Abstract and Introduction
Abstract
The lack of primary care providers who are skilled in delivering palliative care may be contributing to higher utilization of health care services for people at the end of life. The purpose of this study was to explore the impact of combined primary and palliative care on health care utilization by patients with a life-limiting illness. Patients received care from a consistent provider via a primary palliative care clinic founded and directed by a nurse practitioner at a public hospital. Chart reviews were conducted on a convenience sample of 146 patients cared for by a primary palliative care clinic between July 1, 2010, and June 30, 2011. Health care utilization after enrolling with the clinic was compared with utilization in the 12 months before the date of enrollment. Statistical analyses estimated a 28.6% reduction in emergency visits after enrollment (95% confidence interval, 0.9%-48.5%, P = .0437) and a 20.2% reduction in hospital admissions (95% confidence interval, −0.7% to 36.8%, P = .0576). These findings suggest that combined primary and palliative care can decrease utilization of health care services by individuals with life-limiting conditions.
Introduction
Research related to care at the end of life continues to demonstrate the need for improvement. High rates of hospitalizations and emergency department (ED) visits in the last weeks of life are accepted indicators of poor-quality end-of-life care. Despite the desire to avoid ED visits at the end of life and die outside of an institutional setting, most Americans continue to die in health care facilities, often with their symptoms poorly managed. A lack of primary care providers who are skilled in delivering palliative care, along with the lack of continuity of care, may be contributing to undesired institutional deaths for people at the end of life. Common reasons that palliative care recipients are ultimately admitted to an inpatient setting include poor pain control, poor symptom management, an unexpected change in physical condition, and overall caregiver burden. Another contributing factor to hospital admissions can be general practitioners' limited experience in caring for patients dying at home, as well as their limited experience in the use of opioids and psychiatric medications in the setting of a life-limiting illness.
Patients with life-limiting illness are not uncommon in the ED. Several studies have investigated ED utilization among patients enrolled in palliative care programs and have reported ranges of 27% up to 39% of patients using the ED near the end of life. In another study, it was noted that elder patients who died in the ED demonstrated a considerable palliative care need, although most of these patients were referred for palliative care services. Researchers identified several determinants of ED use among their palliative care population, including excessive weight loss, a previous hospitalization, women residing in rural areas, having a parent or other relative other than a spouse or child as the primary caregiver, pain, and appetite disturbance. Emergency departments tend to be high-stress, fast-paced environments with a focus on treatment of acute and traumatic events and are not the ideal place to treat palliative care patients or those nearing the end of life. For example, privacy in the ED is limited, staff members are often not familiar with patients, and staff members are not necessarily trained to deal with many issues associated with the end of life. Furthermore, patients and their caregivers experience high levels of anxiety and uncertainty when accessing the ED.
Although circumstances exist where an ED visit or hospital admission may be appropriate at the end of life, certain models of care may reduce unnecessary utilization. For example, palliative care programs have been associated with a reduction in the number of ED visits made by enrolled patients. To illustrate this, in a pilot study by Owens et al, outpatient primary palliative care patients' mean number of ED visits per week decreased from almost 0.07 visits per week in the earlier period to 0.04 visits per week after enrollment. Outpatient palliative care is relatively new, and there are limited studies validating its benefits. Outpatient primary palliative care, a setting where palliative care providers also act as primary care providers, is even more unusual. Aside from decreased ED utilization, studies have supported that outpatient palliative care may improve symptom control, improve caregiver and patient satisfaction, positively affect quality of life, improve mood, improve spiritual well-being, decrease medical costs, and at least in the case of non–small cell lung cancer, improve median survival.
The primary palliative care practice model differs from an outpatient consultative model in that it seeks to integrate palliative care into primary care. This ensures that the palliative needs of patients are routinely addressed in a comprehensive visit from 1 provider, which also improves continuity of care. The benefits of continuity of care include increased patient and family satisfaction with end-of-life care, reduced ED utilization, increased compliance with treatment recommendations, fewer duplicate diagnostic tests, reduced health care costs, and for some patients, reduced utilization of health care services.
The results of a study by Owens et al, assessing the relationship between primary palliative care and health care utilization, were consistent with previous studies on primary care and continuity of care as it relates to decreased ED utilization; however, further study was indicated to explore which patient characteristics were associated with ED use. Therefore, the purpose of this study was to further explore the impact of combined primary and palliative care on health care utilization by patients with a life-limiting illness. The specific aims were to (1) explore if ED visits and hospital admissions decreased after enrollment into the Primary Palliative and Supportive Care Clinic (PPSCC) and (2) describe which patient characteristics were associated with increased use of ED and hospital admissions.