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Berger GN, O’Riordan DL, Kerr K, Pantilat SZ. Prevalence and Characteristics of Outpatient Palliative Care Services in California. Arch Intern Med. 2011;171(22):2057–2059. doi:10.1001/archinternmed.2011.469
Outpatient palliative care services (PCSs) offer the opportunity to intervene earlier in the disease trajectory and result in improved patient outcomes.1,2 Outpatient PCSs can provide improved continuity of care, reduce unnecessary rehospitalizations, and address the needs of patients and caregivers.3 While the potential benefits of outpatient PCSs are increasingly recognized, there is a paucity of information regarding the structure of outpatient PCSs,4 and, to our knowledge, there are no studies reporting the prevalence and characteristics of existing services. Therefore, the aim of this research is to describe the prevalence and characteristics of outpatient PCSs associated with California hospitals to enhance our understanding of how outpatient PCSs are delivered and inform their growth and development.
Descriptions of the study methods have been previously reported.5 We surveyed the leaders of palliative care (PC) programs in all 351 acute care hospitals in California regarding the presence and characteristics of PCSs. The National Health Foundation (NHF) administered the survey. We asked about hospital characteristics including bed size, system affiliation, ownership, and whether it serves as a teaching site. We assessed presence of an outpatient PCS, defined as an outpatient service focused on addressing physical, intellectual, emotional, social, and spiritual needs of patients and family. We also asked when the outpatient PCS was founded, how many patients were seen in the previous year, and their diagnoses. We calculated staffing levels for outpatient PCSs by summing the full-time equivalent (FTE) reported for advanced practice nurse, registered nurse, physician, social worker, and chaplain. We examined the association between hospital characteristics and the presence of outpatient PCS using χ2 or analysis of variance as appropriate.
Of 351 acute care hospitals in California, 324 responded (92%) and 27 (8%) reported having outpatient PCSs. Hospitals with an outpatient PCS were larger and more likely to have an inpatient PCS, be owned by a nonprofit organization, be a teaching site, and have a system affiliation compared with hospitals without an outpatient PCS (Table).
The mean (SD) outpatient PCS program age was 3 (2.5) years (range,1-9 years), with half (46%) being established in the previous 12 months. Of hospitals that reported program age, 50% (n = 12) of outpatient PCSs were established in the same year as the hospital's inpatient service and only 13% (n = 3) pre-dated their inpatient counterpart. The mean (SD) number of new patients seen by outpatient PCSs in 2007 was 197 (190) (range, 5-670), half the number seen by the corresponding inpatient PCS (n = 347).
More than half of patients seen by outpatient PCSs had a primary diagnosis of cancer (55%), with 3 services seeing only patients with cancer. Other common patient diagnoses included cardiac conditions (22%), dementia (14%), pulmonary conditions (10%), and neurological conditions (7%).
Staffing at the 20 sites that reported data reveals that the mean (SD) FTE of all disciplines devoted to outpatient PCSs was 1.4 (1.2) (range, 0.4-4.6) compared with 2.0 (1.2) (range, 0.3-4.7) for inpatient PCSs. The largest proportion of outpatient FTE is devoted to registered nurses (0.9) and advance practice nurses (0.7). The physician FTE for outpatient PCSs was 0.3, half of that for inpatient PCSs (0.7); however, inpatient services see almost twice as many patients. Outpatient PCSs have a similar social work component (0.8) to inpatient programs (0.7).
Outpatient PCS are rare compared with inpatient services and most are new. Most outpatient PCSs in California have been established within the last 4 years and half within the previous year, which may indicate a commitment to growth in this area consistent with recent evidence that demonstrates that outpatient PCSs improve patient outcomes.
Consistent with national guidelines,6 outpatient PCSs are typically interdisciplinary, with nurses acting as core care providers. Interestingly, outpatient PCSs are proportionally better staffed than their inpatient counterparts (70% as much staffing for 50% as many patients). Providing long-term follow-up in the clinic setting may account for this difference, though our data do not provide a definite explanation.
Compared with 11 leading outpatient PCSs surveyed in a prior study,4 those in our sample see fewer than half as many patients per year (197 vs 501), see a wider range of diagnoses (55% vs 80% cancer), and have fewer FTEs (0.7 vs 0.9 for advance practice nurses; 0.9 vs 1.6 for registered nurses; and 0.3 vs 0.6 for physicians), demonstrating the need to benchmark to similar services.
Demonstrated improvements in care will likely drive demand for outpatient PCSs. The presence of an existing inpatient PCS may help launch an outpatient PCS and the large number of existing inpatient PCSs may serve as a platform for building more palliative care services in the outpatient setting. Our study represents the largest population-based survey of outpatient PCSs to date, yet as more outpatient PCSs are established, research will be needed to understand the quality of care being delivered, the results achieved, the prevalence of outpatient PCSs not associated with hospitals, and the structures and processes of care that provide the best outcomes.
Correspondence: Dr Pantilat, Palliative Care Program, University of California, San Francisco, 521 Parnassus Ave, Ste C-126, San Francisco, CA 94143-0903 (firstname.lastname@example.org).
Published Online: October 10, 2011. doi:10.1001/archinternmed.2011.469
Author Contributions:Study concept and design: O’Riordan and Pantilat. Acquisition of data: Kerr and Pantilat. Analysis and interpretation of data: Berger, O’Riordan, Kerr, and Pantilat. Drafting of the manuscript: Berger, O’Riordan, and Pantilat. Critical revision of the manuscript for important intellectual content: O’Riordan, Kerr, and Pantilat. Statistical analysis: O’Riordan. Obtained funding: Pantilat. Administrative, technical, and material support: Kerr. Study supervision: O’Riordan and Pantilat.
Financial Disclosure: None reported.
Funding/Support: The California HealthCare Foundation provided funding to support the administration of the survey and analysis of findings, as well as limited dissemination of results though the Foundation's communication venues.
Additional Contributions: We thank the members of the advisory board for their input on the survey: Judy Citko, Richard Della Penna, Betty Ferrell, James Hallenbeck, Andrew Halpert, Karl Lorenz, Anna Schenck, Bradley Stuart, Mary Carol Todd, and Charles von Gunten. We also thank the Hospital Council of Northern and Central California, the Hospital Council of Southern California, and the Hospital Council of San Diego and Imperial Counties for their support in encouraging their members to participate. Finally, we thank all of the respondents for their diligence and care in responding to the survey.