Inpatient Palliative Care: A nationwide analysis

Abstract

Objective

The implementation of palliative care (PC) is an important challenge for health policy makers. The primary aim of this study was to analyze the effects of inpatient PC for cancer patients in the last six months of life.

Methods

Based on routine data of a nationwide sickness fund, a retrospective matched-pair analysis was performed to assess the care of cancer patients who were treated at least once on an inpatient PC unit and compare the results to cancer patients who where not treated on an inpatient PC unit. The main categories that were assessed included place of death, cost of health care and surrogates for quality of symptom control, aggressiveness of care, and end of life decisions.

Results

Of 11,355 patients, 841 received PC. Compared with other patients they were more likely to receive opioids (66.8% vs. 55.3%; p < 0.0001) and chemotherapy in an outpatient setting (25.5% vs. 19.9%; p = 0.004). Provision of artificial nutrition and surgery was similar in both groups. Total costs were higher for PC patients compared to routine care (21,879€ (±14,351€) vs. 17,885€ (±14,326€); difference 3994€ (95%-CI: [2648€; 18,973€]; p < 0.0001) and PC patients were more likely to die in hospital (69.9% vs. 55.3%; p < 0.0001).

Conclusion

Cancer patients treated on a PC inpatient unit where more likely to receive opioids (a surrogate for quality of end-of-life care) but where less likely to die at home and the cost of care for these patients was higher. The results can be interpreted both from (i) a methodological standpoint that assumes confounding due to the fact that the PC patients might have been suffering from more complex symptoms and (ii) a health policy view. For the latter it is important to recognize that the whole potential of PC can only be achieved if PC (a) is provided as a cross-sectoral network, (b) is integrated early in the disease (c) assures specialized PC expertise.

Introduction

Implementation of palliative care (PC) programmes is an important issue for health policy makers, clinicians and researchers [1], [2], [3]. According to the World Health Organization (WHO) and the American Society of Clinical Oncology (ASCO) there are still global and local deficits in meeting that PC need of cancer patients even in North America and Europe [4], [5]. PC programmes should be dedicated to provide optimal symptom control (e.g. pain, dyspnoea) and to address all other domains of suffering of patients (and their families). To realize the full potential of PC must be integrated into patient care early in the disease, assure cross-sectoral care (including home, in- and outpatient) care and should be provided by additional multi-professional teams [5]. Patient participation and patient autonomy are the leading principles of PC [6], [7], [8].

The extent to which PC is implemented in western Europe varies [2]. In Germany, Behmann et al. [9] performed a Delphi-process evaluating the public health perspective that involved a variety of major stakeholders concerned with the provision and evolution of PC, Recommendations from this study include that (i) PC should be established as a culture in health care, (ii) quality PC demands interprofessional and interdisciplinary collaboration, (iii) quality standards for PC expertise and education should be implemented and (iv) that PC should be provided in a coordinated (integrated) fashion. Meanwhile, some of these recommendations could be implemented already. For example according to federal law, ambulatory specialized PC (SAPV) has to become available countrywide, a number of chairs for PC have been established at Medical Faculties and PC has become a mandatory part of the curriculum for medical students. Legislators, patients and clinician hope that the implementation of these structural components will decrease both the hospitalization rates and the aggressiveness of care while improving the patients’ quality of life as it has been reported by Temel et al. how analyzed the effect of PC in addition to routine care [1]. Though some investigators have demonstrated a cost-saving effect of PC, these findings are not consistent and not the leading argument for realizing nationwide availability of PC [10], [11], [12], [13], [14].

The primary aim of this study was to analyze the effect of PC on the care of cancer patients in the last six months of life. The domains that were evaluated included (i) provision of symptom control, (ii) place of death, (iii) aggressiveness of care, (iv) end-of-life decisions, and (v) health care costs.