Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial

Abstract

The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).

Electronic Health Record Mortality Prediction Model for Targeted Palliative Care Among Hospitalized Medical Patients: a Pilot Quasi-experimental Study

“…Thus, innovative and systematic strategies are needed to augment clinician referral of patients most likely to benefit from earlier palliative care consultation. [10][11][12] There has been a growing interest in triggering palliative care consultation using several different criteria, such as selected diagnoses, 13,14 disease-specific prognostic indicators, 15,16 or a patient's location. [17][18][19] Although sound in principle, these approaches are nonspecific and assume palliative care needs and are therefore unlikely to be scalable given the growing number of seriously ill patients and the limited palliative care specialist workforce in the USA.…”

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

“…In addition, health coaching and other navigator interventions oriented to palliative care may be a feasible intervention as recently shown effective in a patient hospitalized with a COPD exacerbation (many of them eligible for palliative care). [80][81][82] These studies provide preliminary evidence that is promising, but further research is needed.…”

“…71 Finally, the provision of palliative care as the default option (patients need to opt out if they do not want it) has been recently considered and is currently being tested. 81…”

A systematic review of the use of the electronic health record for patient identification, communication, and clinical support in palliative care

“… 2 An interdisciplinary approach is used to treat the multiple co-morbidities, difficult-to-manage symptoms, psychological disruption, and financial challenges of the patients and their families in order to enhance quality of life. 1 , 3–5 …”

“…1 , 5 , 8–10 Oncology patients are more likely to receive PC than non-cancer patients. 3 , 11 More patients would benefit from PC if screening and assessment were available more broadly and offered earlier. 11 …”