Randomized Evaluation of Default Access to Palliative Services (REDAPS)

Inpatient palliative care (PC) consult services hold great promise to improve care and reduce costs for patients with life-limiting illnesses. However, there is limited experimental evidence available to quantify the effects of inpatient PC consult service in generalizable, real-world settings. There is even less evidence about which types of services work best for which types of patients and how to ensure timely PC delivery. This large, pragmatic trial assesses the effects of default PC consultation for seriously ill patients on clinical, patient-centered, and economic outcomes. The trial was conducted between May 2016 and November 2018 at 11 hospitals across 8 states of a single health system. Using a stepped wedge design, hospitals sequentially changed from the usual care phase (whereby clinicians actively request an inpatient PC consultation) to the intervention phase (whereby PC consults are automatically ordered in the electronic health record by default for eligible patients). Physicians can cancel an order after being alerted to it, and patients or family members can decline such services. During the study period there were 34,239 patients aged >=65 years with advanced chronic obstructive pulmonary disease (COPD), advanced dementia, or end-stage renal disease (ESRD) admitted as inpatients in the study hospitals. This population constitutes the intention-to-treat (ITT) sample. Of patients in the ITT sample, 24,065 had a hospital length of stay of at least 72 hours, making them eligible for inclusion in the modified ITT sample, which represents the primary analytic sample. We also conducted a qualitative substudy of 28 hospitalists at 7 hospitals and interviewed hospitalists about their views on consulting PC services for patients specifically with dementia.

Our qualitative study revealed that PC consult referral decisions for patients with dementia were influenced by multiple factors across four themes: patient, family caregiver, hospitalist, and organization. Consultation was typically only considered for patients with advanced disease, particularly those receiving aggressive care or with family communication needs (navigating conflicts around goals of care and improving disease and prognostic understanding). Hospitalists’ limited time, and for some, a lack of confidence in palliative care skills were strong drivers of consultation. Palliative care needs notwithstanding, most hospitalists were not comfortable with consultation if they perceived families were resistant to engage in goals of care discussions or had minimal presence in the hospital. Additional barriers to referral at the organization level included a hospital culture that conflated palliative and end-of-life care and busy palliative care teams at some hospitals.

Ascension

National Institute on Aging