title: Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration.
abstract: OBJECTIVE
  Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients.
  
  
  OBJECTIVE
  To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system.
  
  
  METHODS
  Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191,280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42,143) or medical (n = 149,137) if the patient did not receive surgical treatment in the last year of life.
  
  
  METHODS
  Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files.
  
  
  RESULTS
  Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment.
  
  
  CONCLUSIONS
  In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.
authors.affiliation: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa2Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City.
authors.forename: Courtney L
authors.initials: CL
authors.lastname: Olmsted
authors.affiliation: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa.
authors.forename: Amy M
authors.initials: AM
authors.lastname: Johnson
authors.affiliation: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa3Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City4Veterans Affairs Office of.
authors.forename: Peter
authors.initials: P
authors.lastname: Kaboli
authors.affiliation: Department of Surgery, Carver College of Medicine, University of Iowa, Iowa City5Surgical Services, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa.
authors.forename: Joseph
authors.initials: J
authors.lastname: Cullen
authors.affiliation: The Comprehensive Access and Delivery Research and Evaluation Center at the Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa3Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City.
authors.forename: Mary S
authors.initials: MS
authors.lastname: Vaughan-Sarrazin
mesh_terms: D015331:Cohort Studies; D019033:Delivery of Health Care, Integrated / Q000706:statistics & numerical data; D017051:Hospice Care / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008511:Medicine / Q000706:statistics & numerical data*; D010166:Palliative Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data