Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial

Abstract

Importance: Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking.

Objective: To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes.

Design, setting, and participants: A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019.

Intervention: Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care.

Main outcomes and measures: The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality.

Results: Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]).

Conclusions and relevance: Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.

Trial registration: ClinicalTrials.gov Identifier: NCT02505035.

Figure 1.. Flow of Participants in a Study of Default Palliative Care Consultation for Seriously Ill Hospitalized Patients

^aIncludes admissions with a discharge date prior to January 31, 2019, when trial outcomes data collection ended. ^bThe electronic health record (EHR) eligibility algorithm screened International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for eligible diagnoses (detailed in eTable 2 in Supplement 3) and chronic oxygen dependence (Z99.81) and ≥2 admissions in the past 12 months. ^cNurse-reported eligibility criteria included chronic oxygen dependence, ≥2 admissions in the past 12 months, dialysis dependence, admission from a long-term care facility, and presence of a jejunostomy or gastrostomy tube. COPD indicates chronic obstructive pulmonary disease.

Figure 2.. Predicted Probability of a Completed Palliative Care Consult by Hospital

Results are shown for the primary analytic sample. Estimates were adjusted for time and cluster. Hospital number corresponds to randomization sequence; see eFigure 3 in Supplement 3 for more details. Horizonal lines denote the overall mean probability of a completed palliative care consult for usual care (16.6%) and intervention (43.9%) groups. Whiskers indicate 95% CIs. Percentages may not total to 100 due to rounding.

Figure 3.. Primary Outcome of Hospital Length of Stay

All estimates are adjusted for time, hospital, age, gender, race, ethnicity, marital status, source of admission, Agency for Healthcare Research and Quality Elixhauser Comorbidity Index, eligible diagnosis (kidney failure, chronic obstructive pulmonary disease [COPD], and dementia), number of days between repeated enrollment, and location in the intensive care unit at enrollment. The primary analytic sample includes encounters with length of stay ≥72 hours. In-hospital deaths were ranked at the 99th percentile of the distribution of LOS for each sample. Whiskers indicate 95% CIs.