title: Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study.
abstract: BACKGROUND
  Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients.
  
  
  METHODS
  A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH.
  
  
  RESULTS
  Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55).
  
  
  CONCLUSIONS
  Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.
authors: School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada.
authors: Lialoma
authors: L
authors: Salam-White
authors: School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada.
authors: John P
authors: JP
authors: Hirdes
authors: School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada.
authors: Jeffrey W
authors: JW
authors: Poss
authors: Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada.
authors: Jane
authors: J
authors: Blums
keywords: Acute hospital admissions; Emergency room visits; Hospice palliative care; InterRAI PC