Research
Original Investigation | ASSOCIATION OF VA SURGEONS
Use of Palliative Care and Hospice Among Surgical and Medical Specialties in the Veterans Health Administration Courtney L. Olmsted, BSE, MD; Amy M. Johnson, PhD; Peter Kaboli, MD, MS; Joseph Cullen, MD; Mary S. Vaughan-Sarrazin, PhD
IMPORTANCE Many hospitals have undertaken initiatives to improve care during the end of
life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. OBJECTIVE To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191 280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42 143) or medical (n = 149 137) if the patient did not receive surgical treatment in the last year of life. MAIN OUTCOMES AND MEASURES Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. RESULTS Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment. CONCLUSIONS AND RELEVANCE In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.
JAMA Surg. 2014;149(11):1169-1175. doi:10.1001/jamasurg.2014.2101 Published online September 24, 2014.
Author Affiliations: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Olmsted, Johnson, Kaboli, Vaughan-Sarrazin); Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City (Olmsted, Cullen); Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City (Kaboli, Vaughan-Sarrazin); Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center–Central Region, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Kaboli); Surgical Services, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Cullen). Corresponding Author: Courtney L. Olmsted, BSE, MD, Iowa City Veterans Affairs Healthcare System, 601 Highway 6 West, Iowa City, IA 52246 ([email protected]).
1169
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Research Original Investigation
Use of Palliative Care and Hospice in the VHA
P
alliative care incorporates many clinical areas other than end-of-life care, including cultural, spiritual, social, psychological, and physical aspects of care for patients with chronic life-limiting illness.1 Several studies and multiple clinical trials demonstrate that hospice and palliative care greatly reduce health care costs while concurrently providing better quality and improved access to care.2,3 Earlier palliative care consultation decreases the use of costly intensive care unit (ICU) care without changing mortality.4 One quantitative study has shown differences in end-of-life care among medical and surgical specialties, focusing only on care received in the ICU.5 The authors found that patients in the ICU with surgical attending physicians had lower ratings of quality of dying than those cared for by medical attending physicians in the ICU. They also found surgical patients had less documented palliative care than medical patients.5 With advancements in cancer treatment, palliative care has shown reduction in morbidity and mortality.6 As a result, many health care systems are focusing on clinical services offered by hospice and palliative medicine. New education curricula now incorporate palliative medicine into family medicine, internal medicine, and surgery to suit the needs of the changing older patient population.7,8 Early communication and structured discussions about end-of-life care may be provided in inpatient settings to reduce suffering in the last days of life. Such communication and goal setting are fundamental to patient-centered care. This issue may be especially salient for the Veterans Health Administration (VHA), given the unique needs of veterans at the end of life. For example, veterans are more likely than nonveterans to experience anxiety and sadness at the end of life.9 Nevertheless, inpatient health care professionals who traditionally emphasize curative care may fail to recognize patients who would benefit from end-of-life discussions. In 2002, the VHA established initiatives to improve clinical programs for end-of-life care. The Best Practices for Endof-Life Care for Our Nation's Veterans Trial intervention was developed to improve health care professional skills for identifying patients in acute-term or long-term inpatient settings who were entering the dying process. That trial produced modest yet statistically significant increases in the use of advanced directives and pain management.10 Since this trial, the VHA has developed further interventions to improve end-of-life care further, reflected in the 2008 VHA directive. Qualitative differences in the medical and surgical specialties are known regarding end-of-life and advanced care planning.11 However, the use of palliative care services among surgical and medical specialties in acute inpatient settings has received little attention, and its use among these specialties is unknown. This study examines the use of end-of-life care in the VHA health system among surgical and medical patients in the last year of life. Specifically, we used VHA national administrative data files to determine the initiation and timing of palliative and hospice services for veterans hospitalized in acute surgery and medical services in VHA hospitals prior to death. 1170
Methods Enrollment data and patient treatment files from the VHA were used to identify VHA patients who died between fiscal years 2009 and 2012 and had an acute inpatient admission (either ICU or acute inpatient) in the VHA system within 365 days prior to death. Patients were excluded if the initial palliative care or hospice point was more than 1 year prior to death. A total of 191 280 patients were included in the analysis. Patients were categorized as surgical if the patient underwent a major surgical procedure in the last year of life (n = 42 143) and medical if the patient did not receive a surgical procedure in the last year of life (n = 149 137). The classifications of major therapeutic or diagnostic surgeries were defined by the Healthcare Cost and Utilization Project (HCUP) Procedure Classes.12 This study was approved by the institutional review board of the University of Iowa and the Iowa City Veterans Affairs Research and Development Committee. A waiver of participation consent was obtained through the institutional review board. Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. Palliative care was designated based on International Classification of Diseases, Ninth Revision diagnostic code V66.7. Hospice care was determined from VHA inpatient, outpatient, and fee-based care files and included home hospice as well as hospice provided in inpatient settings. In general, patients in hospice must have a prognosis of 6 months or less, while patients in palliative care are not restricted by prognostic information. Because hospice is a subset of palliative care, we identified the following 3 service categories: nonhospice palliative care, hospice care, and either nonhospice or hospice palliative care. The number of days in hospice or palliative care was also calculated by subtracting the initial date of hospice or palliative from the date of death. Additional patient characteristics were identified from VHA claims and included demographics (age, sex, and race/ ethnicity), veteran eligibility category (service-connected disability, low income, or other), and comorbid conditions. Specific comorbid conditions were identified by categorizing International Classification of Diseases, Ninth Revision, Clinical Modification codes available on VHA claims during the 12 months prior to death according to the algorithm described by Quan et al.13 Using these comorbid conditions and patient age, we calculated a Charlson Comorbidity Index (CCI) for each patient.14,15
Statistical Analysis First, differences between medical and surgical patients in sex, race/ethnicity, and comorbid conditions were determined using the χ2 test. Second, differences in the proportion of patients receiving palliative or hospice care during the year prior to death were examined in unadjusted analyses using the χ2 test and in riskadjusted analysis using logistic regression. Logistic regression models controlled for patient demographics (age, sex, and race/ ethnicity), veteran eligibility category, and comorbid conditions. The logistic models were estimated as generalized esti-
JAMA Surgery November 2014 Volume 149, Number 11
Copyright 2014 American Medical Association. All rights reserved.
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jamasurgery.com
Use of Palliative Care and Hospice in the VHA
Original Investigation Research
Table 1. Demographic Data and Comorbidities of the 191280 Patients in the Study Population (continued) No. (%) of Patients Medicine Surgery (n = 149 137) (n = 42 143) 9061 (6.1) 3107 (7.4)
Characteristic Pulmonary circulatory disorder
P Value
Original Investigation | ASSOCIATION OF VA SURGEONS
Use of Palliative Care and Hospice Among Surgical and Medical Specialties in the Veterans Health Administration Courtney L. Olmsted, BSE, MD; Amy M. Johnson, PhD; Peter Kaboli, MD, MS; Joseph Cullen, MD; Mary S. Vaughan-Sarrazin, PhD
IMPORTANCE Many hospitals have undertaken initiatives to improve care during the end of
life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. OBJECTIVE To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191 280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42 143) or medical (n = 149 137) if the patient did not receive surgical treatment in the last year of life. MAIN OUTCOMES AND MEASURES Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. RESULTS Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment. CONCLUSIONS AND RELEVANCE In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.
JAMA Surg. 2014;149(11):1169-1175. doi:10.1001/jamasurg.2014.2101 Published online September 24, 2014.
Author Affiliations: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Olmsted, Johnson, Kaboli, Vaughan-Sarrazin); Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City (Olmsted, Cullen); Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City (Kaboli, Vaughan-Sarrazin); Veterans Affairs Office of Rural Health, Veterans Rural Health Resource Center–Central Region, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Kaboli); Surgical Services, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa (Cullen). Corresponding Author: Courtney L. Olmsted, BSE, MD, Iowa City Veterans Affairs Healthcare System, 601 Highway 6 West, Iowa City, IA 52246 ([email protected]).
1169
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Nanyang Technological University User on 06/02/2015
Research Original Investigation
Use of Palliative Care and Hospice in the VHA
P
alliative care incorporates many clinical areas other than end-of-life care, including cultural, spiritual, social, psychological, and physical aspects of care for patients with chronic life-limiting illness.1 Several studies and multiple clinical trials demonstrate that hospice and palliative care greatly reduce health care costs while concurrently providing better quality and improved access to care.2,3 Earlier palliative care consultation decreases the use of costly intensive care unit (ICU) care without changing mortality.4 One quantitative study has shown differences in end-of-life care among medical and surgical specialties, focusing only on care received in the ICU.5 The authors found that patients in the ICU with surgical attending physicians had lower ratings of quality of dying than those cared for by medical attending physicians in the ICU. They also found surgical patients had less documented palliative care than medical patients.5 With advancements in cancer treatment, palliative care has shown reduction in morbidity and mortality.6 As a result, many health care systems are focusing on clinical services offered by hospice and palliative medicine. New education curricula now incorporate palliative medicine into family medicine, internal medicine, and surgery to suit the needs of the changing older patient population.7,8 Early communication and structured discussions about end-of-life care may be provided in inpatient settings to reduce suffering in the last days of life. Such communication and goal setting are fundamental to patient-centered care. This issue may be especially salient for the Veterans Health Administration (VHA), given the unique needs of veterans at the end of life. For example, veterans are more likely than nonveterans to experience anxiety and sadness at the end of life.9 Nevertheless, inpatient health care professionals who traditionally emphasize curative care may fail to recognize patients who would benefit from end-of-life discussions. In 2002, the VHA established initiatives to improve clinical programs for end-of-life care. The Best Practices for Endof-Life Care for Our Nation's Veterans Trial intervention was developed to improve health care professional skills for identifying patients in acute-term or long-term inpatient settings who were entering the dying process. That trial produced modest yet statistically significant increases in the use of advanced directives and pain management.10 Since this trial, the VHA has developed further interventions to improve end-of-life care further, reflected in the 2008 VHA directive. Qualitative differences in the medical and surgical specialties are known regarding end-of-life and advanced care planning.11 However, the use of palliative care services among surgical and medical specialties in acute inpatient settings has received little attention, and its use among these specialties is unknown. This study examines the use of end-of-life care in the VHA health system among surgical and medical patients in the last year of life. Specifically, we used VHA national administrative data files to determine the initiation and timing of palliative and hospice services for veterans hospitalized in acute surgery and medical services in VHA hospitals prior to death. 1170
Methods Enrollment data and patient treatment files from the VHA were used to identify VHA patients who died between fiscal years 2009 and 2012 and had an acute inpatient admission (either ICU or acute inpatient) in the VHA system within 365 days prior to death. Patients were excluded if the initial palliative care or hospice point was more than 1 year prior to death. A total of 191 280 patients were included in the analysis. Patients were categorized as surgical if the patient underwent a major surgical procedure in the last year of life (n = 42 143) and medical if the patient did not receive a surgical procedure in the last year of life (n = 149 137). The classifications of major therapeutic or diagnostic surgeries were defined by the Healthcare Cost and Utilization Project (HCUP) Procedure Classes.12 This study was approved by the institutional review board of the University of Iowa and the Iowa City Veterans Affairs Research and Development Committee. A waiver of participation consent was obtained through the institutional review board. Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. Palliative care was designated based on International Classification of Diseases, Ninth Revision diagnostic code V66.7. Hospice care was determined from VHA inpatient, outpatient, and fee-based care files and included home hospice as well as hospice provided in inpatient settings. In general, patients in hospice must have a prognosis of 6 months or less, while patients in palliative care are not restricted by prognostic information. Because hospice is a subset of palliative care, we identified the following 3 service categories: nonhospice palliative care, hospice care, and either nonhospice or hospice palliative care. The number of days in hospice or palliative care was also calculated by subtracting the initial date of hospice or palliative from the date of death. Additional patient characteristics were identified from VHA claims and included demographics (age, sex, and race/ ethnicity), veteran eligibility category (service-connected disability, low income, or other), and comorbid conditions. Specific comorbid conditions were identified by categorizing International Classification of Diseases, Ninth Revision, Clinical Modification codes available on VHA claims during the 12 months prior to death according to the algorithm described by Quan et al.13 Using these comorbid conditions and patient age, we calculated a Charlson Comorbidity Index (CCI) for each patient.14,15
Statistical Analysis First, differences between medical and surgical patients in sex, race/ethnicity, and comorbid conditions were determined using the χ2 test. Second, differences in the proportion of patients receiving palliative or hospice care during the year prior to death were examined in unadjusted analyses using the χ2 test and in riskadjusted analysis using logistic regression. Logistic regression models controlled for patient demographics (age, sex, and race/ ethnicity), veteran eligibility category, and comorbid conditions. The logistic models were estimated as generalized esti-
JAMA Surgery November 2014 Volume 149, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Nanyang Technological University User on 06/02/2015
jamasurgery.com
Use of Palliative Care and Hospice in the VHA
Original Investigation Research
Table 1. Demographic Data and Comorbidities of the 191280 Patients in the Study Population (continued) No. (%) of Patients Medicine Surgery (n = 149 137) (n = 42 143) 9061 (6.1) 3107 (7.4)
Characteristic Pulmonary circulatory disorder
P Value
