Abstract：
People approaching end of life account disproportionately for health care costs, and the majority of these costs accrue in hospitals. The economic evidence base to improve value of care to this population is thin. Natural experiment methods may be helpful in bridging evidence gaps with credible causal estimates from routine data, but these methods have seldom been applied in this field. This study aimed to evaluate the association between timely palliative care consultation and length of stay for adults with serious illness admitted to acute hospital in Ireland.
In primary analysis we evaluated if timely palliative care receipt following emergency hospital inpatient admission impacted length of stay (LOS); in secondary analysis we verified if palliative medicine service (PMS) implementation co-occurred with any changes in in-hospital mortality, and we estimated cost differences associated with any change in LOS. This was a secondary analysis on routinely collected data for acute admissions to public hospitals in Ireland. We used difference-in-differences analysis to exploit the staggered implementation of PMS teams at acute public hospitals in Ireland between 2010 and 2015. We identified palliative care receipt following PMS implementation using ICD-10 codes, and we matched admissions involving a palliative care interaction to admissions in years prior to PMS implementation using propensity score weights.
Our primary analytic sample included 4,314 observations, of whom 608 (14%) received timely palliative care. We estimated that the intervention reduced LOS by nearly two days, with an estimated associated saving per admission of €1,820. These analyses were robust to multiple sensitivity analyses on regression specification, weighting strategy and site selection. Proportion of admissions ending in death did not change following PMS implementation.
Prompt interaction between suitable patients and palliative care can improve the quality and efficiency of care to this population. Many patients receive palliative care later in the hospital stay, which does not yield cost-savings. Future studies can extend and strengthen our approach with better data, as well as using different methods to understand how to trigger palliative care early in a hospital admission and realise available gains.
In primary analysis we evaluated if timely palliative care receipt following emergency hospital inpatient admission impacted length of stay (LOS); in secondary analysis we verified if palliative medicine service (PMS) implementation co-occurred with any changes in in-hospital mortality, and we estimated cost differences associated with any change in LOS. This was a secondary analysis on routinely collected data for acute admissions to public hospitals in Ireland. We used difference-in-differences analysis to exploit the staggered implementation of PMS teams at acute public hospitals in Ireland between 2010 and 2015. We identified palliative care receipt following PMS implementation using ICD-10 codes, and we matched admissions involving a palliative care interaction to admissions in years prior to PMS implementation using propensity score weights.
Our primary analytic sample included 4,314 observations, of whom 608 (14%) received timely palliative care. We estimated that the intervention reduced LOS by nearly two days, with an estimated associated saving per admission of €1,820. These analyses were robust to multiple sensitivity analyses on regression specification, weighting strategy and site selection. Proportion of admissions ending in death did not change following PMS implementation.
Prompt interaction between suitable patients and palliative care can improve the quality and efficiency of care to this population. Many patients receive palliative care later in the hospital stay, which does not yield cost-savings. Future studies can extend and strengthen our approach with better data, as well as using different methods to understand how to trigger palliative care early in a hospital admission and realise available gains.
摘要：
背景：接近生命尽头的人在医疗保健费用中占了不成比例的比例，这些费用中的大部分是在医院累积的。提高对这一人群的护理价值的经济证据基础很薄。自然实验方法可能有助于弥合证据差距与可靠的因果估计从常规数据，但这些方法很少应用于这一领域。
方法：在主要分析中，我们评估了急诊住院后及时接受姑息治疗是否会影响住院时间（LOS）；在次要分析中，我们验证了姑息医学服务（PMS）的实施是否与住院死亡率的任何变化同时发生，我们估计了与LOS任何变化相关的成本差异。这是对爱尔兰公立医院急性入院常规收集数据的二次分析。我们使用差异差异分析来利用2010年至2015年间爱尔兰急性公立医院PMS团队的交错实施。我们使用ICD-10代码确定了PMS实施后的姑息治疗收据，我们使用倾向评分权重将涉及姑息治疗互动的入院与PMS实施前几年的入院进行了匹配.
结果：我们的主要分析样本包括4,314个观测值，其中608人（14%）接受了及时的姑息治疗。我们估计干预措施使LOS减少了近两天，估计每次入场费为1820欧元。这些分析对回归规范的多重敏感性分析是稳健的，加权策略和选址。实施PMS后，以死亡告终的入院比例没有变化。
结论：适当的患者与姑息治疗之间的迅速互动可以提高该人群的护理质量和效率。许多患者在住院后期接受姑息治疗，这不会产生成本节约。未来的研究可以用更好的数据来扩展和加强我们的方法，以及使用不同的方法来了解如何在入院早期触发姑息治疗并实现可获得的收益。
方法：在主要分析中，我们评估了急诊住院后及时接受姑息治疗是否会影响住院时间（LOS）；在次要分析中，我们验证了姑息医学服务（PMS）的实施是否与住院死亡率的任何变化同时发生，我们估计了与LOS任何变化相关的成本差异。这是对爱尔兰公立医院急性入院常规收集数据的二次分析。我们使用差异差异分析来利用2010年至2015年间爱尔兰急性公立医院PMS团队的交错实施。我们使用ICD-10代码确定了PMS实施后的姑息治疗收据，我们使用倾向评分权重将涉及姑息治疗互动的入院与PMS实施前几年的入院进行了匹配.
结果：我们的主要分析样本包括4,314个观测值，其中608人（14%）接受了及时的姑息治疗。我们估计干预措施使LOS减少了近两天，估计每次入场费为1820欧元。这些分析对回归规范的多重敏感性分析是稳健的，加权策略和选址。实施PMS后，以死亡告终的入院比例没有变化。
结论：适当的患者与姑息治疗之间的迅速互动可以提高该人群的护理质量和效率。许多患者在住院后期接受姑息治疗，这不会产生成本节约。未来的研究可以用更好的数据来扩展和加强我们的方法，以及使用不同的方法来了解如何在入院早期触发姑息治疗并实现可获得的收益。
