Inpatient palliative care consultative services (IPCS) hold great promise to improve care and reduce costs for patients with life-limiting illnesses. As such, hospitals worldwide are heavily investing in such programs, and indeed, their penetrance in U.S. hospitals has increased 157% in the past decade and is projected to reach 84% of hospitals with at least 50 beds this year. However, there is limited experimental evidence available to quantify the effects of IPCS in generalizable, real-world settings, and even less evidence about which types of services work best for which types of patients, or how to ensure timely IPCS delivery. Thus, the investigators propose a large, pragmatic trial to assess the effects of default palliative care consultation for seriously ill patients on clinical, patient-cenered, and economic outcomes. The trial will be conducted among 9 hospitals using the same electronic health record within Ascension Health, the largest non-profit health system in the U.S., and preliminary data suggest that it will enroll more than 15,000 eligible patients. The tria will use a stepped-wedge, cluster randomized design in which hospitals will be randomly assigned to adopt, at different times, an intervention that makes palliative care consultation the default for selected patients with life-limiting illnesses. Instead of relying on the actions of buy physicians to identify needs for IPCS and place corresponding orders, our fully automated approach uses hospitals'electronic health records to order IPCS by default for patients identified on routine screening as likely to benefit. The intervention therefore shifts practice frm a physician-centered, opt-in model for IPCS to an opt-out model whereby palliative care teams routinely engage patients and families unless patients, families, or physicians actively choose otherwise. During the initial UH2 (planning) year, the multidisciplinary research team will develop electronic medical record processes to identify patients meeting palliative care triggers, validate data capture of all proposed outcomes and methods for tracking adherence to the electronically generated palliative care orders, develop methods to ensure high-fidelity data transfer from participating hospitals, establish mechanisms and materials for notifying patients and providers about the research, and complete all regulatory requirements. During the subsequent UH3 (implementation) phase, the team will conduct the largest randomized trial ever in palliative care, answering key questions such as how well IPCS works, which structural characteristics of these services make them particularly effective (e.g., staffing by palliative cae physicians vs. nurse practitioners), and which types of patients derive the greatest benefits (e.g., those seen earlier vs. later in their disease courses, or those in the ICU vs. hospital ward. At the same time, the trial will provide an experimental test of default palliative care - a promising approach for increasing penetration of IPCS among selected patients that, if successful, could be quickly and easily scaled for implementation at hospitals around the world.

Public Health Relevance

Hospitals are heavily investing in inpatient palliative care consultative services given their great promise for improving care and constraining costs for patients with life-limiting illnesses. However, little experimental evidence exists regarding the effectiveness of such services in real-world settings, and even less is known about which types of services work best for which types of patients. To answer these questions, a pragmatic randomized trial will be conducted among seriously ill patients admitted to 9 electronically integrated hospitals within the largest nonprofit health system in the U.S., randomly assigning the order in which each hospital switches from a system whereby patients or providers must actively request palliative care consultation, to a system in which such services are ordered by default for selected patients who may choose to opt out. (End of Abstract)

National Institute of Health (NIH)
National Institute on Aging (NIA)
Exploratory/Developmental Cooperative Agreement Phase I (UH2)
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Special Emphasis Panel (ZHL1)
Program Officer
Nielsen, Lisbeth
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University of Pennsylvania
Biostatistics & Other Math Sci
Schools of Medicine
United States
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Halpern, Scott D (2018) Using Default Options and Other Nudges to Improve Critical Care. Crit Care Med 46:460-464