The Intensive Palliative Care Unit: Changing Outcomes for Hospitalized Cancer Patients in an Academic Medical Center

Abstract

Background:

Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Women's Cancer Center, the intensive palliative care unit (IPCU) admits symptomatic oncology patients with uncontrolled symptoms throughout the trajectory of illness. Patients are uniquely managed by an interdisciplinary team of clinicians who focus on symptom management and advance care planning.

Objective:

The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU.

Design:

We retrospectively reviewed 74 oncology patients admitted to the IPCU in August and September, 2013.

Results:

A total of 67 IPCU patients who were admitted received palliative intent treatment, whereas 7 patients received curative intent care. All patients were engaged in a goals-of-care discussion during admission. Of the palliative intent patients, 58% were transferred to the IPCU from medical oncology and 42% were directly admitted. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint at admission. Twenty-five patients experienced a change in code status from Full Code to do-not-resuscitate/do-not-incubate. A total of eight patients died in the IPCU, and 50% experienced a code status change. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30-day readmission was 4%.

Conclusions:

Among advanced cancer patients, our findings suggest that an inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases hospital readmissions.

Introduction

Cancer is the second leading cause of death in the United States, and patients with end-stage cancer have high rates of hospitalization, with more than 60% admitted in the last month of life.^1,2 Research has shown that discussions about end-of-life care preferences are associated with reduced likelihood of critical care interventions and resuscitation.³ However, end-of-life care discussions only occur about 50% of the time.⁴ When goals-of-care discussions are not addressed, the default care is often aggressive and provides little benefit to this very ill patient population.⁵

At Dana-Farber/Brigham and Women's Cancer Center, the 12-bed intensive palliative care unit (IPCU) serves patients with cancer throughout the trajectory of their illness. Unlike many inpatient palliative care units, IPCU patients may undergo treatment with chemotherapy and/or radiation therapy with curative intent and do not require a do-not-resuscitate/do-not-intubate (DNR/DNI) code status for admission.

We explored the role of the IPCU on advance care planning outcomes by performing a retrospective analysis evaluating quality metrics such as code status changes, hospital readmission rates, and hospice utilization for advanced cancer patients admitted to the IPCU.

Methods

Study design and setting

We conducted a retrospective analysis to describe the oncology patient population admitted to the IPCU at Dana-Farber/Brigham and Women's Cancer Center in Boston, Massachusetts. Our retrospective review was approved as a quality improvement project from the Institutional Review Board at Dana-Farber/Harvard Cancer Center.

Sample and data collection

Medical records were abstracted for 74 oncology patients who had been admitted to the IPCU in August and September 2013. Patient, diagnosis, IPCU admission, readmission, code status, and outcome characteristics were collected.

Statistical analysis

Descriptive statistics were used to analyze patient characteristics. Groups were compared by using a Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables. Overall survival was defined as the time from date of index IPCU admission to death or date last known alive. The cumulative incidence of hospital readmission and IPCU readmission was estimated by identifying death as a competing risk. Time to hospital readmission was defined as the time from the date of discharge from the index IPCU admission to the first hospital readmission. Time to IPCU readmission was defined as the time from the date of discharge of the index IPCU admission to the first IPCU readmission. Patients alive without hospital or IPCU readmission were censored at the date of last follow-up. A two-sided p < 0.05 defined statistical significance. STATA v 13 (StataCorp, College Station, TX) was used for all analyses.

Results

Total patient population

A total of 74 patients were admitted to the IPCU between August and September 2013; 91% of patients received palliative intent care, and 9% of patients received curative intent care (Table 1). The median age at IPCU admission was 61 years (range: 25–90), and the patients were predominantly women (54%). Fifty-six percent of patients were diagnosed with lung, genitourinary, gastrointestinal, or head and neck cancer.

Table 1.

Inpatient Palliative Care Unit Patient Characteristics

	All patients (n = 74)	Palliative intent (n = 67)	Curative intent (n = 7)
Age at IPCU admission, years, median (range)	61 (25–90)	64 (25–90)	58 (44–76)
Length of stay on IPCU, days, median (range)	8 (0–50)	8 (0–50)	7 (4–19)
Gender, n (%)
Male	34 (46)	29 (43)	5 (71)
Female	40 (54)	38 (57)	2 (29)
Diagnosis, n (%)
Lung	12 (16)	12 (18)	0 (0)
Head and neck	9 (12)	4 (6)	5 (71)
Genitourinary	10 (14)	10 (15)	0 (0)
Gastrointestinal	10 (14)	10 (15)	0 (0)
Endocrine	7 (9)	7 (10)	0 (0)
Breast	6 (8)	6 (9)	0 (0)
Hematologic malignancy	6 (8)	5 (7)	1 (14)
Sarcoma	5 (7)	4 (6)	1 (14)
Gynecologic	4 (5)	4 (6)	0 (0)
Melanoma	3 (4)	3 (5)	0 (0)
Unknown primary	1 (1)	1 (1)	0 (0)
Other	1 (1)	1 (1)	0 (0)
Metastatic disease, n (%)
No	5 (7)	2 (3)	3 (43)
Yes	69 (93)	65 (97)	4 (57)
Time from diagnosis to IPCU admit, months, n (%)
Within 12 months of diagnosis	33 (45)	27 (40)	6 (86)
Greater than 12 months of diagnosis	41 (55)	40 (60)	1 (14)
IPCU admitting location, n (%)
Direct admit	32 (43)	28 (42)	4 (57)
Transfer from oncology	42 (57)	39 (58)	3 (43)
Outpatient palliative care before admit, n (%)
No	52 (70)	50 (75)	2 (29)
Yes	22 (30)	17 (25)	5 (71)
Time from last chemotherapy to IPCU admit, n (%)^a
Less than 2 weeks (≤14 days)	19 (30)	17 (30)	2 (33)
2–4 weeks (15–28 days)	12 (19)	10 (18)	2 (33)
4–8 weeks (29–56 days)	10 (16)	9 (16)	1 (17)
8+ weeks (≥57 days)	22 (35)	21 (37)	1 (17)
Time from last radiation to IPCU admit, n (%)^b
Less than 2 weeks (≤14 days)	10 (24)	7 (20)	3 (50)
2–4 weeks (15–28 days)	5 (12)	4 (11)	1 (17)
4–8 weeks (29–56 days)	6 (15)	6 (17)	0 (0)
8+ weeks (≥57 days)	20 (49)	18 (51)	2 (33)

Eleven patients did not receive chemotherapy (10 palliative intent and 1 curative intent).

Thirty-two patients did not receive radiation (31 palliative intent and 1 curative intent), and 1 patient had missing date of last radiation.

IPCU, intensive palliative care unit.

Palliative intent population

Among the palliative intent care patients, the median age was 64 years (range: 25–90) and the patients were predominantly women (57%) (Table 1). Forty-eight percent of patients were diagnosed with lung, genitourinary, or gastrointestinal cancer, 60% were admitted more than a year postdiagnosis, 75% did not receive outpatient palliative care before admission, and 58% were transferred from oncology. The median length of stay for palliative intent care patients transferred from oncology was significantly longer (10 days) than that for palliative intent care patients who were directly admitted (6 days, p = 0.012). Forty percent of patients were admitted to the IPCU within one year of diagnosis, and of those patients, 37% had a diagnosis of lung cancer compared with other diagnoses, p = 0.002.

Eighty-eight percent of palliative intent patients were discharged from the IPCU; 12% expired during admission (Table 2). Fifty-six percent of patients were discharged to general inpatient hospice, home hospice, home with a visiting nurse, or home. Seventy-eight percent of patients were not readmitted to the hospital within one year post-IPCU discharge, and 15% of patients were readmitted to the IPCU within one year post-IPCU discharge. Ninety percent of patients died during follow-up.

Table 2.

Inpatient Palliative Care Unit Patient Outcomes

	All patients (n = 74)	Palliative intent (n = 67)	Curative intent (n = 7)
Status on discharge from IPCU, n (%)
Alive	66 (89)	59 (88)	7 (100)
Expired	8 (11)	8 (12)	0 (0)
IPCU discharge plan, n (%)
Expired in IPCU	8 (11)	8 (12)	0 (0)
Expired in hospital	6 (8)	6 (9)	0 (0)
Hospice general inpatient	11 (15)	11 (16)	0 (0)
Home	14 (19)	8 (12)	6 (86)
Home hospice	11 (15)	11 (16)	0 (0)
Home with a visiting nurse	8 (11)	8 (12)	0 (0)
Hospice house	7 (9)	7 (10)	0 (0)
Long-term acute care	1 (1)	1 (1)	0 (0)
Rehabilitation center	4 (5)	3 (5)	1 (14)
Skilled nursing facility	4 (5)	4 (6)	0 (0)
Follow-up status, n (%)^a
Alive	13 (18)	7 (10)	6 (86)
Expired	61 (82)	60 (90)	1 (14)
Hospital admission one year prior index IPCU admit, n (%)
None	22 (30)	20 (30)	2 (29)
At least one admission	52 (70)	47 (70)	6 (71)
IPCU admission one year prior index IPCU admit, n (%)
None	63 (85)	57 (85)	6 (86)
At least one admission	11 (15)	10 (15)	1 (14)
Hospital admission one year post-index IPCU admit, n (%)
None	53 (72)	52 (78)	1 (14)
At least one admission	21 (28)	15 (22)	6 (86)
IPCU admission one year post-index IPCU admit, n (%)
None	63 (85)	57 (85)	6 (86)
One admission	11 (15)	10 (15)	1 (14)

Eight patients excluded, expired in IPCU.

Curative intent population

Among the curative intent care patients, the median age was 58 years (range: 44–76) and most patients were men (71%) (Table 1). Seventy-one percent of patients were diagnosed with head and neck cancer, 86% were admitted within a year of diagnosis, 71% received outpatient palliative care before admission, and 57% were directly admitted.

All curative intent patients were discharged from the IPCU, and 86% were discharged home (Table 2). Eighty-six percent of patients were readmitted to the hospital within one year post-IPCU discharge; 14% of patients were readmitted to the IPCU within one year post-IPCU discharge. One patient died during follow-up.

Change in code status

All patients admitted to the IPCU had a goals-of-care conversation. Among the palliative intent patients, 34% of patients were admitted to the IPCU with a code status of DNR/DNI, and a total of 25 patients experienced a change in code status from Full Code to DNR/DNI post-index IPCU admission, which resulted in 73% of patients discharged from the IPCU having a code status of DNR/DNI (Fig. 1). Among the patients who experienced a change in code status from Full Code to DNR/DNI, the median time to discussion from admission was seven days (range: 0–31) and among all palliative intent patients, the median time to code discussion was two days (range: 0–75). The length of stay among palliative intent patients who experienced a change in code status from Full Code to DNR/DNI post-index IPCU admission was significantly different from the patients who did not experience a code status change (change: median: 11 days, range: 0–50 days; no change: median: 7 days, range: 0–9 days; p = 0.021). Among the patients who were directly admitted to the IPCU, there were fewer changes in code status compared with the patients admitted from an oncology service (p = 0.022).

FIG. 1.

Percentage of palliative intent patients DNR/DNI at admission and time to code status change to DNR/DNI during IPCU admission. Admission to IPCU is day 0. DNR/DNI, do-not-resuscitate/do-not-intubate; IPCU, intensive palliative care unit.

Cumulative incidence of readmission

Palliative intent patients

Among the palliative intent patients who were discharged from the index IPCU admission and had known follow-up information (n = 57), the cumulative incidence of readmissions (IPCU and non-IPCU) one year postdischarge with the competing risk of death was calculated. A total of 15 patients experienced at least one hospital readmission, and 10 patients experienced an IPCU readmission. The cumulative incidence of first readmission at 30-, 60-, 90-, and 120-days was 4% (95% CI: 1–9), 12% (95% CI: 4–21), 21% (95% CI: 10–32), and 25% (95% CI: 13–36), respectively.

Discussion

Interdisciplinary palliative care programs have shown improvements in quality and reduced medical costs in the past.⁶ The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU as the first steps to a more comprehensive assessment of quality metrics in the IPCU in the future.

Our study reveals the IPCU model to be associated with early and consistent advance care planning discussions, increased change in code status from Full Code to DNR/DNI, decreased 30 day readmission rates, and a high referral to hospice on discharge.

More than 90% of patients admitted to the IPCU during the study dates had metastatic disease on admission and many had either no code status or were Full Code. On discharge, all patients had advance care discussions documented and 73% were DNR/DNI. Factors such as standardized training of the IPCU staff in core communication skills, a culture of “normalizing” advance care planning discussions, and a strong interdisciplinary team may play a large role in these findings.

When taking into account the competing risk of death, the 30 day readmission rate for patients admitted to the IPCU was 4%. This finding is largely due to high utilization of hospice services on discharge from the IPCU. About half of the patients discharged from the IPCU went to hospice.

Limitations of this study include: retrospective, single center, and a time-limited dataset. Our study also does not compare patient outcomes with a similar cohort such as the inpatient Palliative Care consult service at Dana-Farber Cancer Institute (DFCI).

The study data were manually collected by the authors via a retrospective review of patient charts. Future efforts will focus on leveraging the electronic medical record to automate the collection of data. This will make it easier to compare outcomes in the IPCU with other comparable patient cohorts in the future.

Conclusion

Our findings suggest that patients admitted to the IPCU have low 30 day readmission rates, more goals-of-care discussions documented, and increased code status transitions from Full Code to DNR/DNI. We believe that key drivers for these findings include consistent training of a dedicated specialty-level IPCU staff in communication skills around goals of care and an interdisciplinary team approach to patient care. Further investigations are warranted to better explore outcomes, symptom management, and cost savings associated with the IPCU.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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