A total of 1252 abstracts were reviewed by one author, resulting in the identification of ten categories of initiatives grouped under three broad headings (Figure 1, Table 1): 1;‘Facilitating entry into the hospice and community care system’ (27), 2a-2g; ‘Preventing admission’ (28-74) and 3a&3b; ‘Facilitating discharge’ (Table 1) (56, 66, 72, 75-78). Classification was reviewed by a second author. Because of variations in terminology used to describe similar activities and the multifactorial nature of some initiatives, a degree of judgement was required when determining which group the initiative should be assigned to. Differences of opinion were resolved by discussion among the authors.
Fifty publications provided data on hospital utilisation and/or hospital stay. Selected publications often described initiatives with multiple components, resulting in them sometimes being included in more than one category. Studies were generally small and retrospective in nature. Most researchers claimed their services delivered benefits—in descending frequency order, these benefits were, palliative care support in the community (including hospice at home services), provision of integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Elements for success, sustainability, upscaling or adoption elsewhere were not generally addressed in the publications.
1. Single Point of Access
Several organisations offer Single Point of Access (SPA) services for people at the end of their life, but published evidence of the services’ benefits is limited. The Sue Ryder organisation published an evaluation report of a pilot initiative, ‘Partnership for Excellence in Palliative Support’ (PEPS) (27). PEPS is a 24-hour telephone SPA service bringing together 15 organisations across East England, UK, with senior nurses as the first point of access.
During the pilot period, 1051 patients were registered with Partnership for Excellence in Palliative Support. The majority (65%) who died, were supported to die at home, with only 11% dying in an acute hospital. Information from a sample of patients was compared with hospital activity data sets before and after registration and suggested that the introduction of a Single Point of Access service could result in 30% fewer admissions, a 30% shorter stay and cost reductions of around £300 per admission.
2a; Care home innovations
Care home residents at the end of their life are sometimes transferred to hospital when another course of action might be more appropriate (1), possibly due to a knowledge gap among all grades of care home staff which could be addressed by additional training. The problem was explored in three studies using a mixed-methods approach (Table 2) (28-30) or quasi-experimental design (31) or as part of a randomised controlled trial (32). Training varied in terms of duration, frequency and who delivered it. Common topics were, recognition of the end of life, advance care planning, optimising communication with residents and their families and documenting changes in patient preferences and condition.
Staff education was generally linked to a reduction in hospital admissions or a shorter length of hospital stay. Garden et al., for example, reported a 55% decrease in admissions compared to baseline, three years after implementation (28). Livingston et al., found that the average number of days spent in hospital in the last three months of life decreased from four to 1.25 days (29). Chapman et al., reported a 3.22-day decrease in length of stay, equating to a 67% reduction in bed days for residents involved in the intervention, but having no effect on the number of admissions (31). Other demonstrable benefits, were an increased number of deaths in the care home compared with the hospital (29), and care home staff feeling ‘uplifted’ and ‘empowered’ as a result of the intervention (30).
These favourable results are at odds with the findings of a randomised US study designed to evaluate the effects of the high-profile ‘Interventions to Reduce Acute Care Transfers’ (INTERACT) quality improvement programme (33). While there was a trend in favour of additional staff training aimed at improving care at the end of life compared with the pre-intervention period, Kane et al., found no significant difference in admission rates between nursing homes randomised to receive INTERACT training and a control group (32).
Other initiatives have been introduced to support care home residents, such as the ‘Enhanced Health in Care Homes Vanguard’ programme in the United Kingdom. While generally considered beneficial, these initiatives’ effect on hospital admissions has been variable. One simple initiative, the introduction of ‘red bags’ containing all relevant health-related paperwork and medication that travel with the patient, helped simplify hospital transfers and reduced length of stay for residents in Sutton from a local average of 14 days to 9.2 days (34). Meanwhile, the introduction of multidisciplinary teams in Newcastle and Gateshead saw an increase in non-elective admissions, possibly related to increased symptom recognition (35). A Vanguard project in Airedale that implemented telemedicine consultations for care home residents showed a 15% decrease in emergency admissions for homes that infrequently used the service, compared with a 10% increase for homes classified as high usage (36). Also, a prospective observational study in Massachusetts care homes demonstrated that a group receiving telemedicine support, saw greater cost savings and hospitalisation reduction than the control group, especially where there was active engagement with the project (37).
2b; Palliative care support in the community
We identified 18 studies that included a focus on the impact of palliative care support in the community (e.g., hospice at home services) on hospital utilisation (Table 3). As this is a heterogeneous group of initiatives which may include hands-on nursing care, specialist advice from multidisciplinary teams and emergency intervention, we have not sought to separate them. Ten studies were retrospective (39-41, 44, 47-51, 53), five were prospective cohort studies (38, 42, 52, 54, 55) and three were described as population studies (43, 45, 46).
A proportion of studies concentrated on a specific disease area, including cancer (41, 43, 46, 47, 50, 51), chronic obstructive pulmonary disease (44), dementia (45) and heart failure (38). The others included mixed diagnoses.
All studies reported that their programme had one or more benefits over standard care, notably a significant decrease in hospital admissions (38-41, 44, 46, 48-55).
Eight of ten studies examining the impact of palliative care support in the community on emergency department attendance observed a reduction in attendance for patients enrolled in the intervention group versus standard-care patients (41-43, 45-47, 50, 55). In one study, this effect was only seen in male patients, possibly because of greater provision of home palliative care services among those with prostate and colorectal cancer (43). Two studies found no change in visits to the emergency department between intervention and control groups (52, 54).
Duration of hospital stay appeared to be shorter when patients were enrolled in one of the initiatives under examination (40, 43, 49, 51, 52), and fewer of those patients died in hospital (41, 43, 46, 49-51).
An editorial published in response to important findings on specialist palliative care teams’ experiences in Ontario communities, points to what could be achieved elsewhere with additional support: ‘If the associations reported by Seow and colleagues are causal, access to a palliative care team cuts hospitalisations by a third, use of emergency departments by a quarter, and risk of hospital death by a half, compared with usual care’ (41, 79).
2c; Out-of-hours telephone line
Access to advice via an out-of-hours telephone line was often a feature in major initiatives, such as the PEPS programme (27). Three retrospective, quantitative studies examined hospital admission and emergency department attendance (39, 48, 56), and a fourth looked at 30-day readmission rates (46) (Table 4). All were linked to a significant decrease in hospital utilisation. Lustbader et al., found that a home-based palliative care programme including an out-of-hours telephone line was associated with a 34% reduction in hospital admission and nearly 200 fewer emergency department admissions per 1000 patients during their final month of life (39). The benefits of an out-of-hours telephone line were also observed by Ranganathan et al. (48). Patients enrolled in the initiative being studied had a 30-day readmission probability of 9.1%, compared with 17.2% in patients receiving standard care.
Two studies examining the value of telemedicine in care homes from UK and US perspectives are described in the care home initiative discussion above (36, 37). Three additional studies attempted to analyse the influence of telehealth/telecaring on hospital utilisation among patients at the end of life (Table 5). Two were RCTs (57, 58), in which telehealth was the primary variable. The impact of both telehealth versus control, and early versus delayed use of telehealth on hospital utilisation were tested, with neither demonstrating a significant benefit. Interestingly, in Hoek et al.’s study, the mean Total Symptom Distress Score was higher in the intervention group at 12 weeks (57). In contrast, a quantitative retrospective study where tele palliative consultations between patients and any healthcare team member were an essential part of a wider programme, witnessed a reduction in both hospital and emergency admissions (39).
2e; Ambulance and paramedic education
Ambulance and paramedical staff are often the first healthcare professionals to respond to a palliative care emergency outside of hospital. The situations they face are frequently distressing and confusing. Many feel ill prepared (59). There is anecdotal evidence of additional palliative care training for ambulance and paramedical staff helping them make better decisions. Unfortunately, published peer-reviewed articles are lacking. Paramedic initiatives depend not only on training, but also on adequate resources to keep someone at home following an emergency call-out, which may limit ambulance initiatives’ success.
2f; Integrated palliative care models
Fourteen studies examined the use of integrated palliative care and its impact on hospital utilisation. Three of those studies were RCTs (Table 6) (60-73).
The components of care varied, with 12 studies concentrating on one disease type [cancer: seven (60-66), heart failure: two (67, 68), renal failure: one (69), chronic obstructive pulmonary disease: one (70), neurodegenerative disease: one (71)].
A study by Wu et al. examined the benefits of initiating palliative care consultations in emergency departments for patients suffering from a range of terminal diseases (72), while Desrosiers et al., reported on the value of a hospital-based palliative care service for patients with advanced organ failure in sub-Saharan Africa (73).
Overall, 11 studies found the initiative to be beneficial. In contrast, Ferrell et al., in a prospective quasi-experimental study, examined the value of an integrated care group for managing patients with non-small cell lung cancer (NSCLC; n = 272) versus standard care (n = 219). (60). No significant difference in unscheduled hospital admissions in the last two weeks of life was observed between the intervention and control groups.
Two RCTs painted a similar picture. Rogers et al., conducted a single-centre US study involving 150 patients with advanced heart failure. Subjects were randomised to either usual care (n = 75) or usual care plus nurse-implemented integrated palliative care (n = 75). While there were benefits in the intervention group in terms of quality of life, anxiety, depression, and spiritual well-being, there was no effect on rehospitalisation or mortality (67). In a Danish study involving 340 cancer patients, Benthien et al., looked at the value of adding specialised palliative care and psychological interventions to standard care and found that the intervention group actually experienced more admissions (61). These findings contrast with those of a smaller, single-centre Swedish RCT on chronic heart failure (Palliative advanced home caRE and heart FailurE care study; PREFER) (68). Patients were randomised to an intervention group (usual care plus a person-centred palliative care programme (‘PREFER’, n = 36), or a control group (usual care, n = 36). Fewer hospitalisations and bed days were encountered in the PREFER group (15 hospitalisations, 103 days), than in the control group (53 hospitalisations, 305 days).
2g; Palliative care outreach in rural areas
Delivering palliative care to patients outside urban areas is a challenge. The ‘Marie Curie Delivering Choice Programme ’ consisted of several elements and was delivered in rural Somerset, England. In a quantitative retrospective cohort study (56), Purdy et al., investigated the effects of this initiative on place of death and hospital utilisation. Of 3564 patients who died of a chronic condition, 829 used the Delivering Choice Programme service. Users of the service were at least 30% less likely to die in hospital, be admitted for an emergency or attend the emergency department than those who did not use the service. Readmissions after accessing the discharge in-reach service were low, at 6%.
Evaluation of a nurse-led navigation service to provide palliative care to older patients in rural Canada was similarly beneficial (74). Over a two-year period, 25 adult patients and 11 family members living with deteriorating chronic illness received biweekly visits. Support included symptom management, education, advance care planning, advocacy, help with financial matters and psychosocial help. Participants were able to die in their preferred location and emergency room attendance was minimal and largely unpreventable.
3a; Innovations supporting early hospital discharge
The potential benefits of initiating palliative care consultations in emergency departments have been referred to above, with Wu et al., demonstrating a significantly shorter patient stay compared with a control group, of 3.6 days (72). The study by Purdy et al., also included two ‘front-of-house’ hospital-based discharge nurses whose role included identifying patients wanting a non-hospital death and facilitating their transfer back home (56). Additionally, the benefits of an early palliative care inpatient consultation in terms of shorter hospital stays were demonstrated by May et al., in a prospective multi-site cohort study (66). May et al., also found that there were significant cost savings (63%) linked with a shorter length of stay. Further, beneficial effects of an inexpensive quality-of-life checklist on readmission rates were investigated by means of a prospective cohort study (75). The researchers compared outcomes among 48 intervention subjects and 48 controls admitted to hospital with heart failure in Michigan. After adjusting for descendants, there was a significant difference in 30-day readmission in favour of the intervention group (2% vs. 20%.)
There is evidence to support the value of a hospital-based palliative care programme. In a retrospective study, Hua et al., found that patients in the intervention and control group experienced the same length of stay (six days) but patients in the intervention group were 46% more likely to be discharged to a hospice (76). These findings are supported by those of Horton et al. (77).
3b; Nurse-led inpatient initiatives
It is increasingly common for nurses to lead end of life care services, of which this review identified several examples (27, 74). St Gemma’s Hospice in Leeds, England, supported by The Health Foundation, has taken this further by introducing four nurse-led beds for patients with less complex medical needs (78). Data from this pilot project suggests that nurses can safely deliver end of life care, and during the study period, 50 patients achieved their preferred place of death, resulting in a reduction in hospital deaths and an estimated saving of 132 bed days.