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Design and Participants: This pre-post quality improvement study (at a large, urban tertiary care academic medical center affiliated with a comprehensive cancer center) assessed the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to EDs near EOL. The program involved a formalized pathway with email alerts, clinician training, hospice vendor expansion, metric creation, and data tracking. The primary outcome was hospice transition without hospital admission and/or hospice admission within 96 hours of ED visit. Secondary outcomes included length of stay and in-hospital mortality. Analyses used Fisher’s and Wilcoxon rank-sum tests, t tests, and univariable and multivariable logistic regression.
Results: Patients in the control period (n=270; 2018-2020) were aged median 74 years [IQR=62-85]; 49% female; and 2.2% Asian, 12% Black, 68% White, and 4.1% other race/ethnicity. Patients in the intervention period (n=388; 2021-2022) were aged median 73 years [IQR=60-84]; 55% female; and 6.1% Asian, 9.7% Black, 78% White, and 6.6% other race/ethnicity. In control, 23% achieved the primary outcome vs 54% in intervention (P<.001). Intervention was associated with the primary outcome after adjustment for age, race/ethnicity, primary payer, Charlson Comorbidity Index, and presence of a Medical Order for Life-Sustaining Treatment (MOLST) (adjusted odds ratio=5.0; 95% CI=3.2-7.9). MOLST was independently associated with transition across all groups (1.9; 1.2-3.0). There was no between-group inpatient length-of-stay difference, but intervention in-hospital mortality was lower (49% vs 64%; P<.001).
Commentary: This quality improvement study addresses an important area of need for patients approaching EOL in the ED. The authors’ multifaceted approach is notable for leveraging electronic medical record data on just a 15-minute delay to identify potential patients and expanding general inpatient hospice (GIP) availability. Interestingly, the authors found that in-hospital mortality was significantly lower in the intervention period, even accounting for patients enrolled in GIP hospice, and that there was no statistically significant difference in inpatient length of stay between control and intervention cohorts. These findings may provide additional evidence to hospital administrators supporting resource deployment for similar programs elsewhere. The authors acknowledge applicability limitations of their intervention, though their approach could potentially be scaled relative to available resources at other institutions.
Bottom Line: A novel multifaceted ED-to-hospice-care transitions program improved frequency of goal-concordant hospice transitions.
Reviewer: Gabrielle Langmann, MD MS, University of Utah, Salt Lake City, UT
References:
1. Sharafi S, Ziaee A, Dahmardeh H. What are the outcomes of hospice care for cancer patients? A systematic review. Support Care Cancer. 2022;31(1):64. doi:10.1007/s00520-022-07524-2.
2. Shrank WH, Russell K, Emanuel EJ. Hospice carve-in-aligning benefits with patient and family needs. JAMA. 2020;324(1):35-36. doi:10.1001/jama.2020.8459.
3. Enomoto LM, Schaefer EW, Goldenberg D, Mackley H, Koch WM, Hollenbeak CS. The cost of hospice services in terminally ill patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg. 2015;141(12):1066-1074. doi:10.1001/jamaoto.2015.2162.
Source: Baugh CW, Ouchi K, Bowman JK, et al. A hospice transitions program for patients in the emergency department. JAMA Netw Open. 2024;7(7):e2420695. doi:10.1001/jamanetworkopen.2024.20695.
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