title: Association between early palliative care referrals, inpatient hospice utilization, and aggressiveness of care at the end of life.
abstract: BACKGROUND
  Palliative care has a positive effect on many clinical outcomes, yet most referrals to palliative care have occurred late. End-of-life (EOL) cancer care has become increasingly aggressive. There have been no studies investigating the association between early palliative care referrals and aggressive EOL care in Japan.
  
  
  OBJECTIVE
  This study was designed to explore the association between early palliative care referrals, inpatient hospice utilization, and aggressiveness of EOL care by investigating cancer decedents.
  
  
  METHODS
  A retrospective cohort study in a cancer-designated hospital in Japan.
  
  
  METHODS
  This study examined 266 consecutive cancer decedents. Inclusion criteria were adults and patients who died from cancer or causes related to cancer. Patients who died from causes unrelated to cancer were excluded. A total of 265 patients met the criteria.
  
  
  METHODS
  We explored the association between early referrals (>3 months before death) and inpatient hospice utilization and the relationship between the timing of referrals and aggressive EOL care measured by a composite score adapted from Earle and colleagues.
  
  
  RESULTS
  Patients were divided into an early referral group (n=54) and a control group (n=211). The rate of inpatient hospice utilization was significantly higher in the early referral group (74% versus 47%, adjusted p<0.001). While each of six indicators of aggressiveness of EOL care did not differ significantly, the composite score was significantly lower in the early referral group (1.91±0.59 versus 2.14±0.78, adjusted p<0.001).
  
  
  CONCLUSIONS
  Early palliative referrals were associated with more inpatient hospice utilization and less aggressive EOL care.
authors.affiliation: 1 Department of Palliative Medicine, Palliative Care Team, Osaka City General Hospital , Osaka, Japan .
authors.forename: Koji
authors.initials: K
authors.lastname: Amano
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Morita
authors.forename: Ryohei
authors.initials: R
authors.lastname: Tatara
authors.forename: Hirofumi
authors.initials: H
authors.lastname: Katayama
authors.forename: Teruaki
authors.initials: T
authors.lastname: Uno
authors.forename: Ibuki
authors.initials: I
authors.lastname: Takagi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D017051:Hospice Care / Q000458:organization & administration / Q000706:statistics & numerical data*; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007564:Japan; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000451:nursing*; D010166:Palliative Care / Q000458:organization & administration*; D012017:Referral and Consultation / Q000458:organization & administration*; D012189:Retrospective Studies; D013727:Terminal Care / Q000458:organization & administration*; D013997:Time Factors