BACKGROUND/RATIONALE:
Improving end-of-life care is of critical importance to the VA as it faces an increasingly aging and dying veteran population. In FY2000 approximately 104,000 enrolled veterans died in the U.S. including 27,200 that died as inpatients in VA acute or chronic care medical wards. Previous work within and outside of the VA has identified serious deficiencies in the quality of care delivered near the end of life. A pilot program of a collaborative care intervention in patients with advanced illness suggests that palliative care management may lead to improvements in processes and outcomes of care at reduced costs.

OBJECTIVE(S):
The purpose of this project is to test the effectiveness of a chronic illness model-based palliative care intervention that utilizes prognosis-based palliative care evaluation and longitudinal nurse care management on the processes and outcomes of end-of-life care at one VA medical center.

METHODS:
The study uses a randomized, controlled design. All patients admitted to the inpatient medical service during the enrollment period are screened for survival prognosis by their admitting resident physician. Patients estimated to have at least a 25% risk of dying over the following year and who meet other basic inclusion criteria are invited to participate. Consenting patients are randomized to intervention or usual care. The intervention entails initial palliative evaluation followed by nurse care management designed to promote informed goal-setting, symptom management, psycho/socio/spiritual support, and family support. Data collection activities include patient and caregiver surveys, chart reviews, and reviews of administrative databases. Primary study outcomes include caregiver-rated quality of death and dying, hospital-based resource use, and costs; secondary outcomes include patient quality of life, satisfaction with care, continuity and coordination of care, and patient self-determination

FINDINGS/RESULTS:
Of 7,182 admissions to general medicine wards during the enrollment period, 6,819 prognostications (95 percent) were made in 4,567 unique patients. Resident prognostication was strongly associated with one-year mortality, with 51 percent, 77 percent and 92 percent of patients with mortality risk ratings of 26-50 percent, 51-75 percent, and >75 percent, respectively, dying within one year (p < .001). Of the 4,567 unique patients, 1355 (30 percent) had at least one mortality risk estimate of greater than 25 percent, of which 559 (41 percent) were eligible for enrollment and 400 (72 percent of eligible) enrolled. Among enrollees, 65 percent had a life-limiting diagnosis of cancer, and 44 percent of enrollees had greater than 50 percent estimated one-year mortality. One-year mortality was 50 percent, including 60 percent among cancer patients and 26 percent among non-cancer patients.

Intervention and usual care patients had similar mortality during follow-up (64 percent vs. 65 percent, p>.5), time in study (426 vs. 422 days, p>.5), and time until death among those who died (223 vs. 222 days, p>.5). Compared with usual care, the intervention led to more frequent palliative care consultation overall (100 percent vs. 55 percent, p<.01) and among those who died (100 percent vs. 71 percent, p<.01), and it occurred 75 days earlier (228 vs. 153 days prior to death, p<.01). Among patients who died there was a non-significant increase in hospice referral among intervention patients (48 percent vs. 38 percent, p=.13), with time in hospice being significantly longer in intervention than usual care patients (138 vs. 75 days, p<.01).

Over an average follow-up period of 424 days, overall mortality was 65 percent and did not differ between intervention and usual care groups (64 percent vs 65 percent, p>0.5). Among patients who died, time until death was also similar between groups (223 vs. 222 days, p>.05). Among patients who died intervention patients had a lower rate of ICU admission (14 percent vs. 25 percent, p=.03) and fewer ICU days (2.0 vs 1.2, p=.03) in the final 30 days of life than usual care patients, and there was a trend towards fewer total hospital days (31.5 vs. 22.4, p=.08); total ICU days did not differ between groups (3.1 vs. 3.7, p=.14). There was no significant difference between intervention and usual care groups in total hospital days or ICU days for for the entire sample (25.7 vs. 29.1 days, p=.24 and 3.3 vs. 3.0 days, p=.64). In multivariate analysis among patients who died, the intervention was associated with fewer total hospital days ( (log)=.44, p<.01) and a lower likelihood of hospital or ICU admission in the final 30 days of life (OR=.34, p=.01 and OR=.21, p<.01) compared with usual care. The intervention was associated with higher patient and caregiver satisfaction with continuity and coordination of care, and caregiver reports of better communication related to the patient's dying experience. The intervention was not associated with differences in patient symptoms or quality of life or, for patients who died, on caregiver assessment of the quality of the patient's dying experience.

IMPACT:
Compared with standard palliative care consultation, a collaborative care model incorporating active case-finding and longitudinal case management can improve the quality of end-of-life care while reducing end-of-life hospital resource use. This study is the first of its type to demonstrate success of prognosis-based case-finding and palliative care management within the VA. The findings of the study argue for larger-scale implementation studies that will inform models of end-of-life care delivery both within and outside of the VA. Administrators at VAs nationwide, including chiefs of service, chiefs of staff, hospital directors, and VISN directors will be able to use the plans and protocols developed in this project to develop programs at their own institutions. Nurses, generalist physicians, and specialists can gain important insights about the special needs of seriously ill patients and the role of care systems in delivering high-quality end of life care. Finally, the project has immediate relevance to the healthcare system at large, as it struggles to find effective end-of-life care delivery models.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Goebel JR, Doering LV, Lorenz KA, Maliski SL, Nyamathi AM, Evangelista LS. Caring for special populations: total pain theory in advanced heart failure: applications to research and practice. Nursing Forum. 2009 Jul 1; 44(3):175-85. [view]
2. Seow H, Snyder CF, Shugarman LR, Mularski RA, Kutner JS, Lorenz KA, Wu AW, Dy SM. Developing quality indicators for cancer end-of-life care: proceedings from a national symposium. Cancer. 2009 Sep 1; 115(17):3820-9. [view]
3. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, Morton SC, Hughes RG, Hilton LK, Maglione M, Rhodes SL, Rolon C, Sun VC, Shekelle PG. Evidence for improving palliative care at the end of life: a systematic review. Annals of internal medicine. 2008 Jan 15; 148(2):147-59. [view]
4. Casarett D, Pickard A, Amos Bailey F, Ritchie C, Furman C, Rosenfeld K, Shreve S, Shea JA. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. Journal of pain and symptom management. 2008 Feb 1; 35(2):115-25. [view]
5. Chang VT, Sorger B, Rosenfeld KE, Lorenz KA, Bailey AF, Bui T, Weinberger L, Montagnini M. Pain and palliative medicine. Journal of rehabilitation research and development. 2007 Jan 1; 44(2):279-94. [view]
6. Wagner GJ, Riopelle D, Steckart J, Lorenz KA, Rosenfeld KE. Provider communication and patient understanding of life-limiting illness and their relationship to patient communication of treatment preferences. Journal of pain and symptom management. 2010 Mar 1; 39(3):527-34. [view]
7. Lorenz KA, Rosenfeld K, Wenger N. Quality indicators for palliative and end-of-life care in vulnerable elders. Journal of the American Geriatrics Society. 2007 Oct 1; 55 Suppl 2:S318-26. [view]
8. Krouse RS, Mohler MJ, Wendel CS, Grant M, Baldwin CM, Rawl SM, McCorkle R, Rosenfeld KE, Ko CY, Schmidt CM, Coons SJ. The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample. Current Medical Research and Opinion. 2006 Apr 1; 22(4):781-91. [view]
9. Fromme EK, Hughes MT, Brokaw FC, Rosenfeld KE, Arnold RM. Update in palliative medicine 2008. Journal of palliative medicine. 2008 Jun 1; 11(5):769-75. [view]

Conference Presentations

1. Lorenz KA. Cancer care quality measures. Paper presented at: American Academy of Hospice and Palliative Medicine Annual Assembly; 2006 Feb 1; Nashville, TN. [view]
2. Steckart MJ, Sverdlik A, Riopelle D, Wagner G, Rosenfeld KE. Case finding in palliative care: development and evaluation of a resident prognostication tool. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
3. Lorenz KA. Hospice and the opportunity to improve end of life care. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA. [view]
4. Rosenfeld KE. Methodologic issues in palliative care interventions trials: Experience from a VA randomized trial. Paper presented at: American Academy of Hospice and Palliative Medicine Annual Assembly; 2006 Feb 1; Nashville, TN. [view]
5. Lorenz KA, Riopelle D, Steckhart M, Wagner G, Rosenfeld KE. Palliative needs among inpatient veterans with serious, life-limiting illness. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA. [view]
6. Rosenfeld KE, Steckart MJ, Riopelle DD, Magner-Perlin ML, Lorenz KA, Lee ML, Wagner GJ. Prognosis-Based Palliative Care Management: Impact on End-of-Life Resource Use. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD. [view]
7. Riopelle DD, Steckart JM, Magner ML, Cox NC, Rosenfeld KE. Qualitative Description of Palliative Case Management: Implications for Developing Best Practices in the VA System. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA. [view]
8. Mularski RA, Lorenz KA, Asch SM, Ettner SL, Yano EM, Santiago SM. Racial disparity in site of death: African-Americans and Hispanics at higher risk for hospital death. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
9. Rosenfeld KE, Lorenz KA, Steckhart M, Riopelle D, Wagner G. Relationships among patient perception of prognosis, treatment and documented communicated care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 1; Los Angeles, CA. [view]
10. Lorenz KA. State of the art measurement workshop: Using administrative data to evaluate palliative care. Paper presented at: American Academy of Hospice and Palliative Medicine Annual Assembly; 2006 Feb 1; Nashville, TN. [view]
11. Lorenz KA. Symptoms and palliative care assessment in the MDS 3.0. Paper presented at: American Geriatrics Society Annual Meeting; 2005 Nov 1; Orlando, FL. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems Science
DRE: none
Keywords: Advance directives, End-of-life, Managed care
MeSH Terms: none