Exploratory Study of Palliative Care Utilization and Medical Expense for Inpatients at the End-of-Life

Abstract

Background: Previous research mostly analyzed the utilization of palliative care for patients with cancer, and data regarding non-cancer inpatients are limited. Objectives: This research aimed to investigate the current situation regarding palliative care and the important factors that influence its utilization by inpatients (including inpatients with and without cancer) at the end of their lives. We also explored the feasibility of establishing a prediction model of palliative care utilization for inpatients at the end of their lives. These findings will allow medical staff to monitor and focus on those who may require palliative care, resulting in more end-of-life patients receiving palliative care and thereby reducing medical expense and improving their quality of life. Methods: This was a retrospective study based on real-world health information system (HIS) data from 5 different branches of Taipei City Hospital between 1 January 2018 and 31 December 2018 that enrolled a total of 1668 deceased inpatients. To explore palliative care utilization at the end of life, we used 5-fold cross-validation in four different statistical models to obtain the performance of predictive accuracy: logistic regression (LGR), classification and regression tree (CART), multivariate adaptive regression spline (MARS), and gradient boosting (GB). The important variables that may affect palliative care utilization by inpatients were also identified. Results: The results were as follows: (1) 497 (29.8%) inpatients received palliative care; (2) the average daily hospitalization cost of patients with cancer who received palliative care (NTD 5789 vs. NTD 12,115; p ≤ 0.001) and all patients who received palliative care (NTD 91,527 vs. NTD 186,981; p = 0.0037) were statistically significantly lower than patients who did not receive palliative care; (3) diagnosis, hospital, and length of stay (LOS) may affect palliative care utilization of inpatient; diagnosis, hospitalization unit, and length of hospitalization were statistically significant by LGR; (4) 51.5% of patients utilized palliative consultation services, and 48.5% utilized palliative care units; and (5) MARS had the most consistent results; its accuracy was 0.751, and the main predictors of palliative care utilization are hospital, medical expense, LOS, diagnosis, and Palliative Care Screening Tool-Taiwan version (TW-PCST) scores. Conclusions: The results reveal that palliative care utilization by inpatients remains low, and it is necessary to educate patients without cancer of the benefits and advantages of palliative care. Although data were limited, the predictability of the MARS model was 0.751; a better prediction model with more data is necessary for further research. Precisely predicting the need for palliative care may encourage patients and their family members to consider palliative care, which may balance both physical and mental care. Therefore, unnecessary medical care can be avoided and limited medical resources can be allocated to more patients in need.

Analysis of Palliative Care Utilization and Medical Expenses among Patients with Chronic Diseases in Taiwan: A Population-Based Cohort Study

“…PC can improve the quality of patient outcomes [24,35]. Furthermore, several studies have shown that PC reduced the average medical expense of patients with cancer and multiple comorbidities [28,36,37]. Our research shows that the average medical expense is lower in patients with emergency treatment than in those without any emergency treatment at the end of life.…”

“…The main purposes of PC include satisfying the needs of patients and their family members to ease their pain, improving the patients' dignity at the end of life, and reducing unnecessary treatments [28]. In PC consultations, the patient, family members, and medical team often discuss hospice care plans suitable for the patient.…”

Current situation and support need for non-cancer patients’ admission to inpatient hospices/palliative care units in Japan: a nationwide multicenter survey

“…A systematic review reported that hospital-based specialist palliative care (HSPC), which includes inpatient hospices/PCUs and palliative care teams, reduced patient symptom burden, improved health-related quality of life, other person-centered outcomes, and satisfaction of patients with advanced illness (8). In spite of these clear advantages, inpatient hospices/PCUs have not committed to providing palliative care to non-cancer patients in Taiwan (9). This trend is similar in Japan where specialist palliative care has mainly been developed for advanced cancer patients in the last two decades (10).…”

Examining the Psychometric Properties of the Taiwanese Version of the Hospice Quality of Life Index

“…The utilization of palliative and hospice care in Taiwan remains relatively low despite the enactment of the Natural Death Act and Hospice Palliative Care Act 7-9 . Health care providers and family caregivers have encountered truth-telling, traditional social norms related to filial piety and hospice referral as common ethical dilemmas 10,11 .…”

“…6 The utilization of palliative and hospice care in Taiwan remains relatively low despite the enactment of the Natural Death Act and Hospice Palliative Care Act. [7][8][9] Health care providers and family caregivers have encountered truthtelling, traditional social norms related to filial piety and hospice referral as common ethical dilemmas. 10,11 Because of a lack of training in communication and truth-telling skills, health care providers in Taiwan have difficulty in initiating end-of-life care discussions with patients 12 and prefer to discuss sensitive topics with caregivers of patients.…”