Default palliative care orders help more patients with COPD receive consultation
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Key takeaways:
- Compared with usual care, default palliative care consult orders led to more consultations in older patients with COPD.
- Between the two groups, length of stay and in-hospital mortality were similar.
More older patients with COPD, dementia or kidney failure had a palliative care consultation shortly after admission through a default ordering system vs. usual care, according to study results published in JAMA.
Default consult orders were automatically placed through electronic health records and clinicians had the power to opt-out of these orders, according to researchers.
“For many reasons, clinicians often delay engaging palliative care consult teams until the final days or weeks of patients’ lives, particularly for those with chronic, noncancer serious illnesses,” Katherine R. Courtright, MD, MS, assistant professor of medicine in the division of pulmonary, allergy and critical care at Perelman School of Medicine at the University of Pennsylvania and director of research at Penn Medicine Palliative Care, told Healio. “This trial, conducted within community hospitals and as part of routine hospital care, demonstrates that end-of-life care processes are improved for these patients simply by ordering palliative care consultation by default earlier in the hospital course.”
In a pragmatic cluster randomized trial, Courtright and colleagues assessed 24,065 older patients (mean age, 77.9 years; 55.4% women) with advanced COPD, dementia or kidney failure in the hospital for a minimum of 72 hours to find out how default palliative care consult orders vs. usual care impact hospitalization duration.
Researchers also evaluated rates of palliative care consultations, discharge to hospice, do-not-resuscitate orders and in-hospital mortality between the two types of care.
Throughout the trial, additional palliative care staffing was not required or prohibited.
Of the total cohort, a majority of patients had COPD (69.4%), followed by dementia (30.9%) and kidney failure (12.3%).
Within the study population, 10,313 patients had a palliative care consultation ordered by default, whereas 13,752 patients received usual care.
Notably, clinicians opted out of 9.6% of default consultation orders overall. Of the cancelled orders, clinicians said 53.1% had “no palliative care needs at this time.”
Among those who received default consult orders, 43.9% received palliative care consultation. This outcome occurred in fewer patients who received usual care (16.6%), signaling a higher likelihood of receiving palliative care consultation with default orders (adjusted OR = 5.17; 95% CI, 4.59-5.81).
Researchers found that both groups had comparable median hospitalization durations (percent difference, –0.53%; 95% CI, –3.51% to 2.53%); however, in a subset of “patients who would have received a consult only if assigned to the intervention group” (estimated 27.3%), median hospitalization duration with default ordering vs. usual care decreased by 9.6%.
When evaluating the amount of time that passed between admission and consultation, an average of 3.4 days passed in the default order group, whereas 4.6 days passed in the usual care group (P < .001).
In terms of do-not-resuscitate orders, researchers observed elevated odds for this outcome among those who received default consult orders vs. usual care (aOR = 1.4; 95% CI, 1.21-1.63). This patient group was also more likely to be discharged to hospice (aOR = 1.3; 95% CI, 1.07-1.57).
In-hospital mortality did not differ between those in the default care group (4.7%) and those in the usual care group (4.2%), according to researchers.
“Health systems around the country could easily implement this intervention, and while additional staffing isn’t required, it would almost certainly be more effective still if coupled with increased palliative care staffing,” Courtright told Healio.
“Future studies will improve upon this work by more precisely identifying patients most likely to benefit from default orders for palliative care consultation to improve the reach of the palliative care teams,” Courtright added.
Reference:
- Largest-ever study of palliative care demonstrates scalable strategy to increase support for seriously ill patients in the hospital. https://www.pennmedicine.org/news/news-releases/2024/january/penn-researchers-lead-largest-ever-study-of-inpatient-palliative-care. Published Jan. 16, 2024. Accessed Jan. 16, 2024.