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The value of compassion: Healthcare savings of palliative care consults in trauma

Published:October 19, 2022DOI:https://doi.org/10.1016/j.injury.2022.10.021

      Abstract

      Background

      The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.

      Study Design

      We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.

      Results

      140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).

      Conclusion

      Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

      Keywords

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      References

        • Trauma Quality Improvement Program
        ACS tqip palliative care best practice guidelines [Internet].
        American College of Surgeons, 2017 ([cited 2020 Dec 19]. Available from)
        • Sher D.J.
        Economic benefits of palliative care consultation continue to unfold.
        J Clin Oncol. 2015; 33: 2723-2724
        • May P.
        • Garrido M.M.
        • Cassel J.B.
        • Kelley A.S.
        • Meier D.E.
        • Normand C.
        • et al.
        Palliative care teams’ cost-saving effect is larger for cancer patients with higher numbers of comorbidities.
        Health Aff (Millwood). 2016; 35: 44-53
        • Starks H.
        • Wang S.
        • Farber S.
        • Owens D.A.
        • Curtis J.R.
        Cost savings vary by length of stay for inpatients receiving palliative care consultation services.
        J Palliat Med. 2013; 16: 1215-1220
        • Ernecoff N.C.
        • Bilderback A.
        • Bellon J.
        • Arnold R.M.
        • Boninger M.
        • Kavalieratos D.
        Associations between reason for inpatient palliative care consultation, timing, and cost savings.
        J Palliat Med. 2021; 24: 1525-1538
        • Hwang F.
        • Pentakota S.R.
        • Glass N.E.
        • Berlin A.
        • Livingston D.H.
        • Mosenthal A.C.
        Older patients with severe traumatic brain injury: national variability in palliative care.
        J Surg Res. 2020; 246: 224-230
        • Rhee C.
        • McHugh M.
        • Tun S.
        • Gerhart J.
        • O'Mahony S
        Advantages and challenges of an interdisciplinary palliative care team approach to surgical care.
        Surg Clin North Am. 2019; 99: 815-821
        • Suwanabol P.A.
        • Reichstein A.C.
        • Suzer-Gurtekin Z.T.
        • Forman J.
        • Silveira M.J.
        • Mody L.
        • et al.
        Surgeons’ perceived barriers to palliative and end-of-life care: a mixed methods study of a surgical society.
        J Palliat Med. 2018; 21: 780-788
        • Maerz L.L.
        • Mosenthal A.C.
        • Miller R.S.
        • Cotton B.A.
        • Kirton O.C.
        Futility and the acute care surgeon.
        J Trauma Acute Care Surg. 2015; 78: 1216-1219
        • Fiorentino M.
        • Hwang F.
        • Pentakota S.R.
        • Livingston D.H.
        • Mosenthal A.C.
        Palliative care in trauma: not just for the dying.
        J Trauma Acute Care Surg. 2019; 87: 1156-1163
        • Cocanour C.S.
        End-of-life care in trauma.
        J Trauma Acute Care Surg. 2015; 79: 891-896
        • Nelson J.E.
        • Curtis J.R.
        • Mulkerin C.
        • Campbell M.
        • Lustbader D.R.
        • Mosenthal A.C.
        • et al.
        Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (iPAL-ICU) Advisory Board*.
        Crit Care Med. 2013; 41: 2318-2327
        • Mosenthal A.C.
        • Murphy P.A.
        Interdisciplinary model for palliative care in the trauma and surgical intensive care unit: robert Wood Johnson Foundation Demonstration Project for Improving Palliative Care in the Intensive Care Unit.
        Crit Care Med. 2006; 34: S399-S403
        • Aziz H.A.
        • Lunde J.
        • Barraco R.
        • Como J.J.
        • Cooper Z.
        • Hayward T.I.
        • et al.
        Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee.
        J Trauma Acute Care Surg. 2019; 86: 737-743
        • Zhao F.Z.
        • Wolf S.E.
        • Nakonezny P.A.
        • Minhajuddin A.
        • Rhodes R.L.
        • Paulk M.E.
        • et al.
        Estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the Geriatric Trauma Outcome Score.
        J Palliat Med. 2015; 18: 677-681
        • Madni T.D.
        • Ekeh A.P.
        • Brakenridge S.C.
        • Brasel K.J.
        • Joseph B.
        • Inaba K.
        • et al.
        A comparison of prognosis calculators for geriatric trauma: a prognostic assessment of Life and Limitations after Trauma in the Elderly consortium study.
        J Trauma Acute Care Surg. 2017; 83: 90-96
        • Cook A.C.
        • Joseph B.
        • Inaba K.
        • Nakonezny P.A.
        • Bruns B.R.
        • Kerby J.D.
        • et al.
        Multicenter external validation of the Geriatric Trauma Outcome Score: a study by the Prognostic Assessment of Life and Limitations After Trauma in the Elderly (PALLIATE) consortium.
        J Trauma Acute Care Surg. 2016; 80: 204-209
        • Ghaferi A.A.
        • Schwartz T.A.
        • Pawlik T.M.
        STROBE Reporting Guidelines for Observational Studies.
        JAMA Surg. 2021; 156: 577-578
        • Harvey L.
        • Mitchell R.
        • Brodaty H.
        • Draper B.
        • Close J.
        The influence of dementia on injury-related hospitalisations and outcomes in older adults.
        Injury. 2016; 47: 226-234
        • Kruser J.M.
        • Cox C.E.
        • Schwarze M.L.
        Clinical momentum in the intensive care unit. a latent contributor to unwanted care.
        Ann Am Thorac Soc. 2017; 14: 426-431
        • Schwarze M.L.
        • Brasel K.J.
        • Mosenthal A.C.
        Beyond 30-day mortality: aligning surgical quality with outcomes that patients value.
        JAMA Surg. 2014; 149: 631-632
        • Waljee J.F.
        • Dimick J.B.
        Do patient-reported outcomes correlate with clinical outcomes following surgery?.
        Adv Surg. 2017; 51: 141-150
        • Ledbetter R.
        • Marterre B.
        Where's the value in preoperative covenants between surgeons and patients?.
        AMA J Ethics. 2021; 23: e814-e822
        • Kupensky D.T.
        • Emerick E.S.
        • Hileman B.M.
        • Chance E.A.
        The association of time to palliative medicine consultation on geriatric trauma outcomes.
        J Trauma Nurs. 2020; 27: 177-184
        • Lee C.W.
        • Vitous C.A.
        • Silveira M.J.
        • Forman J.
        • Dossett L.A.
        • Mody L.
        • et al.
        Delays in palliative care referral among surgical patients: perspectives of surgical residents across the state of Michigan.
        J Pain Symptom Manage. 2019; 57 (e1): 1080-1088
        • Tilden L.B.
        • Williams B.R.
        • Tucker R.O.
        • MacLennan P.A.
        • Ritchie C.S.
        Surgeons’ attitudes and practices in the utilization of palliative and supportive care services for patients with a sudden advanced illness.
        J Palliat Med. 2009; 12: 1037-1042
        • Epstein R.M.
        • Street R.L.
        The values and value of patient-centered care.
        Ann Fam Med. 2011; 9: 100-103
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making — The pinnacle of patient-centered care.
        N Engl J Med. 2012; 366: 780-781
        • Sigman M.
        • Miller P.
        Practicing primary palliative care: a call to action.
        Bull Am Coll Surg. 2019; 104: 13-21
        • Suwanabol P.A.
        • Kanters A.E.
        • Reichstein A.C.
        • Wancata L.M.
        • Dossett L.A.
        • Rivet E.B.
        • et al.
        Characterizing the role of U.S. surgeons in the provision of palliative care: a systematic review and mixed-methods meta-synthesis.
        J Pain Symptom Manage. 2018; 55 (e5): 1196-1215
        • Amen S.S.
        • Berndtson A.E.
        • Cain J.
        • Onderdonk C.
        • Cochran-Yu M.
        • Gambles Farr S.
        • et al.
        Communication and palliation in trauma critical care: impact of trainee education and mentorship.
        J Surg Res. 2021; 266: 236-244
        • Ballou J.H.
        • Brasel K.J.
        Surgical palliative care education.
        Surg Clin North Am. 2019; 99: 1037-1049
        • Bonanno A.M.
        • Kiraly L.N.
        • Siegel T.R.
        • Brasel K.J.
        • Cook M.R.
        Surgical palliative care training in general surgery residency: an educational needs assessment.
        Am J Surg. 2019; 217: 928-931
        • Marterre B.
        • Kopecky K.
        • Miller P.
        Primary palliative care for surgeons: a narrative review and synthesis of core competencies.
        Ann Palliat Med. 2022; 11: 885-906