COPD is the 3rd leading cause of death in U.S. In 2006, 1,254,703 hospitalizations (NIS) were attributed to COPD and had a mean cost of $9545 +/‐ 12,700. Predicting mortality in COPD has proven difficult, but several indexes have been validated to determine severity and risk of mortality, namely the DOSE and BODE indexes. Hospice criteria generally reflect the characteristics of these indexes. We hypothesized that referral to palliative care in end stage COPD was suboptimal in our institution, Regions Hospital in St. Paul, MN, despite a strong palliative care culture, and that development of a COPD order set would facilitate increased appropriate referrals. Our objectives were to determine characteristics of patients with severe COPD who would benefit from palliative care consult based on current literature, the percentage of patients meeting referral criteria that received a palliative care consult, and the strongest predictors of obtaining a referral, and to facilitate an increase in appropriate palliative care consults by contributing our conclusions to a COPD order set.
A retrospective chart review of patients admitted with a primary diagnosis of COPD at Regions Hospital between June 2011 and June 2012. Variables included age, spirometry data, number of hospitalizations, resting oxygen saturation and heart rate, BMI, and current smoking behaviors. Using standard statistical methods the following data points were generated: 1) general referral rates based on individual patient characteristics, 2) univariate predictors of palliative care referral, and 3) a multivariable model for predictors of palliative care referral. Findings from the literature review and results generated from the chart review were utilized to assist with generation of a COPD order set.
147 patients were included in the analysis. Three patient characteristics correlated with palliative care referrals and were statistically significant: 1) FEV1 of <30%, 2) 2 or more respiratory hospitalizations within the previous year, and 3) out of hospital O2 saturation of <88%. Referral rates for these three characteristics were 53%, 44%, and 72%, respectively. Univariate predictors of palliative care referral included age (OR 1.19, CI 1.01‐1.39, P<0.033), FEV1<30% (OR 3.51, CI 1.49‐8.29, P<0.004), two or more respiratory hospitalizations within the previous year (OR 3.51, CI 1.63‐7.57, P<0.001), out of hospital O2 saturation <88% on room air (OR 6.89, CI 2.28‐20.76, p<0.001), and change in BMI from the 6 months prior to admission (per 1kg/m2 decrease) (OR 1.71, CI 1.29‐2.27, <0.001).
Referral characteristics to palliative care for end stage COPD are poorly defined and not standardized. In our institution about 50% of COPD patients who should be getting a palliative consult by hospice‐defined clinical criteria are referred appropriately. Hypoxia is frequently recognized as an indication for referral, but frequent hospitalization and spirometry trigger a referral less often. The next step has been to incorporate these conclusions into a COPD order set. This has been implemented and data collection to determine its effect is ongoing.
To cite this abstract:Greiner R, Kim J. Improving Palliative Care Referrals in End Stage Copd. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 14. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/improving-palliative-care-referrals-in-end-stage-copd/. Accessed April 2, 2020.