Economic analysis of potentially avoidable hospital admissions in patients with palliative care needs

Abstract

Background

There is a widely acknowledged need to understand more fully the economics of palliative care provision in the UK. In particular, the economic impact of reducing avoidable hospital admissions among patients with palliative care needs has not been extensively researched.

Aim

A recent survey of two English hospitals identified patients with palliative care needs and the proportion of these patients whose admission was potentially avoidable. Using these data, the economic impact of avoiding such hospital admissions is estimated.

Methods

Costs were estimated by attaching an Health Resource Group (HRG) code to each admission classified as potentially avoidable in order to determine the possible savings to be made. Alternative places of care for these patients were identified and estimates of the cost of supporting patients in these locations were derived using published unit costs.

Results

In the two hospitals surveyed, our study suggested that 7% of patients with palliative care needs could have been cared for elsewhere. The estimated cost saving of avoiding these admissions and supporting these patients in the community was £1527 for both hospitals over the survey period. This extrapolates to savings of around £180 000 per annum. Results were most sensitive to the cost perspective used and the estimated cost of the avoided hospital admissions. This exploratory analysis was limited by small study size and uncertainty in the costings.

Conclusions

Further research is required to gain a better understanding of the economic consequences of potentially avoidable hospital admissions and the extent of variations between localities and to clarify disparities in identified costs.     

Supportive care for older people with frailty in hospital: An integrative review

BackgroundGrowing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care.AimTo identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation.DesignAn integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term ‘supportive care’. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken.Data sourcesLiterature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n = 52) were integrated using synthesis of themes.ResultsRelevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings.ConclusionThe findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.     

Palliative care presentations to emergency departments in a secondary and a sub-acute hospital: A one year incidence study

Introduction: There is growing concern that Emergency Departments (ED) are ill equipped to manage rising palliative care demand, but actual demand is unknown. The aim of this study was to estimate the annual incidence of patients with palliative care need presenting to EDs.

Methods: Retrospective case review study across two New Zealand emergency departments from 1 July 2010 to 30 June 2011. We used a two-step process where (1) administrative databases were screened for patients who had presented with 12 diseases associated with palliative care need and (2) the Gold Standard Framework Prognostic Indicator Guidance (GSF PIG) criteria were applied to the clinical records of a random sample of patients meeting the disease criterion.

Results: Fifty-three thousand and fifty-seven patients presented to the EDs; 4488 (8.5%) patients had diagnostic codes indicating potential palliative care need and 1024 were randomly sampled. One hundred and eighty-eight patients (18.4%, 95%CI 16.0–20.8%) from the random sample were identified as meeting GSF PIG criteria for palliative care need. The leading diseases were cancer (26.1%), COPD (26.1%) and heart failure (22.9%). Extrapolating from the estimated incidence, 826 of the 4488 patients with 12 diseases would have met GSF PIG criteria, suggesting only 1.6% of all patients presenting to ED meet GSF PIG criteria.

Conclusions: The incidence of patients with actual palliative care need presenting to EDs was lower than anticipated. Further research is needed to examine for secular trends in palliative care presentations and if the incidence rates are consistent in across ED settings.     

Post-acute rehabilitation care for older people in community hospitals and general hospitals – Philosophies of care and patients' and caregivers' reported experiences: A qualitative study

Purpose.?This article contrasts community hospital and general hospital philosophies of care and examines how they relate to patients' and caregivers' experiences.

Methods.?Semi-structured interviews with 42 staff were used to produce care setting vignettes in six community hospitals and four general hospitals in the midlands and north of England. The vignettes were used with 26 patients and 10 caregivers in semi-structured interviews.

Results.?Community hospital and general hospital staff identified shared understandings of requirements for post-acute rehabilitation care for older people. Distinctive features were: general hospital – medical efficiency, helping patients get better, high standard of care, need for stimulation; community hospital – homelike setting, quiet, calm ambience, good views, orientated to elderly people, encouragement of social interaction, involvement of relatives in care. In the main there was symmetry between staff aspirations and patients' experience. However some concepts used and assumptions made by staff were not recognised by patients. These were characteristically reframed in patients' answers as if they were discussing subjective dimensions of care.

Conclusions.?There was patient and caregiver preference for the homelike environment of community hospitals. In care of older people, where the focus is rehabilitation, patient preferences are particularly pertinent and should be considered alongside clinical outcomes and cost-effectiveness.     

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia

Aim. This paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to end-of-life care in these patients. Background. In UK alone, approximately 100 000 people with dementia die each year and as the number of older people increases, dementia is set to become even more prevalent. Dementia is a progressive terminal illness for which there is currently no cure. Patients dying with dementia have significant health-care needs and in recent years it has been recognised that palliative care should be made available to everyone regardless of diagnosis, as this improves comfort and quality of life. Despite this, patients dying with dementia are often still not given access to palliative care services. Method. A review of English language literature published after 1996 to the present day relating to older people with dementia during the terminal phase of their illness. Results. Twenty-nine articles met inclusion criteria for the review. Most originated from North America and UK and were mostly quantitative in nature. Four key themes were identified: difficulties associated with diagnosing the terminal phase of the illness (prognostication); issues relating to communication; medical interventions; and the appropriateness of palliative care intervention. Conclusions. This review reinforces the importance of providing appropriate palliative care to individuals suffering from end-stage dementia and identifies some of the barriers to extending such specialist palliative care provision. Relevance to practice. There is an urgent need to improve palliative care provision for older people with end-stage dementia and, in addition, more research is required on the needs of patients entering the terminal phase of dementia to assist the allocation of appropriate resources and training to ensure quality and equality in the provision of end-of-life care.     

Palliative care in nursing homes: exploring care assistants' knowledge

Aim.  To explore the level of palliative care knowledge and to identify educational needs of care assistants (CAs) working within a nursing home context.
Background.  In the United Kingdom (UK) many patients at the end-of-life are admitted to (or reside in) nursing homes, where they receive care from unqualified CAs who have little formal training. Mandatory training in specific skills to meet palliative care needs are absent.
Method.  Questionnaire to CAs in 48 of 91 private nursing homes in one UK region.
Findings.  A population of 1135 CAs were targeted with a response rate of 45% ( n  = 508). A high proportion of CAs in this sample required information about the philosophy and principles of palliative care. Results support the need for an educational initiative to improve palliative care in nursing homes.
Conclusion.  Although recognized as a common place of death for older people, CAs are often unprepared to provide end-of-life care to nursing home residents. It is recommended that attention be given towards developing the skills and knowledge of this staff group.     

Evidence on home palliative care: Charting past,present, and future at the Cicely Saunders Institute – WHO Collaborating Centre for Palliative Care,Policy and Rehabilitation

Abstract

The need for home palliative care is increasing globally as the overall number of deaths rise and home remains where most people prefer to die and where most spend their last months of life. Research must accompany this growing demand and inform service developments. We highlight key findings by our team at the Cicely Saunders Institute that have informed policy in the UK, Europe, and beyond, influencing clinical practice and training. We also share the lessons learnt in the process of conducting research on aspects related to home palliative care over the last 15 years. We conclude by presenting priorities for future research, expressing our commitment as the WHO Collaborating Centre for Palliative Care, Policy and Rehabilitation to continue helping the development of quality, accessible, and cost-effective home palliative care for the generations to come.     

How are older people’s care preferences documented towards the end of life?

BackgroundMeeting individuals’ preferences is essential to achieve quality care at the end of life. Documenting these preferences in the healthcare system is an essential step to achieve them.AimTo investigate the documentation of older people’s care preferences including end of life care preferences in health records.MethodsRetrospective audit of health records for the last six months of life of people aged over 74 years who died in hospitals, residential aged care facilities, or community palliative care.FindingsFifty records were audited, including 28 hospital, 12 residential aged care facilities, and 10 community palliative care records with overall 297 documented care preferences. 30% of preferences were recorded on institution-specific forms at admission which focussed on patients’ medical/healthcare needs and less on personal/lifestyle preferences. Documentation mainly included clinical care preferences (35%), resuscitation plans (28%), and place of care (20%). Preferred place of death was not documented in 70% of cases. Increased documentation occurred closer to death with 63% of preferences recorded in the last week of life.DiscussionThe low rates of recorded preferences, especially non-medical choices like preferred place of death, may indicate low rates of preference discussions and/or poor documentation of these conversations. The increase in documentation closer to death may be explained by increased care needs and higher rates of care place transitions towards the end of life.ConclusionDiscussion and documentation of older people’s care preferences needs to be further encouraged within the healthcare system. It is essential not to wait for a crisis at the end of life to begin these processes.     

How many inpatients at an acute hospital have palliative care needs? Comparing the perspectives of medical and nursing staff

The primary aim of this prospective face-to-face interview survey was to identify the proportion of inpatients at an acute hospital (Royal Hallamshire Hospital, Sheffield, UK) considered to have palliative care needs by medical and nursing staff directly responsible for their care. During the 1-week period of the survey (6-10 September 1999), 452 inpatients were present in the hospital. Nursing staff were interviewed for 99% of patients; medical staff for 81%. Staff interview data were supplemented by case note review. Overall, 23% of the total inpatient population were identified as having palliative care needs and/or being terminally ill by staff and 11% were considered suitable for referral to a specialist palliative care bed. However, there was a low level of concurrence between medical and nursing staff as to which individual patients had palliative care needs (although this increased with perceived increased proximity to death), including which would be suitable for referral to a specialist palliative care bed. A need for further palliative care education for medical and nursing staff working within acute hospital settings was identified to ensure that the best use is made of hospital-based specialist palliative care services.     

A patient-centred model of care incorporating a palliative approach: A framework to meet the needs of people with advanced COPD?

Abstract

Background

Current models of care for people with advanced chronic obstructive pulmonary disease (COPD) have been demonstrated to be inadequate, particularly in areas such as advance care planning, symptom control and psychosocial and spiritual care.

Aim

This paper aims to explore how a model of patient-centred care can incorporate a palliative approach to form a practical and useful framework for care that meets the needs of people with advanced COPD.

Discussion

There is increasing recognition of the need to provide active disease management at the same time as supportive care for people with chronic disease. A palliative approach can incorporate these two care imperatives but a number of barriers often make implementation problematic. A patient-centred care approach can help to address these barriers and is increasingly being seen as an appropriate framework for all healthcare service provision. Significant changes are required to health systems and service provision for this model of care to be implemented; specialist palliative care services can take a leading role in change management.

Conclusion

Patient-centred care provides an appropriate framework for the development of a model of care for advanced COPD. It allows for a need-based approach to service provision, rather than the current prognosis-based system and brings patient and carer needs and concerns to the forefront of care.     

What are the goals of care for older people living with frailty when they access urgent care? Are those goals attained? A qualitative view of patient and carer perspectives

Study objectiveLittle is known of the goals of care of older people living with frailty when they access urgent care. Equally whether these goals are attained from a patient and carer perspective is often unclear. This qualitative study examined the views of older people living with frailty and their families in relation to specific episodes of urgent care, what they wanted to achieve and whether those goals were attained.MethodsSemi-structured interviews with older people living with frailty and their families between Jan and July 2019. Patient and carer participants were recruited in three hospitals in England and interviewed following the urgent care episode. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach. Results were validated by an older people’s involvement group.ResultsForty participants were interviewed either alone or jointly (24 patients and 16 carers), describing episodes of urgent care which started in ED for 28 patients. The goals of care for participants accessing emergency care were that their medical problem be diagnosed and resolved; information about tests and treatment be given to them and their relatives; they receive an appropriate well-planned discharge to their own home with support where needed and without readmission or re-attendance at ED; and that they retain mobility, function and normal activities. Participants perceived that many of these goals of care were not attained.ConclusionsOlder people living with frailty have heterogeneous urgent care goals which require individual ascertainment. Identifying these goals of care early could result in improved attainment through person-centred care.     

Palliative Care Need and Availability in Four Referral Hospitals in Senegal: Results from a Multicomponent Assessment

Context

With prevalence of noncommunicable diseases and life expectancy rising in Senegal, the need for palliative care is likely growing. No national palliative care needs assessments have been carried out.

Editor's Page

Abstract

Aim

To explore the views of general practitioners (GPs) regarding the involvement of the practice nurse (PN) in supporting older people with heart failure (HF) throughout the disease trajectory and identify specific implications for initiating advance care planning and improving end-of-life care.

Methods

Thirty GPs in a large urban area of New Zealand (NZ) participated in in-depth qualitative interviews. The interviews were recorded and transcribed verbatim. Data were entered into Nvivo software and were analysed thematically.

Results

While the GPs' experiences of working with the PN as contributor to the management of older patients with HF were positive overall, very minimal involvement of the PN in palliative and end-of-life care management was identified. However, significant potential for expansion was identified, particularly in the areas PNs are currently involved in, namely communication, education, and coordinating services, all of which are considered essential to effective palliative and end-of-life care.

Conclusion

The views of GPs are important as they employ PNs in NZ and are central to the ways in which the PN role can be developed in the future to improve services for older people with HF throughout the disease trajectory. Our study indicates that there is significant potential to expand the role of the PN throughout the HF disease trajectory, a development which could address some of the current gaps in palliative and end-of-life care management for these patients. Further research is required to develop and evaluate a model which optimizes the PN role throughout the disease trajectory of people with HF.     

Chronic Heart Failure Patients' Perceptions on their Palliative Care Needs

Objective

The aim of this study was to investigate the perceptions of patients with chronic heart failure regarding palliative care needs.

Frailty and its significance in older people's nursing

The term frail is commonly used to describe older people, but reports on the care of older adults in hospital highlight that the clinical implications of frailty are not understood fully by all nurses. Frailty can be an indicator of older people's health status and healthcare needs. An understanding of frailty and its mechanisms will help nurses to determine care priorities, particularly the urgency for anticipatory, proactive, preventive and compensatory care to prevent unnecessary mortality and morbidity. This article discusses the significance of frailty in older people's nursing. It highlights the responsibility of registered nurses to recognise deterioration in health as a result of frailty and to implement appropriate interventions.     

A retrospective audit of spirituality assessment in palliative care patients in Singapore

Abstract

Introduction

Spirituality is essential and forms a critical factor in the way palliative care patients cope with their illnesses. It has been recognized as a major and important component of palliative care. There is little data in Singapore on the current state of spiritual care at the end of life.

Materials and methods

A retrospective case-notes audit of the current state of spirituality assessment was conducted in the home care as well as hospital in-patient setting. The case-notes audit was selected from patients who were seen by the palliative medicine teams between June and July 2013.

Results

A total of 108 home care patient case notes and 182 hospital in-patient case notes were analyzed during the period of this study. Only 24.1% of home care patients and 30.2% of hospital in-patients had spirituality assessments conducted, of which most patients (77.8%) had these assessments completed during the first initial clinical review. The common spiritual themes identified were fairly equally distributed among the 81 palliative care patients in whom a spirituality assessment was performed.

Conclusion

Our audit shows that less than one-third of patients have had a spiritual assessment conducted, similar to the results of other studies elsewhere. It is hoped that this spirituality assessment rate can be improved by putting in place a structured spiritual programme in future.     

Factors influencing missed nursing care for older people following fragility hip fracture

BackgroundOlder people suffering fragility hip fractures are among the most fragile and vulnerable hospital patients. They often have complex care needs due to pre-existing and chronic conditions which may exacerbate as a consequence of surgery and hospitalisation. When deviations from best practice occur, care can be missed.AimTo identify factors that influence missed care for the older person with a hip fracture; inform recommendations for change and highlight the need for further research to achieve best practice nursing care for older people following a fragility hip fracture.MethodsA scoping review was conducted using databases Cumulative Index to Nursing and Allied Health Literature, Medline and Scopus, using a combination of keywords.FindingsTwenty-two relevant papers published between 2010-2018 were identified illustrating areas where nursing care was missed for either patients with hip fractures, older patients or both.DiscussionThis paper has reviewed literature related to nursing care for older people following a hip fracture to determine what nursing care may be missed; why it is missed and to identify strategies to improve outcomes through reducing the impact of missed nursing care for this population. Existing missed care literature usually focusses upon structural and organisational issues to the detriment of other factors.ConclusionMissed nursing care for the hospitalised older person with a hip fracture can be organised under three broad themes: organisational factors, nurse and patient characteristics.     

Dementia palliative care: A multi-site survey of long term care STAFF’S education needs and readiness to change

Many people with dementia reside in long-term care, where limited staff knowledge of dementia palliative care has been identified, along with poor awareness that a palliative approach can assist in identifying unmet care needs. Evidence-based guidance in palliative care for people with dementia is available however, implementing this guidance requires staff engagement and a tailored educational approach. This pre-implementation situational analysis informed a tailored staff education intervention to support the implementation of national guidance on dementia palliative care in long term care. Using a cross-sectional study design, underpinned by the Consolidated Framework for Implementation Research, survey data were collected on site profile, staff demographics, learning needs, and readiness-to change at three residential care sites for older people in Ireland. In total, 69 staff (predominantly nurses and healthcare attendants) completed the surveys. Medication management and management of pain were the most frequently identified learning needs. Staff were confident in their ability to implement change but de-motivation and powerlessness were substantial factors as only one-third of staff were “ready for change”. Staffing levels, managing risk during change and perceived reluctance in others were common barriers. These results informed an educational intervention to address the specific care context, staff learning needs and barriers to change prior to implementation.     

‘Through the eyes of the dying’—Identifying who may benefit from bereavement follow-up: A qualitative study

IntroductionBereavement support is an integral element of palliative care. Emerging evidence stipulates that bereavement support should be reserved for those most at risk of poor outcomes. While this evidence makes identifying those at risk of experiencing a complex bereavement a necessary first step, it has been difficult to arrive at a consensus as to whom that should be.AimTo explore whether palliative care in-patients with advanced disease are concerned about the bereavement needs of others and, if so, is it their next-of-kin.DesignA qualitative study using semi-structured interviews, and thematic analysis using a constant comparative method.Setting/participantsPatients identified by their physicians as being aware of their limited prognosis (n = 19) in a specialist palliative care service in Sydney, Australia.FindingsThree key themes emerged: 1) Families considered close and supportive may not require bereavement follow-up; 2) Families with previous significant losses or who have more complex lives are perceived by patients as having greater risk; and 3) Asking palliative care patients about whom they are most concerned in their network after their death is difficult but possible.ConclusionsThere are potentially people in the palliative patients’ networks who may be in need of bereavement support, but who are unlikely to be informed about available bereavement services. New strategies are needed to identify people who may benefit from bereavement support.