Palliative Care Shown to Reduce End-of-Life ED Use

FigureCancer patients who use palliative care services are 50 percent less likely to use the emergency department (ED) during the last month of life compared with cancer patients not receiving palliative care, according to new research. It has been well known that emergency departments are overused by many patients toward the end of life. Identifying risk factors associated with ED may help develop strategies to reduce that use, said the study researchers, all from the Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation at King's College London, U.K. In the meta-analysis published in the February 1 issue of the Journal of Clinical Oncology (2015;4:370-376), the researchers identified the following risk factors for increased use of EDs in the last month of life: Male gender (odds ratio 1.24); Black race (odds ratio 1.45 compared with white race); Lung cancer (odds ratio 1.17, with reference to other cancers); and Lowest socioeconomic group (odds ratio 1.15, with reference to highest socioeconomic status). LESLEY HENSON, MD. LESLEY HENSON, MD: “Our findings may be used to develop screening interventions and assist policy-makers to direct resources. Future studies should also investigate previously neglected areas of research, including psychosocial factors, and patients' and caregivers' emergency care preferences.”Cancer patients receiving palliative care were less likely to attend the ED in their last month of life (odds ratio 0.50), versus those not receiving palliative care. “Palliative care services remain underused for cancer patients, and this finding supports increased referrals of cancer patients to palliative care or supportive care services,” the first author, Lesley Henson, MD, a Clinical Training Fellow at Cicely Saunders and a palliative care physician, said via email. 30 Studies, Data from 1.8 Million Patients The meta-analysis identified 30 studies combining data from 1,181,842 patients. The majority were in the U.S. (18 studies) and Canada (eight studies), with the rest from the Republic of Korea, Spain, and Taiwan. The study used the reporting outcome of more than one ED visit in the patient's last 30 days of life. “Our finding has added further high-quality evidence to the scientific literature demonstrating the benefits that can be gained from palliative care,” the authors wrote. “Since current financial health care constraints have necessitated policy and services to evolve immediately, especially those that can reduce ED attendance... these findings may be used to develop screening interventions for high-risk cancer patients and also provide evidence to assist policy-makers to direct resources.” Henson said there is no evidence that overly aggressive care at the end of life (defined as more than one ED visit) improves life expectancy, and in fact, such care is associated with a reduced quality of life for patients and their families. “Yet, despite the potential negative impact to individuals and society, multiple ED visits by cancer patients in their last 30 days of life has increased over time.” The limitations of the meta-analysis, she said, include the heterogeneity of the review studied, estimates that combined univariable and multivariable effects, and the fact that although the factors identified provide important information on association, causality cannot be inferred. Also, there was a lack of studies investigating patients' and/or caregivers' preferences for health care services. For example, he said, patients may prefer for someone to come to their home, to be admitted directly to the oncology ward, or to have a 911 call (999 in the U.K.). Still, the researchers acknowledged that at times, the ED is actually the most appropriate setting: “The importance of providing individualized patient-centered care, including ED care if required, must not be overlooked.” Future studies, Henson said, may investigate psychosocial factors and patients' and caregivers' preferences for emergency care services. Eduardo Bruera: ‘Simple and Easily Measurable Factors’ Asked for his perspective for this article, Eduardo Bruera, MD, Chair and Professor of the Department of Palliative Care and Rehabilitation Medicine at the University of Texas MD Anderson Cancer Center, said the study provides valuable information because the authors found simple and easily measurable factors associated with ED visits, and confirmed that palliative care referrals are associated with reduced ED visits. “ED visits in the last days of life are distressing for patients and families, and reducing them is an important goal for cancer programs,” he said via email. “Oncology programs can take advantage of these findings and institute early (outpatient) referral to palliative care as a way to prevent ED visits.” The study itself is of high quality, with an important systematic review of the existing literature, Bruera said. “The limited number and small size of outpatient supportive care/palliative care programs in the U.S. is one of the main barriers to implementing checklists for identification of patients at risk and ensuring early palliative care access for them.” He added that more and larger outpatient palliative care programs will allow for large cooperative studies on the prevention of ED visits.

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