title: Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes.
abstract: BACKGROUND
  Palliative care services in the United States are increasing in their prevalence but continue to vary in their implementation, with different referral policies and timing of patient access to services.
  
  
  OBJECTIVE
  To better define a late referral and to understand the association of late referrals to palliative care with patient health outcomes, including postreferral length of hospital stay and in-hospital mortality.
  
  
  METHODS
  We performed a retrospective study using multiple linear and logistic regressions on 1,225 patients with pre-existing oncologic diagnoses who received a referral to Stanford Hospital's palliative care service.
  
  
  RESULTS
  Those oncologic patients who were referred to palliative care in the first week following admission had significantly shorter lengths of stay after referral, as well as lower in-hospital mortality, compared with patients who were referred later than 1 week following admission. Regression analyses, adjusted for demographic variables, DNR status, and sickness, revealed that waiting 1 week or longer to refer a patient was associated with an overall increased length of stay of 2.70 days (P < .001). This increased to 3.40 days (P < .001) when patients who died in the hospital were removed from the data, suggesting that in-hospital mortality was not solely responsible for the trend. Waiting 1 week to refer was associated with increased odds of a patient's dying in the hospital vs being discharged alive by a factor of 3.04 (P < .001).
  
  
  CONCLUSIONS
  This study was limited to analyzing inpatient palliative care consultation services with a emphasis on patients with metastatic solid tumors. We used a proxy for patient sickness burden but did not analyze outcomes specific to cancer stage or individual oncologic diagnosis separately.
  
  
  CONCLUSIONS
  Our study suggests that late referrals may have a marked negative impact on health outcomes, which argues for the design and implementation of hospital policies that encourage early referral to palliative care for advanced cancer patients.
authors: Department of Internal Medicine, Stanford University, CA USA Email: jhumph@stanford.edu.
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