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    1 Comment for this article
    The need to step up
    Frederick Rivara, MD, MPH | University of Washington
    This is another in our series of papers on end of life care. It is a good news article in that use of palliative care is increasing, is being used for other diagnoses in addition to cancer, and is occurring earlier in the course of illness. Yet, there are still many, many patients who would benefit from palliative care and are not receiving it. This is on us as physicians. We must do better.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    Health Policy
    December 6, 2019

    Trends in Hospital-Based Specialty Palliative Care in the United States From 2013 to 2017

    Author Affiliations
    • 1Division of Palliative Medicine, University of California, San Francisco
    JAMA Netw Open. 2019;2(12):e1917043. doi:10.1001/jamanetworkopen.2019.17043
    Key Points español 中文 (chinese)

    Question  How have the practice and outcomes of inpatient, specialty palliative care in the United States changed over time?

    Findings  During the 5 years examined in this cohort study of 135 197 patients, palliative care teams saw an increasing percentage of patients with diagnoses other than cancer, saw an increasing percentage of patients discharged from the hospital alive, and connected more patients with outpatient supportive services.

    Meaning  These trends suggest that inpatient palliative care teams are reaching a broader group of patients with serious illness and are seeing them earlier in their illnesses, consistent with emerging data and guidelines.

    Abstract

    Importance  Although palliative care (PC) historically focused on patients with cancer and those near the end of life, evidence increasingly demonstrates a benefit to patients with a broad range of serious illnesses and to those earlier in their illness. The field of PC has expanded and evolved rapidly, resulting in a need to characterize practice over time to understand whether it reflects evolving evidence and guidelines.

    Objective  To characterize current practice and trends among patients cared for and outcomes achieved by inpatient specialty PC services in the United States.

    Design, Setting, and Participants  This retrospective cohort study was performed from January 1, 2013, to December 31, 2017, at 88 US hospitals in which PC teams voluntarily participate in the Palliative Care Quality Network (PCQN), a national quality improvement collaborative. A total of 135 197 patients were referred to PCQN teams during the study period. Initial analyses of the study data were conducted from March 3 to March 21, 2018.

    Exposure  Inpatient PC consultation.

    Main Outcomes and Measures  A total of 23 standardized data elements collected by PCQN teams that provided information about the characteristics of referred patients, including age, sex, Palliative Performance Scale score, and primary diagnosis leading to PC consult; reason(s) given for the consultation; and processes of care provided by the PC team, including disciplines involved, number of family meetings held, advance care planning documentation completed, and screened for and intervened on needs.

    Results  A total of 135 197 patients were referred to inpatient PC (51.0% female; mean age, 71.3 years [range, 57.8-82.5 years]) and were significantly debilitated (mean Palliative Performance Scale score, 34.7%; range, 14.9%-56.8%). Cancer was the most common primary diagnosis (32.0%; range, 11.3%-93.9%), although rates decreased from 2013 to 2017 (odds ratio [OR], 0.84; 95% CI, 0.79-0.91; P < .001). Pain and other symptoms were common and improved significantly during the consultation period (pain: χ2 = 5234.4, P < .001; anxiety: χ2 = 2020.7, P < .001; nausea: χ2 = 1311.8, P < .001; dyspnea: χ2 = 1993.5, P < .001). Most patients were discharged alive (78.7%; range, 44.7%-99.4%), and this number increased over time (OR, 1.36; 95% CI, 1.27-1.46; P < .001). Compared with 2013, rates of discharge referral to clinic-based (OR, 4.00; 95% CI, 2.95-5.43; P < .001) and home-based PC (OR, 2.63; 95% CI, 1.92-3.61; P < .001) also increased significantly by 2017, whereas referrals to hospice decreased (OR, 0.56; 95% CI, 0.51-0.62; P < .001).

    Conclusions and Relevance  Inpatient PC teams cared for an increasing percentage of patients with diagnoses other than cancer and saw more patients discharged alive, consistent with guidelines recommending specialty PC for all patients with serious illness earlier in their illnesses. Most patients with symptoms improved quickly. Variation in practice and outcomes among PCQN members suggests that there are opportunities for further improvements in care.

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