Integrated respiratory palliative care service works well for patients with advanced lung disease

An Australian model of care that provides palliative and respiratory specialist services for people living with advanced lung disease has achieved a reduction in acute hospitalisation rates and lower-cost management.

Melbourne’s St Vincent’s Hospital has developed an integrated specialist physician outpatient and in-home care service, overcoming the significant barriers for attendance for this cohort of patients.

In a study published in Australian Health Review, the three-year pilot of home visits or outpatient clinic services reported overall cost savings compared to standard care.

“This study builds the evidence base for the benefits of integrated respiratory and palliative care for patients with advanced lung disease,” the researchers said.

“Providing integrated palliative care within respiratory clinics can help overcome some barriers to palliative care referral, as palliative care concepts such as symptom management and advance care planning (ACP), are discussed alongside routine disease-orientated care.”

Lead author Dr Julie McDonald, who is both a respiratory and palliative care specialist, said while this model was specifically for patients with advanced lung disease, integrated palliative care and chronic disease care could provide effective and cost-effective support.

“The main thing that is consistent between all the models is providing those three core components of integrated palliative care, symptom control focus, advanced care planning focus, and also that disease-orientated care focus,” she told the limbic. “If you just had palliative care, perhaps palliative care wouldn’t perhaps quite know what to do with some aspects of the disease, such as inhaler changes or action plans.

“Not every patient needs to be referred to specialist palliative care. There just needs to be time, space and interest within the respiratory review to do it,” she added.

In the research, conducted between April 2017 and April 2019, 51 patients received 59 home visits, while between July 2018 and July 2020, 58 patients had 206 reviews at outpatient clinics. Nineteen patients moved between the groups during 2020.

The predominant diagnosis among the groups was COPD, and there were many comorbidities. The mean age was 75 years.

The home visits were generally one-off visits, but two out of three (63%) were referred on for follow ups at the outpatient clinic but only about one in two completed those appointments (47%).

Reviews were personalised to the needs of the patient, with 81% of people who had home visits receiving disease-specific action plan, 68% a breathlessness action plan, 78% advance care planning and medical rationalisation. For those who attended the outpatient clinic, fewer received advance care planning (51%), a disease-specific action plan (53%) or a breathlessness action plan (60%).

Hospital admissions in the subsequent 90 days were assessed. The total hospital admissions reduced 51% in the home visit group and 46% in the outpatient clinic cohort. Total bed days decreased 29% for the home visit group and 60% for the outpatient clinic.

This combined to create cost savings of 3.5% in hospital costs for the home visit group in the 90 days before or after the physician review, totalling $18,579. For the outpatient clinic group, costs fell by 23%, with a total savings of $109,149.

The researchers noted the higher frequency of key tasks completed in home visits over the outpatient clinic. “This frequency does not suggest a higher quality of care was provided during a home visit; rather, physicians felt it was both possible and appropriate to complete more tasks,” they wrote.

“The high level of ACP [advance care planning] discussion and directive completion seen in this study is comparable to another published Australian model of integrated care, and markedly higher than prevalence studies of respiratory and oncology care, which suggest these discussions usually only occur late, if at all.”

Home environment

The physician involved in the program said they found home-based discussions easier, given they were surrounded by cues such as family, photos, pets, gardens and belongings. However, despite the higher rate of discussions, there were more advanced cared directive completions in the outpatient clinic group.

“Palliative care investment provides economic return by ACP discussion and enabling patients to remain in their home with community support,” the study said. This care reduces preventable emergency visits, acute hospitalisation and intensive care admissions.”

Dr McDonald said an integrated model for palliative care was also available for three other chronic disease streams, advanced heart failure, liver supported care and renal supportive care.

“Our hospital has integrated palliative care into those disease streams, and also, it is very present in the oncology setting. It is appropriate for other chronic diseases as well. There are increasing articles about [palliative care integration] evidence for chronic disease.”

Further, she said patients often preferred to stay with their existing practice and did not want to change to a different clinic or setting.

Dr McDonald said she had discussed the model with national and state forums. “Palliative care in general has significant economic analysis already behind it,” she said.


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