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The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge

Lilley, Elizabeth J., MD, MPH; Lee, Katherine C., MD, MPH; Scott, John W., MD, MPH; Krumrei, Nicole J., MD; Haider, Adil H., MD, MPH; Salim, Ali, MD; Gupta, Rajan, MD, MHCDS; Cooper, Zara, MD, MSc

Journal of Trauma and Acute Care Surgery: November 2018 - Volume 85 - Issue 5 - p 992–998
doi: 10.1097/TA.0000000000002000
2018 WTA PODIUM PAPER

BACKGROUND Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients.

METHODS This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization.

RESULTS Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54–4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15–0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39–0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30–0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36–0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39–0.80).

CONCLUSION Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge.

LEVEL OF EVIDENCE Therapeutic/Care management, level III.

From the Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts (E.J.L., K.C.L., J.W.S., A.H.H., A.S., Z.C.); Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (E.J.L., N.J.K., R.G.); Department of Surgery, University of California San Diego, La Jolla, California (K.C.L.); and Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., Z.C.).

Submitted: February 14, 2018, Revised: April 19, 2018, Accepted: May 8, 2018, Published online: May 30, 2018.

This paper was presented at the following meetings: 48th Annual Meeting of the Western Trauma Association, February 25 to March 2, 2018, in Whistler, British Columbia, Canada; 41st Annual Residents Trauma Papers Competition during the American College of Surgeons Committee on Trauma Annual Meeting, March 8, 2018, in San Antonio, Texas, United States.

Address for reprints: Elizabeth J. Lilley, MD, MPH, Robert Wood Johnson Place, MEB 594, New Brunswick, NJ 08901; email: lilleyej@rwjms.rutgers.edu.

© 2018 Lippincott Williams & Wilkins, Inc.