Surgical Patients Less Likely to Receive Hospice or Palliative Care Compared to Medical Patients
Several studies and multiple clinical trials demonstrate that hospice and palliative care greatly reduce healthcare costs while also providing better quality and improved access to care. In 2002, VA established initiatives to improve clinical programs for end-of-life care. This study examined the use of end-of-life care in the VA healthcare system among surgical and medical patients at the end of life. Using VA data, investigators identified 191,280 VA patients who died between FY09 and FY12, and who had an acute VA inpatient admission within one year prior to death. Veterans were categorized as surgical if they had undergone a major surgical procedure in the last year of life (n=42,143) and medical if they had not received a surgical procedure (n=149,137) within their last year. Investigators assessed receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death. Patient demographics and comorbidities also were examined.
- VA surgical patients were less likely to receive either hospice or palliative care in the year prior to death compared with medical patients (38% vs. 41%, respectively). This difference also was present in a separate analysis of palliative care (37% surgical vs. 39% medical) and hospice care (21% surgical vs. 24% medical). Moreover, differences in the use of palliative or hospice care were intensified after adjusting for patient characteristics. However, among Veterans who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (median of 26 days versus 23 days).
- The use of palliative services increased over the study period – from 29% to 47% for medical patients and from 27% to 45% for surgical patients. Likewise, hospice use increased from 21% to 27% and from 19% to 24% for medical and surgical patients, respectively.
- The median time between palliative or hospice initiation and death increased over the study period – from 22 to 25 days for medical patients and from 22 to 30 days for surgical patients.
- It is possible that Veterans received end-of-life care from non-VA sources, and those data were not included in this study.
- Administrative data may not provide the most clinically relevant information or provide background circumstances for a surgical procedure or referral to palliative care or hospice.
- Authors suggest that further studies explore the clinical significance of the differences between medical and surgical patients, and establish if earlier intervention in surgical patients is possible using triggers.
This study was funded by HSR&D. Drs. Olmsted, Johnson, Kaboli, and Vaughan-Sarrazin are part of HSR&D's Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA.
Olmsted C, Johnson A, Kaboli P, Cullen J, and Vaughan-Sarrazin M. Use of Palliative Care and Hospice among Surgical and Medical Specialties in the Veterans Health Administration. JAMA Surgery; September 24, 2014;e-pub ahead of print.