF. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, the number of hospitals with palliative care has increased significantly. Objective: This study analyzes the availability of palliative care in U.S. hospitals and examines the variation by hospital characteristics, community-level socioeconomic demographics, health care markets, and geographic characteristics. Methods: Data were obtained from the American Hospital Association Annual Survey Database for 2017 and supplemented with 2016 for nonresponders, the United States Census Bureau's 2017 American Community Survey, the Dartmouth Atlas of Health Care's 2016 Spending and 2011 Hospital and Physician Capacity datasets, the National Palliative Care Registry™, state-level directories on palliative care, and web-based searches. Multivariable logistic regression and average marginal effects were used to examine predictors of hospital palliative care programs. Results: Seventy-two percent of hospitals with 50 or more beds had palliative care programs. Hospital and geographic characteristics were significantly associated with the presence of palliative care. Most notably, nonprofit hospitals were 24.5 percentage points more likely than for-profit hospitals to have palliative care, and metropolitan areas were 15.4 percentage points more likely than rural areas, controlling for other variables. Conclusion: This study demonstrates that availability of palliative care in U.S. hospitals is determined by where patients live and the type of hospital to which they are admitted. Equitable and reliable availability to quality palliative care must improve across the nation. [ABSTRACT FROM AUTHOR]

Background: Palliative care program service delivery is variable, and programs often lack data to support and guide program development and growth. Objective: To review the development and key features of the National Palliative Care Registry™ ("the Registry") and describe recent findings from its surveys on hospital palliative care. Description: Established in 2008, the Registry data elements align with National Consensus Project (NCP) guidelines related to palliative care program structures and operations. The Registry provides longitudinal and comparative data that palliative care programs can use to support programmatic growth. Results: As of 2018, >1000 hospitals and 120 community sites have submitted data on their palliative care programs to the Registry. Over the past decade, the percentage of hospital admissions seen by palliative care teams (penetration) has increased from 2.5% to 5.3%. Higher penetration is correlated with teaching hospital status, having a palliative care trigger, and hospital size (p < 0.05). Although overall staffing has expanded, only 42% of Registry programs include the recommended four key disciplines: physician, advanced practice or other registered nurse, social worker, and chaplain. Compliance with NCP guidelines on key structures and processes vary across adult and pediatric programs. Conclusions: The Registry allows palliative care programs to optimize core structures and processes and understand their performance relative to their peers. [ABSTRACT FROM AUTHOR]

The sudden and unprecedented increase in seriously ill patients with COVID-19, coupled with both the lack of core palliative care training and expertise among frontline providers and the specialty-trained palliative care workforce shortage, produced immediate challenges to meet the needs of this novel seriously ill patient population. In this article, we describe the rapid expansion and creation of new specialty palliative care services across a health system to meet demands of the COVID-19 surge in New York City. During April 2020, 1019 patients received inpatient specialty palliative care consultations across the Mount Sinai Health System. This overview demonstrates how palliative care services can be titrated up rapidly to meet the acute increase in hospitalized persons with serious illness due to COVID-19, and how these services tailored to the changing needs across a health system. [ABSTRACT FROM AUTHOR]

Background: The evidence base to support high-quality clinical care and number of scientists available to develop this evidence base are inadequate. Objective: To describe the first 10 years of the National Palliative Care Research Center's (NPCRC) programs and their outcomes. Design: Established in 2005, NPCRC was created in direct response to the recommendations of the Institute of Medicine. Specifically, NPCRC was created to expand the palliative care evidence-based needed for both health policy and clinical practice by supporting research scientists, stimulating research and innovation, and creating a community of researchers focused on the needs of persons with serious illness and their families. Measurements: Subsequent grant funding following NPCRC investment (web searches of NIH Research Portfolio Online Reporting Tools [RePORT], Veterans Administration and Patient Centered Outcomes Research Institute [PCORI] grant databases, grantee on-line surveys, and grantee annual reports) promotions (grantee on-line surveys and annual reports), publications (PubMed searches), and NPCRC participant satisfaction (grantee questionnaires). Results: As of July 2017, NPCRC has funded 47 junior investigators representing over 10 disciplines. These investigators have leveraged NPCRC's $7.8 million investment into 52 federal grants totaling $74.8 million dollars and 69 foundation grants totaling $16 million. Thirty-five grants ($5.8 million) have been awarded to experienced investigators, resulting in additional grant funding of $104.5 million dollars ($78.5 million federal, $26 million nonfederal). Satisfaction with NPCRC's program has been uniformly high and policy efforts have resulted in enhanced federal funding opportunities in palliative care research. Conclusions: NPCRC's focus on people and infrastructure in conjunction with a top-down bottom-up strategy has been critical in improving the palliative care evidence base. [ABSTRACT FROM AUTHOR]

Introduction: Palliative radiation therapy (PRT) is a commonly utilized intervention for symptom palliation among patients with metastatic cancer, yet it is under-recognized as a distinct area of subspecialty within radiation oncology. Objective: We developed a multidisciplinary service model within radiation oncology called the Palliative Radiation Oncology Consult (PROC) service to improve the quality of cancer care for advanced cancer patients. We assessed the service's impact on patient-related and healthcare utilization outcomes. Design: Patients were included in this observational cohort study if they received PRT at a single tertiary care hospital between 2009 and 2017. We compared outcomes of patients treated after (post-intervention group) to those treated before (control group) PROC's establishment using unadjusted and propensity score adjusted analyses. Results: Of the 450 patients in the cohort, 154 receive PRT pre- and 296 after PROC's establishment. In comparison to patients treated pre-PROC, post-PROC patients were more likely to undergo single-fraction radiation (RR: 7.74, 95% CI: 3.84–15.57) and hypofraction (2–5 fraction) radiation (RR: 10.74, 95% CI: 5.82–19.83), require shorter hospital stays (21 vs. 26.5 median days, p = 0.01), and receive more timely specialty-level palliative care (OR: 2.65, 95% CI: 1.56–4.49). Despite shortened treatments, symptom relief was similar (OR: 1.35, 95% CI: 0.80–2.28). Conclusion: The PROC service was associated with more efficient radiation courses, substantially reduced hospital length of stays, and more timely palliative care consultation, without compromising symptom improvements. These results suggest that a multidisciplinary care delivery model can lead to enhanced quality of care for advanced cancer patients. [ABSTRACT FROM AUTHOR]

Background: The evidence base to support palliative care clinical practice is inadequate and opportunities to improve the palliative care evidence base remain despite the field's rapid growth. Objective: To examine current NIH funding of palliative medicine research, changes since our 2013 report, and trends since our 2008 report. Design: We sought to identify NIH funding of palliative medicine from 2011 to 2015 in two stages: (I) we searched the NIH grants database 'RePorter' for grants with key words 'palliative care,' 'end-of-life care,' 'hospice,' and 'end of life' and (II) we identified palliative care researchers likely to have secured NIH funding using three strategies. Methods: We abstracted (1) the first and last authors' names from original investigations published in major palliative medicine journals from 2013 to 2015; (2) these names from a PubMed-generated list of original articles published in major medicine, nursing, and subspecialty journals using the above key words; and (3) palliative medicine journal editorial board members and key members of palliative medicine initiatives. We crossmatched the pooled names against NIH grants funded from 2011 to 2015. Results: The author and NIH RePorter search identified 854 and 419 grants, respectively. The 461 grants categorized as relevant to palliative medicine represented 334 unique PIs. Compared to 2006-2010, the number of NIH-funded junior career development awards nearly doubled (6.1%-10%), articles published in nonpalliative care specialty journals tripled (13%-37%), published palliative care researchers increased by 2.5-fold (839-2120), and NIH-funded original palliative medicine research articles doubled (21%-39%). Conclusions: Despite the challenging NIH funding climate, NIH funding to palliative care remained stable. The increase in early stage career development funding, palliative care investigators, and palliative medicine research published in nonpalliative medicine journals reflects important advances to address the workforce and evidence gaps. Further support for palliative care research is still needed. [ABSTRACT FROM AUTHOR]

Objective: To identify barrier to achieving universal access to high quality palliative care in Canada, review published national strategies and frameworks to promote palliative care, examine key aspects that have been linked to successful outcomes, and make recommendations for Canada. Background: In 2014, the World Health Organization called on members to develop and implement policies to ensure palliative care is integrated into national health services. Methods: Rapid review supplemented by the author's personal files, outreach to colleagues within the international palliative care community, review of European Association for Palliative Care publications, and a subsequent search of the table of contents of the major palliative care journals. Results: Frameworks were found for 10 countries ranging from detailed and comprehensive multi-year strategies to more general approaches including laws guaranteeing access to palliative care services for 'dying' patients or recommendations for the development of clinical infrastructure. Few formal evaluations were found minimal comparative data exist regarding the quality of care, access to palliative care services, timing of access in the disease trajectory, and patient and family satisfaction with care. Factors that appear to be associated with success include: 1) input and early involvement of senior policy makers; 2) comprehensive strategies that address major barriers to universal access and that involve the key constituents; 3) a focus on enhancing the evidence base and developing a national system of quality reporting; and 4) substantial and sustained government investment. Discussion: Comprehensive national strategies appear to improve access to high quality palliative care for persons with serious illness and their families. Such strategies require sustained government funding and address barriers related to infrastructure, professional and public education, workforce shortages, and an inadequate evidence base. [ABSTRACT FROM AUTHOR]

Background: Understanding factors associated with treatment intensity may help ensure higher value healthcare. Objective: To investigate factors associated with Medicare costs among prospectively identified, seriously ill older adults and examine if baseline prognosis influences the impact of these factors. Design/Subjects: Prospective observation of Health and Retirement Study cohort with linked Medicare claims. Measurements: We identified people with incident serious illness (a serious medical condition, for example, metastatic cancer or functional impairment); calculated subjects' one-year mortality risk; and then followed them for one year. We examined relationships between individual and regional characteristics and total Medicare costs, and then stratified analyses by one-year mortality risk: low, moderate, and high. Results: From 2002 to 2012, 5208 subjects had incident serious illness: mean age 78 years, 60% women, 76% non-Hispanic white, and 39% hospitalized in the past year. During one-year follow-up, 12% died. Total Medicare costs averaged $20,607. In multivariable analyses, indicators of poor health (e.g., cancer, advanced heart and lung disease, multimorbidity, functional impairment, and others) were significantly associated with higher costs ( p < 0.05). However, among those with high mortality risk, health-related variables were not significant. Instead, African American race (rate ratio [RR] 1.56) and moderate-to-high spending regions (RR 1.31 and 1.54, respectively) were significantly associated with higher costs. For this high-risk population, residence in high-spending regions was associated with $31,476 greater costs among African Americans, and $11,162 among other racial groups, holding health constant. Conclusions: Among seriously ill older adults, indicators of poor health are associated with higher costs. Yet, among those with poorest prognoses, nonmedical characteristics-race and regional practice patterns-have greater influence on treatment. This suggests there may be novel opportunities to improve care quality and value by assuring patient-centered, goal-directed care. [ABSTRACT FROM AUTHOR]

Background: Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. Objective: To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. Design: Longitudinal, observational cohort study (2008-2010). Setting/Subjects: Medicare beneficiaries ( N = 101,261) enrolled in a national random sample of freestanding hospices ( N = 355). Measurements: We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. Results: Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care ( p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. Conclusions: Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life. [ABSTRACT FROM AUTHOR]

Background: Palliative care is associated with improved patient and family outcomes and lower cost of care, but studies estimate that <50% of hospitalized adults in the United States who are appropriate for palliative care receive it. Few studies have addressed demographic and clinical factors associated with receipt of palliative care. Objective: Our aim was to identify characteristics of hospitalized advanced cancer patients that are associated with referral to an interdisciplinary hospital-based palliative care team. Methods: The data are from a prospective observational study of hospitalized advanced cancer patients in five hospitals. We used multivariable logistic regression to estimate the relationship between patient characteristics and palliative care referral. Results: The sample includes 3096 patients; 81% received usual care and 19% were referred to palliative care. Advanced cancer patients were twice as likely to receive palliative care referral if, at admission, they needed assistance with transfer from bed ( p = 0.002) and about 1.5 times as likely if they were taking medication for pain ( p = 0.002), nausea ( p = 0.04), or constipation ( p = 0.04). Patients with more comorbidities ( p = 0.001) and higher symptom burden ( p = 0.001) were more likely to be referred. Conclusion: Advanced cancer patients were more likely to be referred to the palliative care consultation team if they had high symptom burden at hospital admission. Overall a minority of advanced cancer patients were referred. Standardized screening for palliative care may be needed to ensure that advanced cancer patients receive the highest quality of evidence based care. [ABSTRACT FROM AUTHOR]

Background: Although family satisfaction is recognized as a critical indicator of quality for patients with advanced cancer, it is rarely assessed as part of routine clinical care. Measurement burden may be one barrier to widespread use of family satisfaction measures. Objective: The goal of this study was to test the ability of a new, brief 5-item measure of family satisfaction with care to accurately capture differences across hospital settings. Design: Using data from the Palliative Care for Cancer Patients study, a prospective study of 1979 patients and caregivers, we used multivariate regression analysis to detect significant differences across five sites. Settings: Hospitalized patients with advanced cancer and their caregivers Methods: We used both the shortened 5-item version of the FAMCARE scale (previously developed using Item Response Theory) and the original 20-item FAMCARE to measure family satisfaction. Results: On the 5-item FAMCARE, sites ranged from mean scores of 5.5-6.9 out of a possible high score of 10. Family members at one care site ( n = 783) were significantly ( p < 0.05) less satisfied with their care than family members at four other care sites. The original 20-item measure failed to differentiate satisfaction levels between all hospital sites. Discussion: Variability in family satisfaction with advanced cancer care across hospital settings can be more sensitively detected using a brief 5-item questionnaire versus longer measures. The development of less lengthy and burdensome measures for monitoring family satisfaction, which are still valid, can facilitate routine assessments to maintain and promote high-quality care across care settings. [ABSTRACT FROM AUTHOR]

Background: Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown. Objective: To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation. Design: Retrospective cohort study. Setting/Subjects: All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015. Measurements: Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record. Results: Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846 (1.8%) had usage of the V66.7 code. Sensitivity and specificity for the V66.7 code were 49.9% and 99.1%, respectively. Sensitivity was considerably higher for certain subgroups, such as patients with dementia (76.3%) and metastatic cancer (66.3%); addition of age restrictions further improved sensitivity while maintaining high specificity. Specificity was substantially lower for patients who died during hospitalization (sensitivity 53.9%, specificity 75.1%). Conclusions: In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation. Appropriate use of this code for this purpose should take these characteristics into consideration. [ABSTRACT FROM AUTHOR]

Background: Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles. Objective: We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness. Methods: We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment. Results: Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant ( p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant ( p = 0.76). Conclusions: Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists. [ABSTRACT FROM AUTHOR]

Background: Palliative care is expanding rapidly in the United States. Objective: To examine variation in access to hospital palliative care. Methods: Data were obtained from the American Hospital Association (AHA) Annual Surveys™ for Fiscal Years 2012 and 2013, the National Palliative Care Registry™, the Dartmouth Atlas of Healthcare, the American Census Bureau's American Community Survey (ACS), web searches, and telephone interviews of hospital administrators and program directors. Multivariable logistic regression was used to examine predictors of hospital palliative care programs. Results: Sixty-seven percent of hospitals with 50 or more total facility beds reported a palliative care program. Institutional characteristics were strongly associated with the presence of a hospital palliative care program. Ninety percent of hospitals with 300 beds or more were found to have palliative care programs as compared to 56% of hospitals with fewer than 300 beds. Tax status was also a significant predictor. Not-for-profit hospitals and public hospitals were, respectively, 4.8 times and 7.1 times more likely to have a palliative care program as compared to for-profit hospitals. Palliative care penetration was highest in the New England (88% of hospitals), Pacific (77% of hospitals), and mid-Atlantic (77% of hospitals) states and lowest in the west south central (43% of hospitals) and east south central (42% of hospitals) states. Conclusions: This study demonstrates continued steady growth in the number of hospital palliative care programs in the United States, with almost universal access to services in large U.S. hospitals and academic medical centers. Nevertheless access to palliative care remains uneven and depends on accidents of geography and hospital ownership. [ABSTRACT FROM AUTHOR]

Background: Maintaining the recent expansion of palliative care access in the United States is a recognized public health concern. Economic evaluation is essential to validate current provision and assess the case for new programs. Previous economic reviews in palliative care reported on programs across settings and systems; none has examined specifically the hospital consultative model, the dominant model of provision in the United States. Objectives: To review systematically the economic evidence on specialist palliative care consultation teams in the hospital setting, to appraise this evidence critically, and to identify areas for future research in this field. Data Sources: A meta-review ('a review of existing reviews') was conducted of eight published systematic reviews and one relevant nonsystematic review. To identify articles published outside of the timeframe of these reviews, systematic searches were performed on the PubMed, CINAHL, and EconLit databases. Study Selection: Articles were included if they compared the costs and/or cost effectiveness of a specialist hospital inpatient palliative care consultation for adult patients with those of a comparator. Results: Ten studies were included and these demonstrate a clear pattern of cost-saving impact from inpatient consultation programs. Nevertheless, knowledge gaps still exist regarding the economic effects of these programs. Current evidence has been generated from the hospital perspective; health system costs, patient and caregiver costs, and health outcomes are typically not included. Conclusions: Inpatient palliative care consultation programs have been shown to save hospitals money and to provide improved care to patients with serious illness. With a clear pattern of cost-saving using current methodology, it is timely to begin expanding the scope of economic evaluation in this field. Future research must address the measurement of both costs and outcomes to understand more fully the role that palliative care plays in enhancing value in health care. Relevant domains for such research are identified. [ABSTRACT FROM AUTHOR]

The article announces the Diane Meier, who will step down as director of the Center to Advance Palliative Care (CAPC).

The artic focuses on older people. This age group with the advancement of medical technology has increased in number since the average life span has increased. However, most of the people develop some sort of chronic disease which post diagnosis makes it critical for proper care to be taken. The article states that palliative care for older people and geriatrics are interlinked with several diseases following within their common domain.

Background: Palliative care clinical and educational programs are expanding to meet the needs of seriously ill patients and their families. Multiple reports call for an enhanced palliative care evidence base.Objective: To examine current National Institutes of Health (NIH) funding of palliative medicine research and changes since our 2008 report.1Methods: We sought to identify NIH funding of palliative medicine from 2006 to 2010 in two stages. First, we searched the NIH grants database RePorter2 for grants with key words “palliative care,” “end-of-life care,” “hospice,” and “end of life.” Second, we identified palliative care researchers likely to have secured NIH funding using three strategies: (1) We abstracted the first and last authors' names from original investigations published in major palliative medicine journals from 2008 to 2010; (2) we abstracted these names from a PubMed generated list of all original articles published in major medicine, nursing, and subspecialty journals using the above key words Medical Subject Headings (MESH) terms “palliative care,” “end-of-life care,” “hospice,” and “end of life;” and (3) we identified editorial board members of palliative medicine journals and key members of palliative medicine research initiatives. We crossmatched the pooled names against NIH grants funded from 2006 to 2010.Results: The NIH RePorter search yielded 653 grants and the author search identified an additional 352 grants. Compared to 2001 to 2005, 589 (240%) more grants were NIH funded. The 391 grants categorized as relevant to palliative medicine represented 294 unique PIs, an increase of 185 (269%) NIH funded palliative medicine researchers. The NIH supported 21% of the 1253 original palliative medicine research articles identified. Compared to 2001 to 2005, the percentage of grants funded by institutes other than the National Cancer Institute (NCI), the National Institute for Nursing Research (NINR), and the National Institute of Aging (NIA) increased from 15% to 20% of all grants.Conclusions: When compared to 2001–2005, more palliative medicine investigators received NIH funding; and research funding has improved. Nevertheless, additional initiatives to further support palliative care research are needed. [ABSTRACT FROM AUTHOR]

Background: A large gap exists between the practice of emergency medicine and palliative care. Although hospice and palliative medicine has recently been recognized as a subspecialty of emergency medicine, few palliative care teams routinely interact with emergency providers, and primary palliative care skills among emergency providers are lacking. Objective: To identify the proportion and characteristics of patients who receive a palliative care consultation and arrive via the emergency department (ED). Methods: A descriptive study of adult ED patients from an urban, academic tertiary care hospital who received a palliative care consultation in January 2005 or January 2009. Results: In January 2005, 100 of the 161 consults (62%) arrived via the ED versus 63 of 124 consults (51%) in January 2009 ( p=0.06). Mean days from admission to consultation in January 2005 were six days (standard deviation 11), versus nine days (SD 26) in January 2009 ( p=0.35). Three of the 100 consultations (3%) in January 2005 were initiated in the ED, versus 4 of the 64 (6%) in January 2009. Conclusions: At an urban academic medical center with a well-developed palliative care service, the majority of palliative care consultations were for patients who arrive via the ED. Despite this, only a small minority of consultations originated from emergency providers and consultation was on average initiated days into a patient's hospital stay. [ABSTRACT FROM AUTHOR]

Background: Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging). Discussion: Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition. Conclusion: Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents. Methods: This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training. Results: Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a 'clear idea of the role of palliative care in EM.' The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of self-reported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care. Conclusions: New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training. [ABSTRACT FROM AUTHOR]

Presenting posters at national meetings can help fellows and junior faculty members develop a national reputation. They often lead to interesting and fruitful networking and collaboration opportunities. They also help with promotion in academic medicine and can reveal new job opportunities. Practically, presenting posters can help justify funding to attend a meeting. Finally, this process can be invaluable in assisting with manuscript preparation. This article provides suggestions and words of wisdom for palliative care fellows and junior faculty members wanting to present a poster at a national meeting describing a case study or original research. It outlines how to pick a topic, decide on collaborators, and choose a meeting for the submission. It also describes how to write the abstract using examples that present a general format as well as writing tips for each section. It then describes how to prepare the poster and do the presentation. Sample poster formats are provided as are talking points to help the reader productively interact with those that visit the poster. Finally, tips are given regarding what to do after the meeting. The article seeks to not only describe the basic steps of this entire process, but also to highlight the hidden curriculum behind the successful abstracts and posters. These tricks of the trade can help the submission stand out and will make sure the reader gets the most out of the hard work that goes into a poster presentation at a national meeting. [ABSTRACT FROM AUTHOR]

Background: Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping. Methods: A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care. Results: The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success. [ABSTRACT FROM AUTHOR]

Background: Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice. Methods: We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics. Results: As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%. Conclusions: Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice. [ABSTRACT FROM AUTHOR]

Context: Palliative care consultation teams in hospitals are becoming increasingly more common. Palliative care improves the quality of hospital care for patients with advanced disease. Less is known about its effects on hospital costs. Objective: To evaluate the relationship between palliative care consultation and hospital costs in patients with advanced disease. Design, setting, and patients: An observational study of 3321 veterans hospitalized with advanced disease between October 1, 2004 and September 30, 2006. The sample includes 606 (18%) veterans who received palliative care and 2715 (82%) who received usual hospital care. October 1, 2004 and September 30, 2006. Main outcome measures: We studied the costs and intensive care unit (ICU) use of palliative versus usual care for patients in five Veterans Affairs hospitals over a 2-year period. We used an instrumental variable approach to control for unmeasured characteristics that affect both treatment and outcome. Results: The average daily total direct hospital costs were $464 a day lower for the 606 patients receiving palliative compared to the 2715 receiving usual care ( p < 0.001). Palliative care patients were 43.7 percentage points less likely to be admitted to ICU during the hospitalization than usual care patients ( p < 0.001). Comments: Palliative care for patients hospitalized with advanced disease results in lower costs of care and less utilization of intensive care compared to similar patients receiving usual care. Selection on unobserved characteristics plays an important role in the determination of costs of care. [ABSTRACT FROM AUTHOR]

Background: Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature. Objectives: With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity. Conclusions: The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness. [ABSTRACT FROM AUTHOR]

Data collection and analysis are vital for strategic planning, quality improvement, and demonstration of palliative care program impact to hospital administrators, private funders and policymakers. Since 2000, the Center to Advance Palliative Care (CAPC) has provided technical assistance to hospitals, health systems and hospices working to start, sustain, and grow nonhospice palliative care programs. CAPC convened a consensus panel in 2008 to develop recommendations for specific clinical and customer metrics that programs should track. The panel agreed on four key domains of clinical metrics and two domains of customer metrics. Clinical metrics include: daily assessment of physical/psychological/spiritual symptoms by a symptom assessment tool; establishment of patient-centered goals of care; support to patient/family caregivers; and management of transitions across care sites. For customer metrics, consensus was reached on two domains that should be tracked to assess satisfaction: patient/family satisfaction, and referring clinician satisfaction. In an effort to ensure access to reliably high-quality palliative care data throughout the nation, hospital palliative care programs are encouraged to collect and report outcomes for each of the metric domains described here. [ABSTRACT FROM AUTHOR]

The article discusses the importance of experimental and observational research methods that play a significant role in understanding and improving palliative care. It elaborates the three major types of observational studies, including cross-sectional studies, cohort studies and case-control studies. Moreover, it also examines the precision and the validity of an observational study.

The article discusses various reports published within the succeeding issue, including Drs. Carlson and Morrison on the study design, precision, and validity in observational studies, Drs. Helen Starks, Paula Diehr, and J. Randall Curtis on the challenge of selection bias and confounding in palliative care research, and Drs. Nathan Goldstein, Partha Deb, and Joan Penrod on when and how to consider an instrumental variable in palliative care research.

Background: Hospital palliative care programs provide high-quality, comprehensive care for seriously ill patients and their families. Objective: To examine geographic variation in patient and medical trainee access to hospital palliative care and to examine predictors of these programs. Methods: Primary and secondary analyses of national survey and census data. Hospital data including hospital palliative care programs were obtained from the American Hospital Association (AHA) Annual Survey Database™ for fiscal year 2006 supplemented by mailed surveys. Medical school-affiliated hospitals were obtained from the American Association of Medical Colleges, Web-site review, and telephone survey. Health care utilization data were obtained from the Dartmouth Atlas of Health Care 2008. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of hospital palliative care. Results: A total of 52.8% of hospitals with 50 or more total facility beds reported hospital palliative care with considerable variation by state; 40.9% (144/352) of public hospitals, 20.3% (84/413) of for-profit hospitals, and 28.8% (160/554) of Medicare sole community providers reported hospital palliative care. A total of 84.5% of medical schools were associated with at least one hospital palliative care program. Factors significantly associated ( p < 0.05) with hospital palliative care included geographic location, owning a hospice program, having an American College of Surgery approved cancer program, percent of persons in the county with a university education, and medical school affiliation. For-profit and public hospitals were significantly less likely to have hospital palliative care when compared with nonprofit institutions. States with higher hospital palliative care penetration rates were observed to have fewer Medicare hospital deaths, fewer intensive care unit/cardiac care unit (ICU/CCU) days and admissions during the last 6 months of life, fewer ICU/CCU admission during terminal hospitalizations, and lower overall Medicare spending/enrollee. Discussion: This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study. [ABSTRACT FROM AUTHOR]

The most frequently cited policy solution for improving access to hospice care for patients and families is to expand hospice eligibility criteria under the Medicare Hospice Benefit. However, the substantial implications of such a policy change have not been fully articulated or evaluated. This paper seeks to identify and describe the implications of expanding Medicare Hospice Benefit eligibility on the nature of hospice care, the cost of hospice care to the Medicare program, and the very structure of hospice and palliative care delivery in the United States. The growth in hospice has been dramatic and the central issue facing policymakers and the hospice industry is defining the appropriate target population for hospice care. As policymakers and the hospice industry discuss the future of hospice and potential changes to the Medicare Hospice Benefit, it is critical to clearly delineate the optionsand the implications and challenges of each optionfor improving access to hospice care for patients and families. [ABSTRACT FROM AUTHOR]

Background: Medical care for seriously ill patients has been acknowledged to be inadequate and multiple reports have called for increased investment in palliative medicine research. Objective: To identify funding sources of palliative medicine research published form 2003–2005 and to examine National Institutes of Health (NIH) funding of palliative medicine research from 2001–2005. Methods: We sought to identify United States publications related to adult palliative medicine research from 2003–2005 and their funding sources. We reviewed all articles published in the major palliative medicine journals and additionally, we reviewed all articles published in major medicine journals and relevant sub-specialty journals which were identified in Pub-Med using the key words “palliative care,” “end-of-life care,” “hospice” and “end-of-life.” From all identified articles, we abstracted all sources of funding detailed. We then compiled a list of U.S. palliative medicine researchers from 2001–2005 using the published first and last authors in the above article review, the editorial boards of palliative medicine journals, and other organizations. To examine NIH funding, we cross-matched this list of researchers against all NIH grants funded from 2001–2005. Results: We identified 388 palliative medicine research articles and 2,197 investigators. Seventy-two percent of papers identified received extramural funding: 31% from the NIH, 51% from foundations, and 16% from other sources. Only 109 investigators received NIH funding and the National Cancer Institute (NCI), National Institute of Nursing Research (NINR), and National Institute on Aging (NIA) funded 85% of all NIH awards. Conclusions: Research funding, particularly federal funding, for palliative medicine research is inadequate to support improvements in care for the most seriously ill patients and their families. [ABSTRACT FROM AUTHOR]

The article focuses on the impact of advance directives on outcomes and charges in elderly trauma patients. Topics inlcude the goal-concordant care is the foundation of palliative care, indeed of all health care, the history of advance directives/care planning reminds for family's 1975 Ford Pinto, and the fundamentally has flawed design yet one whose every broken part being dutifully repaired for five years until it was finally and mercifully sold for parts.

Background: Evidence suggests that racial and ethnic disparities exist in access to effective pain treatment. Purpose: To review evidence of these disparities and provide recommendations for care and further research. Design: Systematic review Methods: We conducted a MEDLINE search using the MeSH terms of ethnic groups, minority groups, pain, analgesia, and analgesics. We included studies describing current practice patterns, utilization of available treatments, treatment outcomes, and patient and provider knowledge, attitudes, and behaviors. Results: Our search identified 35 journal articles describing the effect of patient race and ethnicity on pain assessment and management. Three studies on pain assessment revealed that minority patients are more likely to have their pain underestimated by providers and less likely to have pain scores documented in the medical record compared to whites. Eleven of 17 studies found that African Americans and Hispanics are less likely to receive opioid analgesics and more likely to have their pain untreated compared to white patients. Three studies revealed that minority patients are more likely to have negative pain management index (PMI) scores—undertreated pain—compared to whites. Patient-related, provider-related, and pharmacy-related barriers to effective pain management were identified. Conclusion: The majority of studies reveal racial and ethnic disparities in access to effective pain treatment akin to disparities found in other medical services. Quality improvement initiatives that improve treatment of pain for all patients according to established guidelines should decrease disparities by race or ethnicity. Educational interventions should aim to improve patient-provider communication regarding pain and its treatment and should provide support around substance abuse issues. Further research is needed to examine pain treatment outcomes and to determine whether health care system factors lead to these disparities. [ABSTRACT FROM AUTHOR]

Objective: To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission. Design: Retrospective, observational cost analysis using a VA (payer) perspective. Setting: Two urban VA medical centers. Measurements: Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system. Analysis: Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates. Results: PC patients were 42 percentage points (95% CI, –556% to –31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, –387 to –122) lower and ancillary costs were $98 (95% CI, –133 to –57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching. Conclusion: PC was asssociated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs. [ABSTRACT FROM AUTHOR]

Objective: To describe the patterns of opioid prescribing and the factors associated with reductions in the potency of patients' analgesic medications at the time of hospital discharge. Design: Prospective cohort Setting: Two hundred forty-four patients (171 surgical and 73 nonsurgical) hospitalized in an urban academic medical center who have experienced moderate or severe pain and who are taking opioid analgesics prior to discharge. Outcome: Step-down (or reduction) in the potency of patients' analgesic medication at the time of discharge. A step-down is defined as the analgesic medication that a patient is prescribed for outpatient analgesia at the time of discharge being less potent then the last pain medication administered to that patient just prior to hospital discharge. Results: Thirty-three percent of all patients had reductions in the potency of their opioid pain medication at the time of discharge (36% for surgical and 26% for nonsurgical patients). For nonsurgical patients, we found a trend toward Hispanic ethnicity being an independent risk factor for having a step-down in analgesic potency at discharge (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 0.9–14.9). Conclusion: Physicians frequently reduce the potency of hospitalized patients' pain medications at discharge and Hispanic patients may be at increased risk of this occurring. Further research is needed to determine if the reductions in analgesic potency we observed are associated with poor posthospital pain outcomes. [ABSTRACT FROM AUTHOR]

The field of palliative care in the United States developed in response to a public health crisis—namely, poor quality of life for patients with serious illness and their families—and most palliative care research to date has been appropriately focused on identifying patient and family needs and identifying gaps in the current health care system and in the education of our health care professionals. Research has also begun to develop and evaluate new interventions and systems to address these care gaps. Preliminary studies suggest modest benefits of an array of programs designed to deliver palliative care services. These benefits include improved pain and other symptoms, increased family satisfaction, and lower hospital costs. Unfortunately, the validity and reliability of these findings are limited by important methodological weaknesses including small sample sizes, poorly described and nongeneralizable interventions, diverse and nonstandardized outcome measures, and poor study designs (i.e., lack of appropriate control groups, nonblinded designs). Comprehensive and rigorous research is needed to evaluate the effect of well-delineated and generalizable palliative care structures and processes on important clinical and use outcomes. Large multisite studies that have adequate power to detect meaningful differences in clinical and use outcomes, and that use welldefined and generalizable structures and evidence-based care processes, well-defined uniform outcome measures, and analyses that link the outcomes of interest to individual components of the interventions, are needed to guide further development of the field. [ABSTRACT FROM AUTHOR]

Background: Palliative care programs are becoming increasingly common in U.S. hospitals. Objective: To quantify the growth of hospital based palliative care programs from 2000–2003 and identify hospital characteristics associated with the development of a palliative care program. Design and measurements: Data were obtained from the 2001–2004 American Hospital Association Annual Surveys which covered calendar years 2000–2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data. Results: Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor- profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than non- Catholic Church-operated hospitals and hospitals without hospice programs respectively. Conclusions: Our data suggest that although growth in palliative care programs has occurred throughout the nation's hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals. [ABSTRACT FROM AUTHOR]

Discusses the studies regarding palliative medicine. Top priority needs from the healthcare system; Percentage of adult deaths that occur in hospitals or nursing homes; Important methodological weaknesses limiting the validity and reliability of the studies' findings; Growth and development in the field of palliative care in the U.S. as of February 2005.

Background : Previous studies have demonstrated that patients with end-stage dementia receive a high rate of painful and uncomfortable procedures. This study was undertaken to determine whether this finding might be related to physicians' misperceptions about the burden of common hospital experiences and procedures. Methods : Physicians were administered a survey asking them to rank on a five-point scale the pain and discomfort they perceived to be associated with 16 common hospital procedures. These ratings were compared to those previously obtained using the same instrument with cognitively intact patients who had actually undergone these procedures. Results : One hundred twenty-three of 123 resident physicians (100%) and 40 of 50 attending physicians (80%) to whom the questionnaire was administered responded. Overall, physicians more often rated both pain and discomfort associated with these procedures/experiences higher than did patients, and residents typically rated pain and discomfort higher than attending physicians. Resident physicians rated 7 procedures/experiences as significantly more painful and 13 as more uncomfortable than did patients. Attending physicians rated 5 procedures/experiences as significantly more painful and 8 more uncomfortable than did patients. Having a nasogastric tube inserted was the only procedure rated more painful by patients as compared to resident or attending physicians. Conclusions : Physicians have an accurate perception of pain and discomfort associated with common hospital procedures. Further investigation should scrutinize in greater detail the ubiquity and depth of physician knowledge about the issue of procedural burden and should focus on methods and interventions that would allow physicians to consciously weigh the benefits and burdens of routine interventions in the care of persons with serious and lifethreatening illness. [ABSTRACT FROM AUTHOR]

Reviews several journal articles which investigated various aspects of hospice and palliative care. "Sedative Use in the Last Week of Life and the Implications for End-of-Life Decision-Making," by N. Sykes and A. Thorns; "Hospice Enrollment and Pain Assessment and Management in Nursing Homes," by S. C. Miller, V. Mor and J. Teno; "Meta-Analysis of the Effect of Psychoeducational Interventions on Pain in Adults With Cancer," by E.C. Devine.