Variation in Palliative Care Consultation among Severely Injured Patients

Abstract

Dear Editor:

In response to the American College of Surgeons Trauma Quality Improvement Program's (ACS TQIP) Palliative Care Best Practices Guidelines, our Level I Trauma Center conducted an analysis to identify our compliance gaps.¹ According to the guidelines, the trauma team can deliver the majority of the palliative care to injured patients, but patients who are high risk for in-hospital death or discharge to dependent care may require palliative care delivered by a specialist. Our objectives were to determine whether our high-risk patients receive palliative care specialist consultation and to explore the variation in consultation practices.

We obtained deidentified data from the George Washington University Hospital Trauma Registry for injured patients admitted from January 1, 2015 to December 31, 2017. We restricted our population to patients with an Injury Severity Score (ISS) >15. An ISS of >15 is a well-established threshold in the trauma literature for severe injury.² In our hospital, both palliative and geriatric medicine provide palliative-consultative services. We operationalized our specialist palliative care outcome variable as consultation with either service team at any time during the patient's hospitalization.³ Our independent variables included race, age, gender, injury type, length of stay (LOS), Glasgow Coma Scale on admission, transfer from outside hospital, service, and discharge status. We performed chi-square tests and multivariable logistic regression. We conducted all analyses in STATA 15.1. The study was exempted by the George Washington University Institutional Review Board.

Results are presented in Table 1. There were 584 patients in our trauma registry with an ISS >15. In total 198 (33.9%) received specialist consultation. We found that patients <35 years of age (18.45%) and patients between the ages of 35 and 64 (29.34%) had significantly lower rates of consultation than patients >64 years of age (55.17%). We also found that male patients (30.91%) and patients with penetrating injuries (17.39%) had significantly lower rates of consultation than their counterparts. Patients with an LOS greater than four days (39.03%) had significantly higher rate of consultation than patients with an LOS of one day (19.82%) or two to four days (33.74%).

Table 1.

Percentage of Patients Who Received a Specialist Consult by Characteristic and Multivariable Logistic Regression Analyses of Palliative Specialist Consult Regressed on Patient Characteristics (n = 584)

Category	Characteristic	% Consults	p	AOR	p	95% CI
Race	White	38.26% (88/230)	0.18	Reference
	Black	30.36% (75/247)		1.066	0.77	0.691–1.643
	Other	32.71% (35/107)		0.974	0.92	0.570–1.663
Age	>64 years	55.17% (96/174)	<0.001^***	Reference
	35–64 years	29.34% (71/242)		0.190	<0.001^***	0.111–0.324
	<35 years	18.45% (31/168)		0.349	<0.001^***	0.223–0.547
Gender	Female	42.04% (66/157)	0.012^*	Reference
Gender	Male	30.91% (132/427)	0.012^*	0.790	0.27	0.521–1.196
Length of stay	1 day	19.82% (22/111)	0.001^**	Reference
	2–4 days	33.74% (55/163)		1.944	0.038^*	1.037–3.644
	>4 days	39.03% (121/310)		2.744	0.001^**	1.528–4.925
Transfer	Yes	43.66% (31/71)	0.06	Reference
Transfer	No	32.55% (167/513)	0.06	1.429	0.27	0.761–2.686
Service	Nontrauma	31.58% (24/76)	0.65	Reference
Service	Trauma	34.25% (174/508)	0.65	1.402	0.32	0.721–2.725
Discharge status	Alive	33.80% (168/497)	0.90	Reference
Discharge status	Dead	34.48% (30/57)	0.90	1.313	0.35	0.739–2.333
Injury type	Blunt	36.99% (182/492)	<0.001^***	Injury type not included in model due to correlation with age (0.405)
Injury type	Penetrating	17.39% (16/92)	<0.001^***
GCS	Mild (>12)	34.75% (147/423)	0.75	GCS not included in model due to correlation with death (0.597)
	Moderate	30.00% (15/50)
	Severe (<9)	32.43% (36/111)

p < 0.05, ^**p < 0.01, ^***p < 0.01, log-likelihood ratio = 72.75, pseudo R² ⁼ 0.0973, VIF = 1.51.

AOR, adjusted odds ratio; CI, confidence interval; GCS, Glasgow Coma Scale; VIF, variance inflation factor.

In our regression, we found that when controlling for all other independent factors, age was still significantly associated with consultation. As compared with patients >65 years of age, the odds of receiving a consult was 65% lower for patients between 35 and 64 years and 81% lower for patients <35 years. We also found that patients with an LOS more than four days had significantly greater odds of receiving consultation than patients hospitalized for one day.

To our knowledge, this is the first published work exploring variation in palliative care specialist consultation for injured inpatients. Our center is using these findings to build a protocol that ensures that all patients receive the appropriate consultations and that consultations occur as early as possible. Although these findings cannot be generalized to all trauma centers, we hope that this letter encourages other centers to conduct similar analyses and identify any variation that they may have in palliative consultation.

References

American College of Surgeons Trauma Quality Improvement Program: ACS TQIP Palliative Care Best Practices Guidelines. American College of Surgeons. https://www.facs.org/~/media/files/quality%20programs/trauma/tqip/palliative_care.ashx. 2018. (Last accessed July 11, 2018).

Palmer

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Pacala

: Is palliative care the “new” geriatrics? Wrong question—We're better together. J Am Geriatr Soc, 2014; 62:1968–1970.