In the Journals

Palliative care in ESLD increasing despite socioeconomic, ethnic barriers

From 2006 to 2012, researchers observed an increased use of palliative care in patients with end-stage liver disease, according to a recently published study. However, they also observed socioeconomic and ethnic barriers to access.

“The current study is one of the largest nationwide studies of palliative care referral in patients with end-stage liver disease. Although palliative care referrals in patients with end-stage liver disease is increasing, the rate of referrals is still very low,” Mayur Brahmania, MD, from the Toronto General Hospital, University Health Network, said in a press release. “We must emphasize that palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and treatment of pain along with other physical and psychosocial issues.”

The researchers accessed the Nationwide Inpatient Sample and included in the study 39,349 patients with end-stage liver disease hospitalized between 2006 and 2012. The researchers also included a sample of patients with metastatic cancer also hospitalized during the same period and were known to use palliative care.

Of the patients with end-stage liver disease, 1,789 had palliative care consultation. The rate of palliative care referral increased similarly from 2006 to 2012 in both patients with end-stage liver disease (0.97% to 7.1%; P < .01) and those with metastatic cancer (2.9% to 11.9%; P < .01).

Factors associated with lower palliative care referral included Hispanic race (OR = 0.77; 95% CI, 0.66-0.89) and insurance coverage (OR = 0.74; 95% CI, 0.65-0.84).

Factors associated with increased palliative care referral included age per 5-year increase (OR = 1.05; 95% CI, 1.03-1.08), do-not-resuscitate status (OR = 16.24; 95% CI, 14.2-18.56), treatment performed in a teaching hospital (OR = 1.25; 95% CI, 1.12-1.39), treatment in a medium (OR = 1.36; 95% CI, 1.09-1.7) or large hospital (OR = 1.49; 95% CI, 1.22-1.82) compared with small hospitals, presence of hepatocellular carcinoma (OR = 2; 95% CI, 1.71-2.33) and presence of metastatic cancer (OR = 2.39; 95% CI, 1.8-3.18).

Additional factors related to higher rates of palliative care included hospitalization in the Midwest (OR = 1.31; 95% CI, 1.09-1.58), South (OR = 1.24; 95% CI, 1.05-1.47) or West (OR = 1.81; 95% CI, 1.53-2.14) regions of the U.S. and the second median zip-code income quartile compared to the lowest quartile (OR = 1.18; 95% CI, 1.04-1.35).

“While there has been a traditionally accepted role for [palliative care] in oncology patients, the benefits of [palliative care] in noncancer patients has been increasingly recognized,” the researchers concluded. “The association between insurance coverage and referral to [palliative care] services, with patients who have insurance coverage less likely to be referred, is interesting and needs to be validated. One question our results raise is if [palliative care] referral limits tests and treatments subconsciously and if this presents a conflict of interest with providers and hospitals in a fee-for-service payment system If so, then a switch to bundle payment may improve referral to [palliative care] services.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.

From 2006 to 2012, researchers observed an increased use of palliative care in patients with end-stage liver disease, according to a recently published study. However, they also observed socioeconomic and ethnic barriers to access.

“The current study is one of the largest nationwide studies of palliative care referral in patients with end-stage liver disease. Although palliative care referrals in patients with end-stage liver disease is increasing, the rate of referrals is still very low,” Mayur Brahmania, MD, from the Toronto General Hospital, University Health Network, said in a press release. “We must emphasize that palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and treatment of pain along with other physical and psychosocial issues.”

The researchers accessed the Nationwide Inpatient Sample and included in the study 39,349 patients with end-stage liver disease hospitalized between 2006 and 2012. The researchers also included a sample of patients with metastatic cancer also hospitalized during the same period and were known to use palliative care.

Of the patients with end-stage liver disease, 1,789 had palliative care consultation. The rate of palliative care referral increased similarly from 2006 to 2012 in both patients with end-stage liver disease (0.97% to 7.1%; P < .01) and those with metastatic cancer (2.9% to 11.9%; P < .01).

Factors associated with lower palliative care referral included Hispanic race (OR = 0.77; 95% CI, 0.66-0.89) and insurance coverage (OR = 0.74; 95% CI, 0.65-0.84).

Factors associated with increased palliative care referral included age per 5-year increase (OR = 1.05; 95% CI, 1.03-1.08), do-not-resuscitate status (OR = 16.24; 95% CI, 14.2-18.56), treatment performed in a teaching hospital (OR = 1.25; 95% CI, 1.12-1.39), treatment in a medium (OR = 1.36; 95% CI, 1.09-1.7) or large hospital (OR = 1.49; 95% CI, 1.22-1.82) compared with small hospitals, presence of hepatocellular carcinoma (OR = 2; 95% CI, 1.71-2.33) and presence of metastatic cancer (OR = 2.39; 95% CI, 1.8-3.18).

Additional factors related to higher rates of palliative care included hospitalization in the Midwest (OR = 1.31; 95% CI, 1.09-1.58), South (OR = 1.24; 95% CI, 1.05-1.47) or West (OR = 1.81; 95% CI, 1.53-2.14) regions of the U.S. and the second median zip-code income quartile compared to the lowest quartile (OR = 1.18; 95% CI, 1.04-1.35).

“While there has been a traditionally accepted role for [palliative care] in oncology patients, the benefits of [palliative care] in noncancer patients has been increasingly recognized,” the researchers concluded. “The association between insurance coverage and referral to [palliative care] services, with patients who have insurance coverage less likely to be referred, is interesting and needs to be validated. One question our results raise is if [palliative care] referral limits tests and treatments subconsciously and if this presents a conflict of interest with providers and hospitals in a fee-for-service payment system If so, then a switch to bundle payment may improve referral to [palliative care] services.” – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.