Reducing overtreatment of older people near the end of life: the role of hospitals in a culture change

Abstract

Background/objectivesFrail elderly people with comorbidities, repeatedly use hospitals in their last year of life. Our research program aims to reduce overtreatment of these patients. We present our results thus far.MethodsWe conducted two systematic reviews; developed a prediction checklist (CriSTAL) to estimate risk of death; undertook two prospective validation studies of the checklist; led a national pilot consultation with emergency staff (ED); and completed universal frailty screening in emergency departments. ResultsSystematic review #1 (38 studies with 1.2 million subjects) revealed that a third of older patients in their last 6-months of life are subjected to non-beneficial treatments. Systematic review #2 (16 eligible studies of 491,697 elderly) identified medically inappropriate hospitalisations ranged from 2.0% to 67.0%, and socially-driven admissions prompted by shortage of community services. CriSTAL validation in ~3,000 subjects (4 countries) yielded high predictive short-term death accuracy (AUROC 79.0%-82.5%). The ED staff consultation supported nurse-led interventions to manage frailty. Frailty prevalence measured by 3 frailty instruments varied (9.7%-43.7%) but frailty consistently and independently predicted poor outcome irrespective of instrument (OR (95%CI): 2·58 (1·72–3·86); 2.20 (1·55–3.12); 2.46 (1.16–5.05)). Our future research to reduce low-value care includes building electronic decision support for terminal illness; new service models including systematic screening for risk of death and pre-frailty; and determining effective deprescribing strategies near end-of-life. Conclusion A hospital culture of less aggressive interventions can enhance the end-of-life experience through identifying frailty and impending death early, initiating end-of-life discussions, and providing coordinating care pathways that meet the demands of the ageing population.