Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study

doi:10.21203/rs.3.rs-4058171/v1

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Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study

https://doi.org/10.21203/rs.3.rs-4058171/v1

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Context:

Palliative car aims to provide comprehensive care, since end of life can be marked by somatic, psycho-social and spiritual distress, requiring interdisciplinary care. However, interdiscoplinary care is costly, and palliative care services, as all other medical services, get under pressure to be as cost-effective as possible.

Objectives

To describe the case complexity of palliative care inpatients, to evaluate possible correlations between complexity and provision of care and to identifycomplexity subgroups.

Methods

Patients (N = 222) hospitalized in a specialized palliative care unit (Switzerland) were assessed regarding their biopsychosocial case complexity by means of the INTERMED. Based on a chart review, INTERMED scores were determined at admission and the end of hospitalization/death. Descriptive statistics and Pearson correlation coefficients were estimated for the association between biopsychosocial case complexity and amount and type of care provided. A principal component analysis (PCA) was conducted to explain variance and to identify patient subgroups.

Results

Almost all patients (98.7 %) qualified as complex as indicated by the INTERMED. Provision of care correlated positively (r=0.23, p=0.0008) with the INTERMED scores upon admission. The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p=0.0001). PCA performed with two factors explained 49% of the total variance and identified two subgroups which differed regarding the psychosocial item scores of the INTERMED.

Conclusion

Specialized palliative care inpatients show the highest complexity score of all populations assessed up to now with the INTERMED. Correlations between biopsychosocial complexity and care provided, and between care and decrease of complexity scores, can be considered as an indicator for care efficiency. Patient subgroups with specific needs (psychosocial burden) suggest that palliative care teams need specialized staff.

Trial registration

The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud (CER-VD 2023-01200).

“INTERMED”

“palliative care”

“case complexity”

“biopsychosocial”

“interdisciplinary”

“economicity”

Provision of palliative care correlates with case complexity and is effective.

Palliative care, based on the biopsychosocial model of disease (1), enlarged by the spiritual dimension (2), aims to provide holistic care (3–7). Since cure is no longer possible (7, 8), palliative care patients evolve towards death (9, 10), often affected by both somatic (11–15) and psychiatric morbidities (16–18), as well as by social problems (19–22). The vast majority of palliative care patients suffer from cancer (10) and the therapeutic objective is often limited to a temporary stabilization of their condition and relief of symptoms (23). Especially the end of life can be marked by somatic, psycho-social (20) and spiritual distress (16), often requiring hospitalization and interdisciplinary and interprofessional care (7).

To the best of our knowledge, only one study using the INTERMED to assess the biopsychosocial case complexity has been conducted in the palliative care setting: conducted almost twenty years ago, this study included inpatients of a University hospital, for whom palliative care consultation were requested (24). The study showed biopsychosocial heterogeneity of the sample and concluded that the INTERMED could be a useful tool to comprehensively assess patients’ health care needs and to tailor interdisciplinary interventions.

However, over the last twenty years, palliative care has evolved and has become - as any other medical discipline - pressured to be as cost-effective as possible. The ambition of a holistic approach of palliative care implies that care is based on an interdisciplinary and interprofessional approach, considered to respond to the needs of this patient population. The question, however, policy makers and insurance companies have raised is: is this expensive approach really needed and is it efficient (25, 26)? Moreover, there has been a call in a recent narrative review on the evidence of the economic value of end-of-life palliative care interventions for greater consistency in reporting outcome measures and costs associated with hospice care (27). This study has been conducted with this economic background issues in mind.

Aim of the study:

The main objective of this study was to describe the biopsychosocial complexity of specialized palliative care inpatients and to compare their complexity prevalence with other populations.

Secondary objectives were to determine if a correlation exists between case complexity and amount of interdisciplinary care provided, and if complexity subgroups of patients with different health care needs can be identified.

Setting

The Rive-Neuve specialized palliative care hospice, founded in 1988, is located in the French-speaking Canton of Vaud, in Western Switzerland, and can accommodate 20 inpatients. Admissions aredocumented in a file reviewed by a nurse, who is specialized in palliative care. Referrals are made by neighbouring hospitals or by the physicians of the mobile palliative home care team. Indications for hospitalization are the palliative situation of the patient, especially when symptoms are present, which are difficult to managesuch as pain, anxiety or dyspnea. In 2019, 222 patients were admitted; all of them were included in this study, since the documentation of all charts allowed the scoring with the INTERMED. The study period corresponds to the habitual situation, prior to the Covid pandemic. The staff consists of a multidisciplinary team of nurses, physiotherapists, an occupational therapist, an art therapist, a chaplain, about fifty volunteers, physicians, psychologists, psychiatrists, and administrative personal. The study was accepted by the ethics committee of the Canton of Vaud (CER-VD 2023 − 01200) - based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research. Given the aim of the study, no medical data were recorded. Comparison was intended only on a populational level or with regard to setting (e.g., palliative care patients versus patients affected by obesity). Since this is a descriptive study, we decided to include a whole year of admissions.

Assessment instruments

The study was based on a retrospective medical chart review. Sociodemographic and medical data, as well as patient symptom assessments with the ESAS (Edmonton Symptom Assessment System) were retrieved from the charts (28).

Biopsychosocial case complexity was assessed by means of the INTERMED. The INTERMED is a reliable and valid instrument to evaluate patients’ case complexity by taking into account their biopsychosocial situation and the complexity of their interactions with the care system (29, 30). The 20 items rated by the INTERMED are shown in the Appendix. Developed in 1995 (31), numerous studies have been conducted with the INTERMED in different countries, and different health care settings and patient populations. These studies have consistently shown - for example in low back pain (32, 33), chronic shoulder pain (34), diabetes (35), or internal medicine (36) - that the INTERMED identifies complex patients who have a less favorable response to medical treatments (37, 38). Moreover, early and targeted psychosocial interventions in complex patients identified by means of the INTERMED have demonstrated beneficial effects with regard to medical and psychological outcomes, as well as health care utilization (39, 40).

The INTERMED can be scored by means of a semi-structured interview, a self-assessment or retrospectively based on patient charts (41). Retrospective chart-based rating has been proved to be reliable: in a previous study: interrater reliability of retrospective ratings reached an intra class correlation (ICC) of 0.91 (41).

The INTERMED is composed of three columns for each domain (biological, psychological, social and healthcare system domain) (see Fig. 1). The first column refers to the past (history), the second to the present (current state) and the third to the future (prognosis). Two items in the past and present domains and one items in the future domain are rated with a score ranging from 0 (no complexity) to 3 (indicating the highest level of complexity). Each domain can thus reach a score of 15, with a total INTERMED score of 60. A score ≥ 21 is considered as indicating biopsychosocial complexity (42).

The amount of interdisciplinary palliative care interventions – without the care provided by medical doctors and nurses – was documented by the routine registration of minutes per patient spent by the different care professionals for 211 of the 222 patients (for 11 patients data were missing). All patients in Rive-Neuve are equally cared for by physicians and nurses, as in other medical settings. Therefore, care minutes calculated in this study only relates to the additional support provided by psychologists and psychiatrists, the chaplain, physiotherapists and occupational therapists, dietitians, social workers, hypnotherapy nurses, and others. The time spent with patients by volunteers was not collected and is therefore not taken into account in the calculations.

Statistical Analysis

Initially, descriptive statistics for the INTERMED total and domain scores were conducted for admission and the end of the stay (death or end of hospitalization). Differences between groups were analyzed using t-tests for independent or dependent groups. Percentages were calculated to estimate the prevalence of patients with complex health care needs. Correlations between the INTERMED change scores calculated by INTERMED T2-T1 and amount of palliative care provision were estimated by calculating Pearson’s correlation coefficients. Hierarchical cluster analysis was conducted, to investigate if the sample might consist of clearly distinct subgroups. It was worked out thoroughly using several criteria to check for the existence of more than one main cluster. However, cluster analysis - as a relatively rough method to determine clusters - did not result in easily separable groups. To further investigate the main sources of variance with respect to the INTERMED items, we conducted a principal component analysis (PCA). Results identified two factors with an Eigenvalue > 1 with one main factor (1) explaining 35.5% and the second factor (2) explaining 13.5% of the variance. For all 20 items of the INTERMED, the factor loadings were calculated. Items with a high positive factor loading on the main Factor 1 were related to psychological or social health care needs (see Appendix).

All charts allowed to score the INTERMED items at admission and discharge (N = 62) or death (N = 160).

Sociodemographic and administrative data

Table 1 shows the sociodemographic and administrative data of the sample.

Table 1

Sociodemographic and administrative data
	N	%
Gender
Female	112	50.45
Male	110	49.55
Outcome
Discharged Home	62	27.93
Died	160	72.07
Number of stays
One stay	209	94.14
Two stays	12	5.4
Three stays	1	0.46
	Mean Value (SD)	[Range]
Age	69	[31–100]
Length of stay (days)	22.4	[1–115]

Patients’ case complexity

Mean INTERMED score at admission was 31 (standard deviation, 5; range 19–46), and 31 (standard deviation, 5; range 13–43) at discharge or death. INTERMED scores at admission did not differ significantly between discharged patients and patients who died (t(220)= -1.13; p = 026).

Nearly all patients (n = 219, 98.7%) had an INTERMED score ≥ 21 and thus qualified as complex.

Regarding the INTERMED domain scores (biological, psychological, social, health care system), 42.5% of the total score was due to the biological, 23% to the social, 19% to the psychological, and 15.5% to the health care domain.

Provided health care

Of the 222 patients, 11 had missing data and 4 stayed so shortly that they could not receive specific palliative care (there are no therapists at weekends apart from the nurses and the physicians on duty), which reduces the sample, regarding care interventions to 207 patients. Information regarding additional care for patients (number of patients) and amount of care per patient (in minutes) is provided in Table 2. “Interviews (staff)” relates to time taken by nurses during their working hours to talk with patients who wished specifically to talk.

Table 2

Number of patients benefiting from additional car and amount of care per patient
Interventions	Number of Patients	Average Duration (minutes)	Duration Range (minutes)
Total Care	207	388	5–2876
Psychotherapists	201	152	5–1111
Physiotherapists	136	169	5–905
Chaplain	153	65	5–735
Interviews (staff)	186	44	5–425
Dietitians	132	47	5–245
Social Workers	17	89	10–315
Nurse hypnosis	3	145	60–195
Others	17	23	5–75

Provided amount of care correlated significantly with the total INTERMED score at admission (r = 0.23, p = 0.0008): patients with higher biopsychosocial complexity received more interdisciplinary care.

The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p = 0.0001).

Identification of subgroups

PCA revealed two factors with one main factor explaining a high amount of variance. For all patients, an individual score for this main factor 1 was computed resulting in either a score ≤ 0 or > 0. Subsequently, the patients were divided in two subgroups according to this score: subgroup 1 includes n = 121 patients and is related to a factor 1 score > 0 (red points) whereas patients of subgroup 2 (n = 101) have a factor score ≤ 0 (blue points, see Fig. 2). According to the factor loadings patients with a score > 0 should be psychosocially more burdened compared to patients with a score ≤ 0.

Figure 2 shows the mean values of these two subgroups for each of the INTERMED items. Mean values are similar in the two subgroups regarding items 1, 2, 7, 9, 13, 15, 16, 17. However, regarding items 3, 4, 6, 12, and 18, subgroup 2 shows consistently lower mean values compared to subgroup 1. All these items reflect the past, current, or future psychological or social complexity of the patients. Subgroup 1 could thus be described as highly complex with a heavy psychosocial burden, whereas subgroup 2 as highly complex regarding biological (somatic) aspects and less psychosocially burdened. The total amount of received interdisciplinary care differed significantly between the two groups (subgroup 1: mean = 452.6, SD = 463.8; subgroup 2: 293.6, SD = 277.5; t₂₀₉ = 2.94; p < 0.0001). Specifically, the amount of received additional psychiatric and social care was significantly higher for subgroup 1 compared to subgroup 2 (psychiatric care: mean = 181.1 (205.2) vs.101.8 (121.6), t₂₀₉ = 3.32, p < 0.0001; social care: mean = 48.9 (65.9) vs. 27.0 (25.8), t₂₀₉ = 3.06; p < 0.0001).

We will first discuss the results and then situate our study within the literature on economic aspects of palliative care.

While patient populations may differ between palliative care inpatient units, the mortality rate of our study population is similar to those of other palliative care inpatient units (43). Regarding the prevalence of case complexity, almost all patients showed an INTERMED score above 21, which is a three times higher prevalence than the prevalence found in patients with chronic disease (38, 41). This population’s extraordinarily high biopsychosocial complexity, which remains stable over the course of the hospital stay, justifies interdisciplinary care and associated human resources. There is no significant difference in complexity scores at admission between patients who will be discharged and those who will die, which indicates that care cannot be guided by means of the INTERMED or targeted upon admission, as suggested in the discussion of the first study using the INTERMED in a population referred to palliative care consultations (24). Regarding specific domains of complexity, the somatic symptom burden (biological domain) unsurprisingly contributes most to the total case complexity. However, the social and psychological complexity domain equal together the contribution of the biological domain, which again demonstrates the need for interdisciplinary care taking into account the psychosocial suffering of patients in need of palliative care. Moreover, there is a correlation between the INTERMED, and the amount of care provided, which increases with increased case complexity of the patients. Moreover, changes in the INTERMED scores correlate negatively with provided care. Care thus reduced health care needs during stay, demonstrating that interdisciplinary interventions seem to be efficient.

Our first approach to identify different patient groups by means of a cluster analysis did not lead to a statistically good fitting cluster result. Only when applying the more sophisticated PCA two factors were identified, with one main factor explaining a high amount of variance and the two subgroups differing markedly regarding the amount of psychosocial burden. The finding that the psychosocially heavy burdened subgroup received significantly more psychosocial care underlines again the need of an interdisciplinary team with specialists such as psychiatrists and psychologists, social workers, chaplains and physiotherapists, occupational and art therapists.

Our study is situated within the body of studies investigating economic aspects of palliative care. A recent study has shown that palliative care intervention at the end of life reduces healthcare costs, mostly when it is home-based; however hospice-based intervention significantly reduces costs (27). Another study attempted to quantify these costs (25): the greatest savings were made when a palliative care program was implemented in inpatients. We therefore consider that our study contributes in that is shows, that palliative inpatient care cannot only reduce costs, but is also a cost-effective way to reduce costs.

In a time of increasing financial pressure on the health care system, which does not spare palliative care, this study shows that the extremely high prevalence of case complexity of palliative care inpatients and justifies the interdisciplinary care approach. The effectiveness of the care interventions in this setting provides additional arguments for the need of human resources for this most vulnerable population, which deserves the attention of medicine and society.

Ethics approval and consent to participate: The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud (CER-VD 2023-01200) - based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research.

Consent for publication: All parties accepting to participate in the study and writing of the manuscript accepted to publish the results of the study.

Availability of data and materiels: The data that support the findings of this study are available from the correponding author (KS), upon reasonable request.

Competing interest: The authors declare that they have no conflict of interest or competing interests.

Funding: The authors did not receive funding for realizing this study.

Author’s contribution: KS wrote the manuscript and collected the data. FS is the thesis director and accompanied KS throughout the whole process of the study (from design to submission of the manuscript). YC trained KS in using INTERMED, discussed design methodology and supervised chart review; he also reviewed the manuscript. BW and DS analyzed the data, summerized the statistics and corrected the methodology and results section and reviewed the manuscript.

Acknowledgments: The first author would like to thank the Rive-Neuve Foundation for letting us use their data.

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No competing interests reported.

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Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study

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Abstract

Figures

Key message

Introduction

Aim of the study:

Methods

Setting

Assessment instruments

Statistical Analysis

Results

Sociodemographic and administrative data

Patients’ case complexity

Provided health care

Identification of subgroups

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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