Poor utilization of palliative care amongst medicare patients with chronic limb threatening ischemia

Article indépendant

KWONG, Mimmie | RAJASEKAR, Ganesh | UTTER, Garth H. | NUNO, Miriam | MELL, Matthew W.

BACKGROUND: Patients with chronic limb threatening ischemia (CLTI) experience high annual mortality and would benefit from timely palliative care intervention. We sought to better characterize use of palliative care among CLTI patients in the Medicare population. METHODS: Using Medicare data from 2017-2018, we identified patients with CLTI, defined as two or more encounters with a CLTI diagnosis code. Palliative care evaluations were identified using ICD-10-CM Z51.5 "Encounter for palliative care." Time intervals between CLTI diagnosis, palliative consultation, and death or end of follow up were calculated. Associations between patient demographics, comorbidities, and palliative care consultation were assessed. RESULTS: A total of 12,133 Medicare enrollees with complete data were categorized as having CLTI. Of these, 7.4% (894) underwent a palliative care evaluation at a median of 170 (IQR 45 - 352) days from their CLTI diagnosis. Compared with those who did not undergo evaluation, palliative patients were more likely to be dual eligible for Medicaid (45.2% vs. 38.1%, p<.001) and had more comorbid conditions (p<.001). After controlling for gender and race, age (OR 1.03; CI 1.02-1.04), dual eligibility (OR 1.40, CI 1.22-1.62), solid organ malignancy (OR 2.82; CI 1.92-4.14), hematologic malignancy (OR 2.24, CI 1.27-3.98), congestive heart failure (OR 1.44, CI 1.15-1.88), complicated diabetes (OR 1.35, CI 1.11-1.65), dementia (OR 1.32, CI 1.04-1.66), and severe renal failure (OR 1.56, CI 1.24-1.98) were independently associated with palliative care evaluation. During mean follow up of 410 ± 220 days, 16.9% (2044) of patients died at a mean of 268 (± 189) days after their CLTI diagnosis. Among living patients, only 3.2% (325) underwent palliative evaluation. Comparatively, 27.8% (569) of patients who died received palliative care at a median of 196 (IQR 55-362) days after their diagnosis and 15 (IQR 5-63) days prior to death. CONCLUSIONS: Despite high mortality, palliative care services were rarely provided to Medicare patients with CLTI. Age, medical complexity, and income status may play a role in the decision to consult palliative care. When obtained, evaluations occurred closer to time of death than to time of CLTI diagnosis, suggesting misuse of palliative care as end-of-life care.

http://dx.doi.org/10.1016/j.jvs.2023.02.023

Voir la revue «Journal of vascular surgery»

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