MODELS OF CARE CSIRO PUBLISHING
Australian Health Review, 2015, 39, 404–405 http://dx.doi.org/10.1071/AH14256
Letter
Underutilisation of Victorian in-patient palliative care consultation services? Results of an exploratory study Peter Eastman1,2 BPhty, MBBS, FRACGP, FAChPM, Palliative Care Consultant Brian Le1 MBBS(Hons), MPH, FRACP, FAChPM, Head of Department 1
Department of Palliative Care, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3052, Australia. Email: [email protected] 2 Corresponding author. Email: [email protected]
Received 9 January 2015, accepted 20 February 2015, published online 13 April 2015
The recent Australian Institute of Health and Welfare (AIHW) report on Australian palliative care services highlighted several important issues, including increasing demand for palliative care services and differences in provision across health care settings.1 In response to this report, the peak national organisation, Palliative Care Australia, raised concerns around access, suggesting that the majority of Australians with a need for palliative care services were not currently receiving them.2 The AIHW report addressed many aspects of Australian palliative care service provision; however, limited specific attention was paid to the role of palliative care consultation services (PCCS) for in-patients of acute hospitals. The role of PCCS are worthy of consideration because 51% of all deaths in Australia in 2011–12 occurred in hospital and, of these, more than 60% were not specifically palliative care patients.1 There is increasing evidence showing the benefits of PCCS. Improvements have been demonstrated in symptom control, satisfaction with care, patient–clinician communication and end-of-life care.3,4 Important reductions have also been reported in healthcare costs and resource utilisation.5 Attempts have been made to quantify the palliative care needs of hospital in-patients in several international settings. Recent data from the UK, Australia and New Zealand identified between 20% and 36% of in-patients as having palliative care needs.6–8 For the majority of patients, these needs will be met by generalist rather than specialist palliative care services;7 however, the ideal referral rate to PCCS remains unspecified. A recent US report into palliative care utilisation suggested that between 5% and 10% of all hospital admissions should receive a specialist palliative consultation.9 In response to this report, we investigated referral rates from an Australian viewpoint by using the Victorian Admitted Episodes Database (VAED) and the Victorian Integrated Non-Admitted Health (VINAH) dataset to assess PCCS utilisation across Victorian metropolitan public hospital networks. Each network consists of a varying number of separate in-patient facilities and collection and submission of clinical data to these datasets is mandatory for all Victorian health services and Health Department-funded PCCS. No specific paediatric hospitals were included in our analysis and only multiday acute admitted episodes were analysed. Journal compilation Ó AHHA 2015
Using palliative care consultancy episodes as a numerator and total acute multiday admitted episodes as a denominator we calculated a percentage that approximated PCCS uptake for individual Victorian metropolitan public hospital networks. For 2012–13, across the eight networks with 500 or greater annual palliative care consultancy episodes, this percentage ranged from 2.1% to 18.1%. The 18.1% was from a solely cancer tertiary hospital and, when this was excluded, the range was 2.1%–4.2%. The median of 3.1% is in keeping with US data, suggesting that currently between 2% and 4% of admitted patients receive a palliative care consultation. Many in-patients will never require involvement from specialist palliative care services; however, determining when referral is appropriate can be difficult. Factors influencing this decision include differing goals of care, prognostic uncertainty, variations in clinician recognition of care needs, patient and/or family belief systems, particularly around death and dying, palliative care workforce limitations and concerns around deskilling generalist staff. Given the demonstrated benefits of such consultations across a range of health metrics and in the context of an aging and increasingly frail population, a median referral rate of 3% to PCCS in metropolitan hospital settings with welldeveloped and highly rated palliative care systems10 seems low. The importance of ongoing discussion and research into the who, when and why of referrals to PCCS cannot be under-stated. Competing interests The authors have no competing interests. Acknowledgements The authors wish to thank Mr Gregory W. Dalton (Manager, Palliative Care, Wellness, Integrated Care and Aging Division, Victorian Department of Health) for his assistance with data collection.
References 1
Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia 2014. Catalogue no. HWI 128. Canberra: AIHW; 2014.
www.publish.csiro.au/journals/ahr
Victorian in-patient palliative care consultations
2
3
4
5
6
Australian Health Review
Palliative Care Australia. Demand for palliative care increasing, but most will miss out. Deakin, ACT: Palliative Care Australia; 2014. [Media Release] Jack B, Hillier V, Williams A, Oldham J. Hospital based palliative care teams improve the symptoms of cancer patients. Palliat Med 2003; 17: 498–502. doi:10.1191/0269216303pm794oa Gade G, Venohr I, Connor D, McGrady K, Beane J, Richardson RH, Williams MP, Liberson M, Blum M, Della Penna R. Impact of an inpatient palliative care team: a randomized controlled trial. J Palliat Med 2008; 11: 180–90. doi:10.1089/jpm.2007.0055 Smith S, Brick A, O’Hara S, Normand C. Evidence on the cost and cost effectiveness of palliative care: a literature review. Palliat Med 2014; 28: 130–50. doi:10.1177/0269216313493466 Gardiner C, Gott M, Ingleton C, Seymour J, Cobb M, Noble B, Bennett M, Ryan T. Extent of palliative care need in the acute hospital setting: a survey of two acute hospitals in the UK. Palliat Med 2013; 27: 76–83. doi:10.1177/0269216312447592
7
405
Gott M, Frey R, Raphael D, O’Callaghan A, Robinson J, Boyd M. Palliative care need and management in the acute hospital setting: a census of one New Zealand Hospital. BMC Palliat Care 2013; 12: 15. doi:10.1186/1472-684X-12-15 8 To THM, Greene AG, Agar MR, Currow DC. A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care. Intern Med J 2011; 41: 430–3. doi:10.1111/j.1445-5994.2011.02484.x 9 The Advisory Board Company. Realizing the full benefit of palliative care. Service optimization and strategic growth. Washington, DC: The Advisory Board Company; 2014. Available at: http://www.advisory. com/research/physician-executive-council/studies/2013/realizing-thefull-benefit-of-palliative-care [verified 30 October 2014]. 10 Economist Intelligence Unit. The economist. The quality of death: ranking end-of-life care across the world. London: Economist Intelligence Unit; 2010. Available at: http://graphics.eiu.com/upload/eb/quality ofdeath.pdf [verified 18 December 2014].
www.publish.csiro.au/journals/ahr
Australian Health Review, 2015, 39, 404–405 http://dx.doi.org/10.1071/AH14256
Letter
Underutilisation of Victorian in-patient palliative care consultation services? Results of an exploratory study Peter Eastman1,2 BPhty, MBBS, FRACGP, FAChPM, Palliative Care Consultant Brian Le1 MBBS(Hons), MPH, FRACP, FAChPM, Head of Department 1
Department of Palliative Care, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3052, Australia. Email: [email protected] 2 Corresponding author. Email: [email protected]
Received 9 January 2015, accepted 20 February 2015, published online 13 April 2015
The recent Australian Institute of Health and Welfare (AIHW) report on Australian palliative care services highlighted several important issues, including increasing demand for palliative care services and differences in provision across health care settings.1 In response to this report, the peak national organisation, Palliative Care Australia, raised concerns around access, suggesting that the majority of Australians with a need for palliative care services were not currently receiving them.2 The AIHW report addressed many aspects of Australian palliative care service provision; however, limited specific attention was paid to the role of palliative care consultation services (PCCS) for in-patients of acute hospitals. The role of PCCS are worthy of consideration because 51% of all deaths in Australia in 2011–12 occurred in hospital and, of these, more than 60% were not specifically palliative care patients.1 There is increasing evidence showing the benefits of PCCS. Improvements have been demonstrated in symptom control, satisfaction with care, patient–clinician communication and end-of-life care.3,4 Important reductions have also been reported in healthcare costs and resource utilisation.5 Attempts have been made to quantify the palliative care needs of hospital in-patients in several international settings. Recent data from the UK, Australia and New Zealand identified between 20% and 36% of in-patients as having palliative care needs.6–8 For the majority of patients, these needs will be met by generalist rather than specialist palliative care services;7 however, the ideal referral rate to PCCS remains unspecified. A recent US report into palliative care utilisation suggested that between 5% and 10% of all hospital admissions should receive a specialist palliative consultation.9 In response to this report, we investigated referral rates from an Australian viewpoint by using the Victorian Admitted Episodes Database (VAED) and the Victorian Integrated Non-Admitted Health (VINAH) dataset to assess PCCS utilisation across Victorian metropolitan public hospital networks. Each network consists of a varying number of separate in-patient facilities and collection and submission of clinical data to these datasets is mandatory for all Victorian health services and Health Department-funded PCCS. No specific paediatric hospitals were included in our analysis and only multiday acute admitted episodes were analysed. Journal compilation Ó AHHA 2015
Using palliative care consultancy episodes as a numerator and total acute multiday admitted episodes as a denominator we calculated a percentage that approximated PCCS uptake for individual Victorian metropolitan public hospital networks. For 2012–13, across the eight networks with 500 or greater annual palliative care consultancy episodes, this percentage ranged from 2.1% to 18.1%. The 18.1% was from a solely cancer tertiary hospital and, when this was excluded, the range was 2.1%–4.2%. The median of 3.1% is in keeping with US data, suggesting that currently between 2% and 4% of admitted patients receive a palliative care consultation. Many in-patients will never require involvement from specialist palliative care services; however, determining when referral is appropriate can be difficult. Factors influencing this decision include differing goals of care, prognostic uncertainty, variations in clinician recognition of care needs, patient and/or family belief systems, particularly around death and dying, palliative care workforce limitations and concerns around deskilling generalist staff. Given the demonstrated benefits of such consultations across a range of health metrics and in the context of an aging and increasingly frail population, a median referral rate of 3% to PCCS in metropolitan hospital settings with welldeveloped and highly rated palliative care systems10 seems low. The importance of ongoing discussion and research into the who, when and why of referrals to PCCS cannot be under-stated. Competing interests The authors have no competing interests. Acknowledgements The authors wish to thank Mr Gregory W. Dalton (Manager, Palliative Care, Wellness, Integrated Care and Aging Division, Victorian Department of Health) for his assistance with data collection.
References 1
Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia 2014. Catalogue no. HWI 128. Canberra: AIHW; 2014.
www.publish.csiro.au/journals/ahr
Victorian in-patient palliative care consultations
2
3
4
5
6
Australian Health Review
Palliative Care Australia. Demand for palliative care increasing, but most will miss out. Deakin, ACT: Palliative Care Australia; 2014. [Media Release] Jack B, Hillier V, Williams A, Oldham J. Hospital based palliative care teams improve the symptoms of cancer patients. Palliat Med 2003; 17: 498–502. doi:10.1191/0269216303pm794oa Gade G, Venohr I, Connor D, McGrady K, Beane J, Richardson RH, Williams MP, Liberson M, Blum M, Della Penna R. Impact of an inpatient palliative care team: a randomized controlled trial. J Palliat Med 2008; 11: 180–90. doi:10.1089/jpm.2007.0055 Smith S, Brick A, O’Hara S, Normand C. Evidence on the cost and cost effectiveness of palliative care: a literature review. Palliat Med 2014; 28: 130–50. doi:10.1177/0269216313493466 Gardiner C, Gott M, Ingleton C, Seymour J, Cobb M, Noble B, Bennett M, Ryan T. Extent of palliative care need in the acute hospital setting: a survey of two acute hospitals in the UK. Palliat Med 2013; 27: 76–83. doi:10.1177/0269216312447592
7
405
Gott M, Frey R, Raphael D, O’Callaghan A, Robinson J, Boyd M. Palliative care need and management in the acute hospital setting: a census of one New Zealand Hospital. BMC Palliat Care 2013; 12: 15. doi:10.1186/1472-684X-12-15 8 To THM, Greene AG, Agar MR, Currow DC. A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care. Intern Med J 2011; 41: 430–3. doi:10.1111/j.1445-5994.2011.02484.x 9 The Advisory Board Company. Realizing the full benefit of palliative care. Service optimization and strategic growth. Washington, DC: The Advisory Board Company; 2014. Available at: http://www.advisory. com/research/physician-executive-council/studies/2013/realizing-thefull-benefit-of-palliative-care [verified 30 October 2014]. 10 Economist Intelligence Unit. The economist. The quality of death: ranking end-of-life care across the world. London: Economist Intelligence Unit; 2010. Available at: http://graphics.eiu.com/upload/eb/quality ofdeath.pdf [verified 18 December 2014].
www.publish.csiro.au/journals/ahr
