Veterans' use of inpatient and outpatient palliative care: The national landscape

Abstract

Background: Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters).

Methods: This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245).

Results: Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64).

Conclusions: This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

Keywords: end‐of‐life care; health services research; hospice; palliative care; veterans.

FIGURE 1

Timing and duration of veterans’ palliative care and hospice use by care setting and dose (2014–2017). LLC, life-limiting conditions; PC, palliative care of unknown type; SPC=specialty palliative care. Among veterans with LLC who had at least one palliative care encounter, we defined four groups: (1) veterans with no encounters with the specialty palliative care clinic, but who did have palliative services outside the specialty clinic (indicated by ICD-9/10 PC codes); (2) veterans with only one palliative care encounter in an inpatient or outpatient specialty clinic (indicated by stop codes); (3) veterans with more than one encounter for palliative care in an inpatient specialty clinic, but no outpatient encounters; (4) veterans with more than one encounter for palliative care in an outpatient specialty clinic. Time since life-limiting condition (LLC) is reported among those with any LLC documented.