Commentary by:
Dr. Qutaibah Alotaibi, Canuck Place Pediatric Palliative Fellow, Canada
Feature Article:
Bower, K. A., Lau, M., Short, R., Lawrence, S., Beauchamp-Walters, J., & Marc-Aurele, K. (2022). Impact of Home-Based Pediatric Palliative Care on Hospital and Emergency Department Utilization at a Single Institution. Journal of Palliative Medicine, 25(2), 301–306.
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As I am attempting to introduce a pediatric palliative care program in a country with no considerable organized pediatric palliative service, I will need tools to convince the deciding policymakers. In such places, palliative care is usually surrounded by myths and pushed back by “palliphobia”, as described by Friedrichsdorf et al. in 2018. Hence, a well-targeted approach has to be shaped according to the audience. For policymakers, cost is usually the driving force, as palliative care is globally underfunded and dependent on donations. This article is an excellent tool to approach them. Although better quality of life should be the main reason for establishing palliative care, cost-effectiveness is an attractive hook for policymakers.
The study “Impact of Home-Based Pediatric Palliative Care on Hospital and Emergency Department Utilization at a Single Institution,” published in the Journal of Palliative Medicine, used a simple method to describe one aspect of palliative care: home care. Bower et al. studied the effect of home care on hospital utilization (ER visits and number/length of admissions). The study was a retrospective medical chart review of patients, from birth to their 21st birthday, who received home-based PPC and had at least one year of pre-program data and one year of post-program data. I assume that they were diagnosed with the disease a year before receiving palliative care. The population was 96 patients out of 154 who received home palliative care from Rady Children’s Hospital-San Diego.
This study shows that a specialized team of physicians, nurses, and social workers who review patients in the office or via telemedicine, 14 home visits per patient per year on average, and 24/7 nurse phone call support would save 47 days/year of inpatient care beds per patient. These results are easily measured compared to quality of life, which is difficult to measure and define. Furthermore, as other studies showed that only a small percentage of patients who need palliative care receive it, the number of freed inpatient beds can be expanded further. The fact that 17 patients passed away during this study confirms that admissions and hospital stays were reduced despite the progression of the diseases, and confirms the absence of patient selection bias.
The study would have been more valuable if more information was provided, including the number of average calls per patient, palliative clinic visits, and the number of staff who worked on the team. Another limitation is the absence of a control group, as mentioned by the author. The other limitation mentioned by the author is that the data was from a single center and was dependent on medical records.
Some may argue that this reduction of inpatient bed occupations is a normal phenomenon. For example, patients with complex diseases might need to be admitted more often for detailed investigation and multiple disease-directed treatments early in the diagnosis. When those efforts fail, they would be referred to palliative care, reducing admissions and hospital stays. However, Fitzpatrick et al. in 2018 have shown that the medical cost would drop further if those patients had been referred even earlier.
There are studies, although limited, that were carried out similarly and showed similar results, such as Ananth et al. in 2009 and Gans et al. in 2014. On the other hand, Conte et al.’s 2018 study with two groups (palliative and control) from BC did not show the same positive finding. However, the study only included 11 patients in each group. The potential for cost-effectiveness in palliative care is massive and well evident. In addition, it provides better care and improves the quality of life. This study adds to the argument that pediatric palliative care is a necessity, not a luxury, in providing justice for all patients and providing a better quality of life for patients who desperately need it.