gms | German Medical Science

Background: Palliative care is commonly associated with a change in patients’ care regimes in the time leading up to their death. According to the guideline regulating the most intensive form of palliative home care in Germany (specialised palliative home care or Spezialisierte Ambulante Palliativversorgung, SAPV), the focus in the last days, weeks or months before death should not be on curative measures but rather on the management of symptoms with the aim of maintaining quality of life [1]. Medication plays a key role in the management of relevant symptoms such as pain, nausea, dyspnea or anxiety. If there was a successful change in care regime after the start of palliative home care services, this change should become visible in the medication prescribed to the patients.

Materials and methods: The analysis is based on the statutory health insurance claims data of 89,525 people insured by German health insurance AOK Rheinland-Hamburg who died between 2014 and 2016 while residing in the Northrhine region (southern half of Northrhine-Westphalia). The data were originally analysed as part of the APVEL project evaluating the above-mentioned SAPV guideline [2]. The analysis looked at the prescription of medication in primary care in the last year of life both before and after the start of palliative home care services. Palliative medication was defined on the basis of [3], [4] and [5] and analysed in contrast to all other prescribed medication. The unit of measurement was medication cost.

Results: Table 1 [Tab. 1] shows the average share of medication cost for palliative medication and all other medication prior to and after the start of specialised palliative home care for all patients that received this level of service (n=5,316). Before the start of palliative care, an average 81.5% of medication cost was spent on non-palliative medication, compared to 15.7% for palliative medication. After receiving palliative services, the average cost share for palliative medication increased more than threefold to 48.6%. Standard deviation for all averages is high, indicating that there is considerable individual variation.

Conclusion: The results provide an indication that – on average – the start of specialised palliative home care leads indeed to a shift in care regime from curative care to symptom management, as far as drug therapy is concerned. Other results of the APVEL study support these findings, e.g. showing a decrease in the number and length of hospital stays after the start of palliative care, as well as a marked increase in the number of palliative patients dying in the home environment. At the same time, both service utilization levels (average 6.1% of all deceased from 2014 to 2016) and comparatively late start of service before death (median 22 days) seem to indicate that the impact could be considerably higher if services were more widely available.