Does early palliative identification improve the use of palliative care services?

Abstract

Purpose: To evaluate whether the early identification of patients who may benefit from palliative care impacts on the use of palliative, community and acute-based care services.

Methods: Between 2014 and 2017, physicians from eight sites were encouraged to systematically identify patients who were likely to die within one year and would were thought to benefit from early palliative care. Patients in the INTEGRATE Intervention Group were 1:1 matched to controls selected from provincial healthcare administrative data using propensity score-matching. The use of palliative care, community-based care services (home care, physician home visit, and outpatient opioid use) and acute care (emergency department, hospitalization) was each evaluated within one year after the date of identification. The hazard ratio (HR) in the Intervention Group was calculated for each outcome.

Results: Of the 1,185 patients in the Intervention Group, 951 (80.3%) used palliative care services during follow-up, compared to 739 (62.4%) among 1,185 patients in the Control Group [HR of 1.69 (95% CI 1.56 to 1.82)]. The Intervention Group also had higher proportions of patients who used home care [81.4% vs. 55.2%; HR 2.07 (95% CI 1.89 to 2.27)], had physician home visits [35.5% vs. 23.7%; HR 1.63 (95% CI 1.46 to 1.92)] or had increased outpatient opioid use [64.3% vs. 52.1%); HR 1.43 (95% CI 1.30 to 1.57]. The Intervention Group was also more likely to have a hospitalization that was not primarily focused on palliative care (1.42 (95% CI 1.28 to 1.58)) and an unplanned emergency department visit for non-palliative care purpose (1.47 (95% CI 1.32 to 1.64)).

Conclusion: Physicians actively identifying patients who would benefit from palliative care resulted in increased use of palliative and community-based care services, but also increased use of acute care services.

Fig 1. Cumulative probability curves.

(A) Cumulative probability of having palliative care during follow-up, with death as a competing event. (B) Cumulative probability of having a home care visit during follow-up, with death as a competing event. (C) Cumulative probability of having a physician home visit during follow-up, with death as a competing event. (D) Cumulative probability of using opioid as an outpatient during follow-up, with death as a competing event.

Fig 2. Number of resources used.

(A) Number of palliative care visits per 360 patient days during each month of follow-up (B) Number of home care visits per 360 patient days during each month of follow-up (C) Number of physician home visits per 360 patient days during each month of follow-up.