Telehealth, Default Orders Show Promise in Palliative Care

A palliative telecare intervention improved quality of life for patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD), the ADAPT randomized clinical trial found.

Patient phone calls with a nurse and social worker — who met separately with a primary care and palliative care physician and specialists as needed — resulted in Functional Assessment of Chronic Illness Therapy-General (FACT-G) scores at 6 months improving by 6 points in these patients, an improvement over the modest 1.4-point boost for peers receiving usual care (difference 4.6 points, 95% CI 1.8-7.4), reported David Bekelman, MD, MPH, of the VA Eastern Colorado Health Care System in Aurora, and co-authors in JAMA.

Compared with usual care involving educational handout reviewing self-care specific to the three conditions, the palliative care intervention in ADAPT also led to significant improvements in specific health outcomes over the course of the 6 months in the single-blind, multisite trial:

• COPD health status per the Clinical COPD Questionnaire
• HF health status per Kansas City Cardiomyopathy Questionnaire-12 criteria
• Depression per Patient Health Questionnaire-8 criteria
• Anxiety per Generalized Anxiety Disorder-7 criteria

“This intervention presents opportunities for health systems and payors in context of value-based care. Effective delivery to patients with complex multimorbidity or serious illness often requires teams of individuals with advanced knowledge. Health care systems can develop multidisciplinary teams that are organized around patient needs, reducing the need for patients to coordinate their care services,” Bekelman’s group wrote.

Researchers also noted that the virtual aspect of the study suggested potential for the intervention to reach patients who may not typically have access to such care.

Indeed, a cluster-randomized trial, also published in JAMA, revealed some limitations of palliative care in the hospital setting.

Default palliative care consult orders ultimately did not reduce a patient’s length of stay, but this approach — ordering palliative care consultation by default for eligible patients — successfully increased orders for palliative care (43.9% vs 16.6% with standard care, adjusted OR 5.17, 95% CI 4.59-5.81) and produced earlier orders (average 3.4 days vs 4.6 after admission, P<0.001), reported Katherine Courtright, MD, MS, of the University of Pennsylvania in Philadelphia, and co-authors.

“Although default options are understood to be ethical approaches to change patients’ decisions and clinicians’ drug ordering practices, this study demonstrates that health systems may also use default options to improve the timing and frequency of guideline recommended clinical consultation,” Courtright’s group wrote.

The pragmatic study was conducted at 11 U.S. centers and included over 24,000 patients 65 years or older with advanced COPD, dementia, or kidney failure. Do-not-resuscitate orders at discharge were more common in the default order cohort (adjusted OR 1.40, 95% CI 1.21-1.63), as was discharge to hospice (adjusted OR 1.30, 95% CI 1.07-1.57). With default or usual referrals to palliative care, however, patients had similar in-hospital mortality rates (4.7% vs 4.2%).

“A key lesson from dissemination and implementation science is that attention to acceptability and sustainability, including adequate resources and staffing, is critical to testing the full potential of interventions,” noted Ashwin Kotwal, MD, MS, of the University of California, San Francisco, and co-authors in an accompanying editorial.

The editorialists pointed out that default orders tested in the second study were not paired with increased palliative care team staffing, which may explain why nearly 46% of the default consult group were ultimately not seen by palliative care teams.

“Testing models of palliative care delivery in noncancer serious illness remains critically important because palliative care is a limited resource and many clinicians continue to have a poor understanding of when it is appropriate to involve palliative care in noncancer serious illness,” they wrote. “Although the findings from each study are promising, more work is needed to adapt these models of care to real world settings to ensure high-value, cost-effective, and patient-centered palliative care.”

The ADAPT intervention had brought a team of providers to each patient, including a nurse to address the patient’s symptoms and a social worker to provide counseling. The intervention was conducted via phone, with each provider planning six phone calls twice per month. Interventions lasted, on average, for 115.1 days and patients received an average of 10.4 intervention calls.

The trial included 306 patients: 57.8% with COPD, 21.9% with HF, 16% with both COPD and HF, and 4.2% with ILD. Men accounted for 90.2% of the group and 80.1% of the study population were white. The average patient age was about 69. Approximately 76% of participants completed FACT-G assessments after 6 months.

The large population of both male and white patients may have limited the applicability of findings from the ADAPT trial. Other potential limitations included a low mortality rate that may indicate that some of the sickest patients did not participate, as well as small numbers of ILD patients.

The patient population for the default palliative care trial was 55.4% women, with an average age of 77.9 years. As was the case in ADAPT, white patients comprised approximately 80% of the cohort.

Kotwal’s group stressed that while the two trials have their respective limitations, they “break new ground in developing sustainable and transferable models to address the needs of persons with noncancer serious illness.”

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