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How to Promote Palliative Care? Order by Default, Penn Study Finds

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Shifting from an opt-in to an opt-out approach boosted palliative care consults from 16.6% of eligible patients to 43.9%, the investigators found.

More patients could receive palliative care, which focuses on symptom relief and improving quality of life, if this care was ordered by default, a new study published today finds.

Investigators from the University of Pennsylvania’s Perelman School of Medicine published the largest-ever study of palliative care today in JAMA, which found that setting up automatic orders for palliative care consultations raised the likelihood that patients who would benefit from this care would receive it. The study found that shifting from an opt-in to an opt-out approach boosted palliative care consultation rates from 16.6% to 43.9% while cutting the time to a consult by 1.2 days.

Kate Courtright, MD, MS | Image credit: Penn Medicine

Kate Courtright, MD, MS | Image credit: Penn Medicine

“While early palliative care consultation could help many patients with chronic serious illnesses better understand their diagnosis and align their treatment choices to their individual care goals, there's never been an established approach to realizing that goal at scale. We found that a simple, pre-programmed order within the electronic medical record can get more palliative care to more people more quickly,” lead author Kate Courtright, MD, MS, an assistant professor of critical care and palliative medicine, said in a statement. “This strategy was low-cost and easily implemented in community hospitals, which is where most Americans receive their health care.”

Palliative care is designed to create a treatment plan that aligns with a patient’s individual goals, values, and priorities. Too often, palliative care is confused with hospice, which is reserved for patients with a life expectancy of 6 months or less. A 2020 study found that only 12% of adults understood what palliative care was, while 44% associated it with death and 18% believed, incorrectly, that other treatments had to be stopped.

In truth, palliative care can be started at any stage, and many payment models promote its use to keep patients out of the hospital.

The Penn study included more than 34,000 patients with chronic obstructive pulmonary disease (COPD), dementia, or kidney failure at 11 hospitals in 8 states, which were all part of a large nonprofit health system. The research team noted that patients with these conditions have often been underrepresented in prior studies of palliative care delivery, as most studies focus on those with cancer or heart failure. A statement released with the study said, “These patients often experience challenges with coping, as well as breathlessness, anxiety, pain, and other symptoms that palliative care can help address through medications, other treatments, and/or referrals to other specialists.”

The 11 hospitals in the study, which occurred between March 2016 and November 2018, were neither encouraged nor barred from increasing or decreasing palliative care, while physicians could place an order for palliative care throughout the study.

In the first phase, clinicians were asked to enroll patients for usual care. Later, hospitals shifted to an intervention phase that called for ordering palliative care by default. In this phase, palliative care was canceled for less than 10% of the patients that had the automatic orders.

“Our results suggest that the default order strategy was generally acceptable to clinicians, which is important because if we want to reach as many eligible patients as possible, we need to design approaches that are feasible for ‘real-world’ practice and not just in the research setting,” Courtright said.

Having default orders made no difference in how long patients stayed in the hospital, because during the intervention phase, less than half of patients received a palliative care consultation. However, a secondary outcomes analysis showed that when patients received palliative care only due to the default order, the median length of stay went down 9.6%. In addition, the default orders led to more patients being discharged to hospice with no effect on mortality.

Scott D. Halpern, MD, PhD | Image credit: Penn Medicine

Scott D. Halpern, MD, PhD | Image credit: Penn Medicine

As a follow-up, the investigators at Penn’s Palliative and Advanced Illness Research Center will conduct a randomized trial with $27.5 million in funding from the Patient-Centered Outcomes and Research Initiative (PCORI). This study will evaluate a system that trains all members of the patient’s hospital team, including doctors, nurses, advanced practice providers, and social workers, to provide palliative care.

“We know that health care systems have limited resources and need more evidence to guide future scaling and delivery of inpatient palliative care in an equitable and cost-effective manner,” senior author Scott D. Halpern, MD, PhD, the John M. Eisenberg Professor of Medicine, Epidemiology, and Medical Ethics and Health Policy, said in the statement. “As we build on this work, our goal is to continuously improve inpatient palliative care so that all patients and families facing a serious illness have access to the support they need to carry on with their daily lives throughout their treatment journey.”

Reference

Courtright KR, Madden V, Bayes B, et al. Default palliative care consultation for seriously ill hospitalized patients: a pragmatic cluster randomized trial. JAMA. 2024;331(3):224-232. doi:10.1001/jama.2023.25092

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