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Temporal Trends, Setting, and Timing of Palliative and Hospice Care in COPD in the Veterans Health Administration,
Natalia Smirnova1, Sarah H Cross1, Jordan A Kempker1
1Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine (N. Smirnova and J. A. K.) and the Division of Palliative Medicine, Department of Family and Preventive Medicine (S. H. C. and D. K.), Emory University, Atlanta, GA; the Division of Pulmonary, Allergy and Critical Care Medicine (D. R. S.), Oregon Health and Science University, Portland, OR; the Center to Improve Veteran Involvement in their Care (CIVIC) (D. R. S.), VA Portland Health Care System, Portland, OR; the Knight Cancer Institute (D. R. S.), Oregon Health and Science University, Portland, OR; The College of Nursing (L. F. R.), University of Utah, Salt Lake City, UT; the Department of Respiratory and Sleep Medicine (N. Smallwood), Alfred Hospital, Prahran, VIC, Australia; the School of Translational Medicine (N. Smallwood), Monash University, Melbourne, VIC, Australia; the Center of Innovation for Veteran-Centered and Value-Driven Care (R. P. and D. A.), Veterans Affairs Puget Sound Health Care System, Seattle, WA; the Division of Respiratory Medicine (K. D.), Department of Medicine, University of British Columbia, Vancouver, BC, Canada; the School of Nursing (S. L. F.), Yale University, New Haven, CT; the Department of Veterans Affairs (S. L. F.), West Haven, CT; the Department of Biostatistics and Bioinformatics, Rollins School of Public Health (Y. M.) and the Division of Geriatrics and Gerontology, Department of Medicine (C. V.), Emory University, Atlanta, GA; the Department of Veterans Affairs Birmingham/Atlanta Geriatric Research Education and Clinical Center (C. V.), Atlanta, GA; and the Division of Pulmonary, Critical Care, and Sleep Medicine (D. A.), University of Washington, Seattle, WA.
Background:
People with COPD experience physical, psychosocial, and health care burdens that decrease their quality of life. Early specialist palliative care is recommended to alleviate these burdens.
Research Question:
What factors are associated with palliative care use among decedents with COPD?
Study Design And Methods:
This was a national retrospective cohort study of veterans with COPD who died between 2010 and 2020. Mixed-effects multivariate regression was used to assess the relationship between baseline patient characteristics and the primary outcome of receipt of palliative care within 1 year of death. Secondary outcomes included Veterans Affairs inpatient hospice, timing of palliative care, and trend in palliative care use over time.
Results:
Among 332,770 decedents, 16.8% received palliative care (61.6% in the inpatient setting) in the year before death. Patient characteristics associated with receipt of palliative care included lung cancer (adjusted OR [aOR], 2.48; 95% CI, 2.40-2.55), congestive heart failure (aOR, 2.02; 95% CI, 1.97-2.06), being underweight (aOR, 1.75; 95% CI, 1.70-1.82), housing instability (aOR, 1.38; 95% CI, 1.33-1.43), Latino/Hispanic ethnicity (aOR, 1.22; 95% CI, 1.12-1.32), and Black race (aOR, 1.21; 95% CI, 1.17-1.26). In contrast, married patients (aOR, 0.88; 95% CI, 0.86-0.90) and those receiving care in a rural facility (aOR, 0.94; 95% CI, 0.91-0.97) were less likely to receive palliative care. Palliative care use increased from 10.4% to 16.0% (P < .05). The median time between first palliative care encounter and death was 46 days (interquartile range, 12-138).
Interpretation:
Despite an increase in palliative care use over the past decade among veterans with COPD, our findings indicate that most did not receive palliative care or Veterans Affairs inpatient hospice within their final year of life. Those who received palliative care received it late in the illness course. These results highlight the need for targeted strategies to increase access to palliative care and hospice services for patients with COPD.
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