Early initiation of palliative care is associated with reduced late-life acute-hospital use: a population-based retrospective cohort study

Background — Early palliative care can reduce end-of-life acute-care use, but findings are mainly limited to cancer populations receiving hospital interventions. Few studies describe how early versus late palliative care affects end-of-life service utilization.

Aim — To investigate the association between early versus late palliative care (hospital/community-based) and acute-care use and other publicly funded services in the two weeks before death.

Design — Retrospective population-based cohort study using linked administrative healthcare data.

Setting/Participants — Decedents (cancer, frailty, and organ failure) between April 1st, 2010 and December 31st, 2012 in Ontario, Canada. Initiation time before death (days): early (⩾60) and late (⩾15 and <60). ‘Acute-care settings’ included acute-hospital admissions with (‘palliative-acute-care’) and without palliative involvement (‘non-palliative-acute-care’).

Results — We identified 230,921 decedents. 27% were early palliative care recipients, 13% were late. 45% of early recipients had a community-based initiation, 74% of late recipients had a hospital-based initiation. Compared to late recipients, fewer early recipients used palliative-acute care (42% vs. 65%) with less days (mean days: 9.6 vs. 12.0). Late recipients were more likely to use acute-care settings; this was further modified by disease: comparing late to early recipients, cancer decedents were nearly two times more likely to spend >1 week in acute-care settings (OR=1.84, 95%CI:1.83-1.85), frailty decedents were three times more likely (OR=3.04, 95%CI:3.01-3.07), and organ failure decedents were four times more likely (OR=4.04, 95%CI:4.02-4.06).

Conclusions — Early palliative care was associated with improved end-of-life outcomes. Late initiations were associated with greater acute-care use, with the largest influence on organ failure and frailty decedents, suggesting potential opportunities for improvement.