Disease and race-based differences in inpatient palliative care consultation in cancer and noncancer serious illnesses

BACKGROUND: Guidelines recommend timely palliative care consultation (PCC) for hospitalized patients with serious illness, but adherence to such guidelines and variability in access are not well described.

METHODS: Prospective cohort study from March 21, 2016 to August 8, 2018 during the usual care period of a cluster-randomized trial at 11 hospitals in 8 US states. We included adults age 45 and older with cancer, chronic obstructive pulmonary disease (COPD), dementia, heart failure, or kidney failure. Exposures included diagnoses, demographics, and hospital characteristics, and outcomes included predicted probability and timing of PCC.

RESULTS: Among 40,074 inpatient encounters (median age 72 years [IQR 62-82], 46.9% male, 22.7% Black, 4.6% Hispanic), the most common serious illness was heart failure (66.0%), followed by COPD (39.3%), kidney failure (12.4%), cancer (12.3%), and dementia (11.6%). The overall rate of PCC was 11.6% (95% CI 11.3%-11.9%), ranging across hospitals from 4.2% (95% CI 3.3%-5.3%) to 23.3% (95% CI 19.6%-27.4%). Patients with dementia (20.6%, 95% CI 19.4%-21.7%) and cancer (19.5%, 95% CI 18.5%-20.7%) received PCC the most, and those with kidney failure the least (8.2%, 95% CI 7.5%-9.0%). Median time to PCC after admission was 3 days (IQR 1-6); patients with heart failure, COPD, and kidney failure received PCC 1 day later at the median compared to cancer and dementia. Predictors of increased odds of receiving PCC included being Black or Asian (aOR 1.12, 95% CI 1.02-1.23; aOR 1.67, 95% CI 1.31-2.12, respectively) and being admitted to a hospital with a higher overall rate of PCC orders (aOR 1.11, 95% CI 1.08-1.13).

CONCLUSION: PCC was underutilized overall and varied substantially in frequency and timing across hospitals, diseases, and patient race. These findings underscore the need to implement standardized approaches to improve adherence to guideline-recommended PCC.

National Institute on Aging

Emily E Moin, Brian Bayes, Vanessa Madden, Scott D Halpern, Katherine R Courtright