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Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis

Published online by Cambridge University Press:  15 February 2017

Xibei Liu ,
Yaser Dawod ,
Alex Wonnaparhown ,
Amaan Shafi ,
Loomee Doo ,
Ji Won Yoo ,
Eunjeong Ko  and
Youn Seon Choi
Xibei Liu
Affiliation:
University of Nevada, Reno School of Medicine, Reno, Nevada
Yaser Dawod
Affiliation:
Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, Nevada
Alex Wonnaparhown
Affiliation:
University of Nevada, Reno School of Medicine, Reno, Nevada
Amaan Shafi
Affiliation:
University of Nevada, Reno School of Medicine, Reno, Nevada
Loomee Doo
Affiliation:
Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, Nevada
Ji Won Yoo*
Affiliation:
Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, Nevada
Eunjeong Ko
Affiliation:
School of Social Work, San Diego State University, San Diego, California
Youn Seon Choi
Affiliation:
Department of Family Medicine, Guro Hospital, Korea University, Seoul, Korea
*
Address correspondence and reprint requests to: Ji Won Yoo, Department of Internal Medicine, University of Nevada School of Medicine, 1701 West Charleston Boulevard, #230, Las Vegas, Nevada 89102. E-mail: jwyoo@medicine.nevada.edu.
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Abstract

Objective:

Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality.

Method:

A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence.

Results:

Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI95%] = –2.22–2.61 days; p = 0.87; I2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI95% = 0.52–0.84; p < 0.01; I2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively.

Significance of results:

Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.

Keywords

End-of-life careIn-hospital mortalityLength of stayPalliative care
Type
Review Article
Information
Palliative & Supportive Care , Volume 15 , Issue 6 , December 2017 , pp. 741 - 752
Copyright
Copyright © Cambridge University Press 2017 

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References

REFERENCES

Ahrens, T., Yancey, V., Kollef, M., et al. (2003). Improving family communications at the end of life: Implications for length of stay in the intensive care unit and resource use. American Journal of Critical Care, 12(4), 317–323. Available from http://ajcc.aacnjournals.org/content/12/4/317.full.pdf+html.CrossRefGoogle ScholarPubMed
American Hospital Association (2016). Trends in hospital financing. In Trends affecting hospitals and health systems, chap. 4. Washington, DC: American Hospital Association. Available from http://www.aha.org/research/reports/tw/chartbook/index.shtml.Google Scholar
Carson, S.S., Cox, C.E., Wallenstein, S., et al. (2016). Effect of palliative care-led meetings for families of patients with chronic critical illness: A randomized clinical trial. The Journal of the American Medical Association, 316(1), 51–62. Available from http://jamanetwork.com/journals/jama/fullarticle/2532011.Google Scholar
Ciemins, E.L., Blum, L., Nunley, M., et al. (2007). The economic and clinical impact of an inpatient palliative care consultation service: A multifaceted approach. Journal of Palliative Medicine, 10(8), 1347–1355.Google Scholar
Cox, C.E., Lewis, C.L., Hanson, L., et al. (2012). Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation. Critical Care Medicine, 40(8), 2327–2334. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3826165/pdf/nihms511910.pdf.Google Scholar
Curtis, J.R., Back, A.L., Ford, D.W., et al. (2013). Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness. The Journal of the American Medical Association, 310(21), 2271–2281. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310457/pdf/nihms654563.pdf.CrossRefGoogle ScholarPubMed
Daly, B.J., Douglas, S.L., O'Toole, E., et al. (2010). Effectiveness trial of an intensive communication structure for families of long-stay ICU patients. Chest, 138(6), 1340–1348. Epub ahead of print Jun 24. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998207/pdf/100292.pdf.CrossRefGoogle ScholarPubMed
Digwood, G., Lustbader, D., Pekmezaris, R., et al. (2011). The impact of a palliative care unit on mortality rate and length of stay for medical intensive care unit patients. Palliative & Supportive Care. 9(4), 387–392.Google Scholar
Drummond, M.F., Sculpher, M.J., Torrance, G.W., et al. (2005). Methods for the economic evaluation of health care programmes, 3rd ed. Oxford: Oxford University Press.Google Scholar
Dumanovsky, T., Augustin, R., Rogers, M., et al. (2016). The growth of palliative care in U.S. hospitals: A status report. Journal of Palliative Medicine, 19(1), 8–15. Epub ahead of print Sep 29, 2015. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692111/pdf/jpm.2015.0351.pdf.Google Scholar
Fowler, F.J., Gallagher, P.M., Anthony, D.L., et al. (2008). Relationship between regional per capita Medicare expenditures and patient perceptions of quality of care. The Journal of the American Medical Association, 299(20), 1406–2412. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2438036/pdf/nihms53687.pdf.Google Scholar
Gabriel, E., Kukar, M., Groman, A., et al. (2015). A formal palliative care service improves the quality of care in patients with stage IV cancer and bowel obstruction. The American Journal of Hospice Palliative Care, pii: 1049909115603960. Epub ahead of print Sep 15. Available from http://journals.sagepub.com/doi/pdf/10.1177/1049909115603960.Google Scholar
Gibbs, K.D., Mahon, M.M., Truss, M, et al. (2015). An assessment of hospital-based palliative care in Maryland: Infrastructure, barriers, and opportunities. Journal of Pain and Symptom Management, 49(6), 1102–1108. Epub ahead of print Jan 30. Available from http://www.jpsmjournal.com/article/S0885-3924(15)00039-1/pdf.CrossRefGoogle ScholarPubMed
GradePRO (2016). GRADE's software for summary of findings tables, health technology assessment and guidelines. Available from http://www.guidelinedevelopment.org.Google Scholar
Guyatt, G.H., Oxman, A.D., Montori, V., et al. (2008). GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336(7650), 924–926. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2335261/pdf/bmj-336-7650-analysis-00924.pdf.CrossRefGoogle ScholarPubMed
Guyatt, G.H., Oxman, A.D., Kunz, R., et al. (2011). GRADE guidelines, 7: Rating the quality of evidence—inconsistency. Journal of Clinical Epidemiology, 64(12), 1294–1302. Epub ahead of print Jul 31. http://www.jclinepi.com/article/S0895-4356(11)00182-X/pdf.Google Scholar
John A. Hartford Foundation, The (2016). Improving advance care planning: Research results from the “conversation starters” focus groups and “conversation stopper” physician survey. New York: The John A. Hartford Foundation. Available from http://www.johnahartford.org/newsroom/view/advance-care-planning-poll.Google Scholar
Hatler, C.W., Grove, C., Strickland, S., et al. (2012). The effect of completing a surrogacy information and decision-making tool upon admission to an intensive care unit on length of stay and charges. The Journal of Clinical Ethics, 23(2), 129–138.Google Scholar
Horton, J.R., Morrison, R.S., Capezuti, E., et al. (2016). Impact of inpatient palliative care on treatment intensity for patients with serious illness. Journal of Palliative Medicine, 19(9), 936–942. Epub ahead of print Jun 1.Google Scholar
Hozo, S.P., Djulbegovic, B. & Hozo, I. (2005). Estimating the mean and variance from the median, range, and the size of a sample. BMC Medical Research Methodology. 5, 13. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1097734/pdf/1471-2288-5-13.pdf.Google Scholar
Kaiser Family Foundation (2015). Health status of the Medicare population. In A primer on Medicare. Menlo Park, CA: The Kaiser Family Foundation. Available from http://kff.org/report-section/a-primer-on-medicare-what-are-the-characteristics-of-people-with-medicare/.Google Scholar
Kelley, A.S. & Morrison, R.S. (2015). Palliative care for the seriously ill. The New England Journal of Medicine, 373(8), 747–755. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671283/pdf/nihms736777.pdf.Google Scholar
Kelley, A.S., Morrison, R.S., Wenger, N.S., et al. (2010). Determinants of treatment intensity for patients with serious illness: A new conceptual framework. Journal of Palliative Medicine, 13(7), 807–813. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968277/pdf/jpm.2010.0007.pdf.Google Scholar
Kelley, A.S., Deb, P., Du., Q., et al. (2013). Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths of stay. Health Affairs, 32(3), 552–561. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655535/pdf/nih ms464299.pdf.Google Scholar
Khandelwal, N., Kross, E.K., Engelberg, R.A., et al. (2015). Estimating the effect of palliative care interventions and advance care planning on ICU utilization: A systematic review. Critical Care Medicine, 43(5), 1102–1111. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499326/pdf/nihms699588.pdf.CrossRefGoogle ScholarPubMed
Khandelwal, N., Benkeser, D.C., Coe, N.B., et al. (2016). Potential influence of advance care planning and palliative care consultation on ICU costs for patients with chronic and serious illness. Critical Care Medicine, 44(8), 1474–1481.Google Scholar
Lamba, S., Pound, A., Rella, J.G., et al. (2012). Emergency medicine resident education in palliative care: A needs assessment. Journal of Palliative Medicine. 15(5), 516–520.CrossRefGoogle ScholarPubMed
Martins, B.D., Oliveira, R.A. & Cataneo, A.J. (2016). Palliative care for terminally ill patients in the intensive care unit: Systematic review and metaanalysis. Palliative & Supportive Care, 1–8. Epub ahead print Jul 27.Google Scholar
May, P., Normand, C., Morrison, R.S. (2014). Economic impact of hospital inpatient palliative care consultation: Review of current evidence and directions for future research. Journal of Palliative Medicine, 17(9), 1054–1063. Epub ahead of print Jul 1. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158953/pdf/jpm.2013.0594.pdf.CrossRefGoogle ScholarPubMed
Medicare Payment Advisory Commission (2016). Acute inpatient services: Short-term hospitals, inpatient psychiatric facilities. In A data book: Health care spending and the Medicare program. Washington DC: Medicare Payment Advisory Commission. Available from http://medpac.gov/docs/default-source/data-book/june-2016-data-book-section-6-acute-inpatient-services.pdf.Google Scholar
Mittler, J.N., Landon, B.E., Fisher, E.S., et al. (2010). Market variations in intensity of Medicare service use and beneficiaries experiences with care. Health Services Research, 45, 647–669.Google Scholar
Moher, D., Liberati, A., Tetzlaff, J., et al. (2009). Preferred reporting items for systematic review and meta-analyses: The PRISMA Statement. PLoS Medicine, 6(7), e1000097. Epub ahead of print Jul 21. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707599/pdf/pmed.1000097.pdf.Google Scholar
Morrison, R.S. (2013). Models of palliative care delivery in the United States. Current Opinion in Supportive and Palliative Care. 7(2), 201–206. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4651439/pdf/nihms-736775.pdf.Google Scholar
Morrison, R.S., Penrod, J.D., Cassel, J.B., et al. (2008). Cost savings associated with US hospital palliative care consultation programs. Archives of Internal Medicine, 168(16), 1783–1790. Available from http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414449.Google Scholar
Morrison, R.S., Dietrich, J., Ladwig, S., et al. (2011). Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Affairs. 30(3), 454–463. Available from http://content.healthaffairs.org/content/30/3/454.long.CrossRefGoogle ScholarPubMed
National Hospice and Palliative Care Organization (2015). NHPCO facts and figures: Hospice care in America. Alexandria, VA: NHPCO. Available from http://www.nhpco.org/sites/default/public/statistics_research/2015_facts_figures.pdf.Google Scholar
National Institute for Health Care Management Foundation (2016). Health care's big spenders: The characteristics behind the curve. Washington DC. NIHCM. Available from http://www.nihcm.org/topics/cost-quality/health-cares-big-spenders-chart-story.Google Scholar
Norton, S.A., Hogan, L.A., Holloway, R.G., et al. (2007). Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high-risk patients. Critical Care Medicine. 35(6), 1530–1535.Google Scholar
Oczkowski, S.J., Chung, H., Hanvey, L., et al. (2016). Communication tools for end-of-life decision-making in the intensive care unit: A systematic review and meta-analysis. Critical Care, 20, 97. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826553/pdf/13054_2016_Article_1264.pdf.Google Scholar
Paris, J. & Morrison, R.S. (2014). Evaluating the effects of inpatient palliative care consultations on subsequent hospice use and place of death in patients with advanced GI cancers. Journal of Oncology Practice. 10(3), 174–177. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018455/pdf/jop174.pdf.Google Scholar
Penrod, J.D., Deb, P., Luhrs, C., et al. (2006). Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. Journal of Palliative Medicine. 9(4), 855–860.CrossRefGoogle ScholarPubMed
Penrod, J.D., Deb, P., Dellenbaugh, C., et al. (2010). Hospital-based palliative care consultation: Effects on hospital cost. Journal of Palliative Medicine. 13(8), 973–979.Google Scholar
Silveira, M.J., Wiitala, W. & Piette, J. (2014). Advance directive completion by elderly Americans: A decade of change. Journal of the American Geriatrics Society. 62(4), 706–710. Epub ahead of print Apr 2.CrossRefGoogle ScholarPubMed
SUPPORT Principal Investigators (1995). A controlled trial to improve care for seriously ill Hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The Journal of the American Medical Association, 274(20), 1591–1598. Erratum in The Journal of the American Medical Association, 275(16), 1232.Google Scholar
Teno, J.M., Mor, V., Ward, N., et al. (2005). Bereaved family member perceptions of quality of end-of-life care in U.S. regions with high and low usage of intensive care unit care. Journal of the American Geriatrics Society, 53(11), 1905–1911.Google Scholar
Teno, J.M., Shu, J.E., Casarett, D, et al. (2007). Timing of referral to hospice and quality of care. Journal of Pain and Symptom Management, 34(2), 120–125. Epub ahead of print Jun 21. Available from http://www.nhpco.org/sites/default/files/public/JPSM/Aug07article.pdf.Google Scholar
Teno, J.M., Gozalo, P.L., Bynum, J.P., et al. (2013). Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. The Journal of the American Medical Association, 3095), 470–477. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674 823/pdf/nihms458689.pdf.Google Scholar
Wan, X., Wang, W., Liu, J, et al. (2014). Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Medical Research Methodology, 14, 135. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4383202/pdf/12874_2014_Article_1175.pdf.Google Scholar
Wennberg, J.E., Bronner, K., Skinner, J.S., et al. (2009). Inpatient care intensity and patients' ratings of their hospital experiences. Health Affairs, 28(1), 103–112. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729566/pdf/nihms133191.pdf.Google Scholar
Whitford, K., Shah, N.D., Moriarty, J., et al. (2014). Impact of a palliative care consult service. The American Journal of Hospice and Palliative Care, 31(2), 175–182. Epub ahead of print Apr 2, 2013. Available from http://journals.sagepub.com/doi/pdf/10.1177/1049909113482 746.Google Scholar
Yoo, J.W., Nakagawa, S. & Kim, S. (2012). Integrative palliative care, advance directives, and hospital outcomes of critically ill older adults. The American Journal of Hospice and Palliative Care. 29(8), 655–662. Epub ahead of print Feb 5. Available from http://journals.sagepub.com/doi/pdf/10.1177/1049909111435813.Google Scholar
Yoo, J.W., Nakagawa, S. & Kim, S. (2013). Relationships among advance directives, principal diagnoses, and discharge outcomes in critically ill older adults. Palliative & Supportive Care. 11(4), 315–322. Epub ahead of print Aug 15, 2012.Google Scholar
Zuckerman, R., Stearns, S. & Sheingold, S. (2016). Hospice use, hospitalization, and Medicare spending at the end of life. The Journals of Gerontology, Series B, Psychological Sciences and Social Sciences, 71(3), 569–580.Google Scholar