Primary Palliative Care for Emergency Medicine, a Clustered-Randomized Stepped Wedge Trial Across 29 EDs (RP323)

Outcomes 1. Define primary palliative care and its role in emergency medicine.2. Explain the components of a multi-level, complex palliative care intervention. Key Message A multi-level, complex primary palliative care intervention in 18 emergency departments did not decrease acute care utilization in older adults at high risk for short-term mortality. Importance Palliative care interventions in the Emergency Department (ED) capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes. Objective(s) To test the impact of primary palliative care education, training, and technical support for emergency medicine (PRIM-ER) on ED disposition, healthcare utilization, and survival in older adults with serious, life-limiting illness. Scientific Methods Utilized PRIM-ER was a cluster-randomized stepped wedge designed to administer interventions aimed at improving providers’ palliative care practices across 29 EDs in the United States. Our study used Medicare claim records accessed through the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse. Patients were included if they were aged 66 and older, visited one of our 29 EDs between May 1, 2018 and December 31, 2022, had 12 months of prior inpatient, outpatient, and carrier claims with a Gagne Index > 6 representing a >30% risk of mortality. We used summary statistics and a generalized additive model (GAM) to estimate the effect of our primary outcome, the patient's ED disposition to an acute care setting (Yes/No) in the 6 months following their initial ED visit. Results We identified 98,922 initial visits with 52% occurring during the baseline period and 48% in the intervention period. Mean age was 78 (SD 8.4), 50% of patients were female, 78% were White and the average Gagne score was 9.0 (SD 2.2). 63% of the patients had an inpatient admission during the baseline period and 62% in in the intervention period. After adjusting for naturally occurring changes over time, there was no difference between acute care admission in the intervention period (OR 0.94, CI: 0.84 - 1.05) compared to the baseline period. Conclusion(s) A multi-level, complex primary palliative care intervention in 18 emergency departments did not decrease acute care utilization in older adults at high risk for short-term mortality. Impact Unlike the strong evidence base for specialty palliative care, a primary palliative care intervention in the emergency department did not demonstrate an impact on healthcare utilization in older adults at high risk for short-term mortality. Keywords Models of palliative/hospice care delivery/Educational, training and supervision