Background: Palliative care in seriously ill patients has been shown in some studies to improve satisfaction, symptoms, inpatient mortality rates, healthcare utilization and cost. While inpatient palliative care has been shown to improve symptoms and quality of life measures, the literature on its association with 30-day readmissions have been mixed for heart failure hospitalizations. We aimed to determine the association between palliative care encounters and 30-day rehospitalization for patients with heart failure using a large U.S.-based administrative database.
Methods: Using the 2010 Nationwide Readmission Database, a nationally representative sample of U.S. hospitalization, we analyzed readmissions for congestive heart failure with and without palliative care encounters. Diagnoses were identified using the International Classification of Diseases, Ninth Revision (ICD-9) codes. The Index hospitalization was defined as those with a principal diagnosis of Congestive Heart Failure (CHF). Included were patients aged > 18 years, survived the Index hospitalization, and had a discharge destination of home, home with home health, or facility. A Palliative Care Encounter (PCE) was identified using the ICD-9 code V66.7. Propensity scores were derived based on the Charlson Comorbidity score for the allocation the PCE. Survey logistic regression provided population-based unadjusted and adjusted estimates for the association between PCE and 30-day rehospitalization. The adjusted model included comorbid conditions, discharge destination after Index hospitalization, and hospital characteristics of size, location, and status. Logistic models were provided with discharge destination as a covariate and then as a stratification factor. Adjusted models with and without the propensity scores enabled accounting for the possibility of confounding by indication.
Results: There were an estimated 291,117 total hospitalizations, including 4,012 with and 287,106 without a PCE. Patients with PCE were more likely to be aged over 65 years (92.8 vs. 74.8%), female (61.5 vs. 56.1%), have comorbid conditions of Chronic Kidney Disease (49.1 vs 41.4%), cancer (12.1 vs 4.1%), and less likely to have diabetes (29.4 vs. 42.7%) or hypertension (25.8 vs. 37.4%). Those with PCE were more likely to be at a large, teaching, metropolitan hospital and to have a discharge destination to facility or with home health services. Relative to those without PCE, patients with PCE were at 67% reduced odds of 30-day rehospitalization after accounting for comorbid conditions, hospital characteristics, payor type, and discharge destination after Index hospitalization (Odds Ratio [OR], 0.33; 95% Confidence Interval [CI], 0.27 to 0.41). Stratified by discharge destination after the Index hospitalization, the lower adjusted relative risk for 30-day readmission among patients with PCE remained for those with a discharge destination of home health (OR, 0.31; 95% CI, 0.23 to 0.41), or facility (OR, 0.26; 95% CI, 0.18 to 0.36) but not with those with discharge destination classified as routine (OR, 0.86; 95% CI, 0.58 to 1.28).
Conclusions: Inpatient palliative care encounter in heart failure hospitalizations is associated with a lower 30-day readmission. Given the interaction between readmission risk and discharge destination, the reduced 30-day readmission risk may be mediated thru the provision of higher level of services at discharge.