The New Type of Outpatient Palliative Care

An Analysis of Routine Data From a Statutory Health Insurance Carrier After Its Introduction

It is expected that demographic trends will lead to an increase in the proportion of people requiring palliative care. Estimates indicate that 80–90% of all people will require some form of palliative care at the end of their lives (1, 2). In order to further develop the existing forms of outpatient palliative care, an intermediate form of palliative medical care (IPC) was introduced in 2017 in accordance with Section 87 (1b) of the German Social Code (SGB) Part V. It is intended to serve as an intermediate stage between general and specialized outpatient palliative care (GPC/SPC) (3).

In this article, routine data from a statutory health insurance (SHI) carrier will be used to analyze how many and which patients received IPC in their last year of life before passing away.

Methods

A retrospective cross-section analysis of the utilization of outpatient palliative care services in the last year of life was performed, based on routine SHI data from the local health care carrier AOK Lower Saxony. The analysis population comprised deceased insured patients from 2019 who were at least 18 years old at the time of death, lived in Lower Saxony, and had been continuously insured during the observation period (n = 34 012). For these insured persons, utilization of IPC as well as general and specialized palliative care (prescriptions) in their last year of life (365 days before death) were selected on the basis of coded fee schedule items of the German Uniform Assessment Standard (EBM). In addition, age, gender, level of nursing care, and morbidity were also included in the analysis. IBM SPSS Statistics version 25 was used for the analysis. The results were presented in descriptive form.

Results

Of those who died in 2019 (n = 34 012), a total of 4.5% (n = 1518) had received IPC services. GPC was provided in 23.6%, and an SPC prescription was received by 10.0%.

About half of the insured patients with IPC received only this form of outpatient palliative service. The Figure shows how many patients also received GPC or received a prescription for SPC.

Figure

Utilization of outpatient palliative care services by deceased insured patients with IPC

Insured patients receiving both GPC and IPC (n = 365) received GPC first and then IPC in half of the cases (49%). The other half received these two forms of care in the reverse order (29.6%) or simultaneously (21.9%). When IPC and SPC were provided (n = 204), 64% of patients were initially started on IPC and then prescribed SPC. In 28% of patients, SPC was prescribed first and then IPC was provided. 7.8% received both forms of care on the same day. This was also the tendency when all three outpatient palliative care services were utilized (n = 221). The Table provides a description of the IPC population in terms of age, gender, and morbidity.

Table

Age, sex, and morbidity of the deceased insured patients with IPC

Discussion

The results show that within the analysis population, 4.5% of those who died in 2019 had received IPC services, and these services were often provided in addition to other outpatient palliative care services. With regard to the sequence of care, the staged sequence of different services of outpatient palliative care, as intended by the legislator, seems to have been observed in half of the cases.

Because there has not yet been a needs estimation of how many patients require care with IPC, it is not possible to assess whether the demand for care will be met. However, if the assumed demand for GPC (approximately 80–90%) or SPC (approximately 10–20%) (1, 4) and the results of this study on utilization are considered, it can be assumed that the overall need for care is somewhat higher. Obstacles to IPC could be the special (qualification) requirements for physicians, for example on-call duty, and an associated increase in resources (3).

The results show that a large proportion of patients with IPC have cardiovascular diseases and 62% have a malignant neoplasm. These findings suggest that this patient population has a high level of morbidity with an increased need for outpatient palliative care. IPC was introduced by the legislator for patients who tend to be underserved by basic GPC care but do not require more intensive SPC care. This study is unable to answer the question of whether this target group is actually receiving IPC. Further analyses should examine how patients with IPC differ from those receiving other forms of, or no, outpatient palliative care services.

Strengths of the study and of the use of SHI routine data are, in particular, the large number of cases and the exclusion of selection bias. Limitations include the fact that the analyses are based on secondary data from 2019 collected primarily for billing purposes. Quality of life, need for palliative care, and symptom burden of the insured patients cannot be determined from SHI data. Furthermore, selection bias due to this type of insured patient is also possible. It is also not apparent whether the coded diagnoses are comorbidities or the underlying life-limiting condition. Nevertheless, routine data are an important and increasingly utilized source of information in palliative care research.

Finally, it may be concluded that, until 2019, physicians comparatively rarely utilized IPC. Taking into account other study findings, it is clear that the demand for outpatient palliative care remains unmet (5). Reasons why IPC is provided rather infrequently and the impact of its introduction on other outpatient palliative care settings cannot be demonstrated from this analysis and should be determined in further studies.

Melissa Hemmerling, Jona Theodor Stahmeyer, Sabrina Schütte, Katharina van Baal, Stephanie Stiel

Funding

The study is part of the “Polite” project funded by the innovation fund of the Federal Joint Committee (grant number: 01VSF20028).

Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 21 March 2022, revised version accepted on 28 April 2022

Translated from the original German by Dr. Grahame Larkin, MD

Cite this as:

Hemmerling M, Stahmeyer JT, Schütte S, van Baal K, Stiel S:
The new type of outpatient palliative care—an analysis of routine data
from a statutory health insurance carrier after its introduction.
Dtsch Arztebl Int 2022; 119: 548–9. DOI: 10.3238/arztebl.m2022.0217

References

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2. Nationale Akademie der Wissenschaften Leopoldina: Palliativversorgung in Deutschland: Perspektiven für Praxis und Forschung. 1. Aufl. Halle (Saale) 2015. www.leopoldina.org/uploads/tx_leopublication/2015_Palliativversorgung_LF_DE.pdf (last accessed on 3 June 2022).

3. Kassenärztliche Bundesvereinigung, GKV-Spitzenverband: Vereinbarung nach § 87 Abs. 1b SGB V zur besonders qualifizierten und koordinierten palliativmedizinischen Versorgung. 2016. www.kbv.de/media/sp/Anlage_30_Palliativversorgung.pdf (last accessed on 3 June 2022).

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5. van Baal K, Stiel S, Hemmerling M, et al.: Ambulante Palliativversorgung in Niedersachsen – regionale Unterschiede in der Versorgung von Menschen am Lebensende anhand von Qualitätsindikatoren. Zentralinstitut für die kassenärztliche Versorgung in Deutschland (Zi). Versorgungsatlas-Bericht Nr. 21/04. Berlin 2021. https://doi.org/10.20364/VA-21.04 (last accessed on 3 June 2022).