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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 26 Research Studies DisplayedCzosek RJ, Anderson JB, Baskar S
Predictors and outcomes of heart block during surgical stage I palliation of patients with a single ventricle: a report from the NPC-QIC.
This study investigated patient and surgical risks of heart block and its effect on 12-month transplant-free survival in children with a single ventricle. In total, 1423 patients were identified from the National Pediatric Cardiology Improvement Collaborative with and without heart block. One-year outcomes were analyzed. A very small percentage (2%) developed heart block during their surgical admission. Associated risk factors for block included heterotaxy syndrome and atrial flutter/fibrillation. Patients with complete heart block had lower 12-month survival, which wasn’t true for patients with second degree block. At 12 months of age, 43% of patients with heart block died and were more likely to experience mortality than patients without heart block.
AHRQ-funded; HS021114.
Citation: Czosek RJ, Anderson JB, Baskar S .
Predictors and outcomes of heart block during surgical stage I palliation of patients with a single ventricle: a report from the NPC-QIC.
Heart Rhythm 2021 Nov;18(11):1876-83. doi: 10.1016/j.hrthm.2021.05.019..
Keywords: Children/Adolescents, Heart Disease and Health, Cardiovascular Conditions, Surgery, Palliative Care, Risk, Outcomes
Kaufmann TL, Getz KD, Hsu JY
Identification of patient-reported outcome phenotypes among oncology patients with palliative care needs.
This retrospective study used patient-reported outcome (PRO) data to characterize oncology patients with palliative care needs. The objective was to determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. Self-reported symptoms were collected on the Edmonton Symptom Assessment Symptom from solid tumor oncology patients (n = 745) referred to outpatient palliative care at eight community and academic sites from October 2012 to October 2018. The authors identified four PRO phenotypes: low symptoms (39.6%); moderate pain/fatigue + mood (24.2%); moderate pain/fatigue + appetite + dypsnea (27%); and high symptoms (9.3%). A secondary analysis of 421 patients found that two brief items assessing social and existential needs aligned with higher severity symptoms and psychological distress phenotypes.
AHRQ-funded; HS023681.
Citation: Kaufmann TL, Getz KD, Hsu JY .
Identification of patient-reported outcome phenotypes among oncology patients with palliative care needs.
JCO Oncol Pract 2021 Oct;17(10):e1473-e88. doi: 10.1200/op.20.00849..
Keywords: Cancer, Palliative Care, Patient-Centered Outcomes Research, Outcomes
Enzinger AC, Ghosh K, Keating NL
US trends in opioid access among patients with poor prognosis cancer near the end-of-life.
This study looked at trends in opioid prescriptions for cancer patients near the end-of-life (EOL) defined as the 30 days before death or hospice enrollment. The authors looked at Medicare part D data from 2007 to 2017 for 270,632 Medicare fee-for-service decedents with poor prognosis cancers. During that time, the proportion of decedents with poor prognosis cancers receiving 1 or greater opioid prescriptions near EOL declined 15.5% and the proportion receiving 1 or greater long-acting opioid prescriptions declined 36.5% to 18.1%. The mean daily dose fell from 24.5%, from 85.6 morphine milligram equivalents per day (MMED) to 64.6. The total amount of opioids prescribed fell from 1,075 morphine milligram equivalents per decedent to 666 morphine milligram equivalents per decedents. At the same time, the proportion of patients with pain-related ED visits increase 50.8% from 13.2% to 19.9%.
AHRQ-funded; HS024072.
Citation: Enzinger AC, Ghosh K, Keating NL .
US trends in opioid access among patients with poor prognosis cancer near the end-of-life.
J Clin Oncol 2021 Sep 10;39(26):2948-58. doi: 10.1200/jco.21.00476..
Keywords: Cancer, Opioids, Palliative Care, Pain, Access to Care, Medication, Practice Patterns
Wells R, Dionne-Odom JN, Azuero A
Examining adherence and dose effect of an early palliative care intervention for advanced heart failure patients.
The objective of this study was to examine the "dose" effect of PC intervention completion vs. noncompletion on quality of life (QoL) and healthcare use in patients with advanced heart failure (HF) over 32 weeks. The investigators concluded that higher intervention completion rates of an early PC intervention was associated with QoL improvements in patients with advanced HF.
AHRQ-funded; HS013852.
Citation: Wells R, Dionne-Odom JN, Azuero A .
Examining adherence and dose effect of an early palliative care intervention for advanced heart failure patients.
J Pain Symptom Manage 2021 Sep;62(3):471-81. doi: 10.1016/j.jpainsymman.2021.01.136..
Keywords: Palliative Care, Heart Disease and Health, Cardiovascular Conditions, Quality of Life, Telehealth, Health Information Technology (HIT)
Wells RD, Guastaferro K, Azuero A
Applying the multiphase optimization strategy for the development of optimized interventions in palliative care.
This article provides a brief overview and application of Multiphase Optimization Strategy, a framework informed by engineering principles, that uses a systematic process to empirically identify an intervention comprised of components that positively contribute to desired outcomes under real-life constraints. The paper includes the authors’ insights from conducting a pilot factorial trial of an early palliative care intervention to enhance the decision support skills of advanced cancer family caregivers (Project CASCADE).
AHRQ-funded; HS013852.
Citation: Wells RD, Guastaferro K, Azuero A .
Applying the multiphase optimization strategy for the development of optimized interventions in palliative care.
J Pain Symptom Manage 2021 Jul;62(1):174-82. doi: 10.1016/j.jpainsymman.2020.11.017..
Keywords: Palliative Care, Research Methodologies
Bogetz JF, Revette A, DeCourcey DD
Clinical care strategies that support parents of children with complex chronic conditions.
This paper examines the best clinical care strategies that support parents of children with complex chronic conditions facing inpatient and end-of-life care in the ICU. Qualitative analysis of 21 open-response items from the cross-sectional “Survey of Caring for Children with Complex Chronic Conditions” was done. Open-ended responses from 110 of 114 survey respondents who were parents of children who received care at a large academic institution and died between 2006 and 2015 were analyzed. Most of the children had congenital/chromosomal complex chronic conditions and had died an average of 3.9 years prior to their parents’ study participation. The respondents emphasized the relational aspects of clinical care including inclusivity of their expertise on their child’s needs, recognition of their unique experiences as parents, and maintenance of connection with clinicians through bereavement.
AHRQ-funded; HS022986.
Citation: Bogetz JF, Revette A, DeCourcey DD .
Clinical care strategies that support parents of children with complex chronic conditions.
Pediatr Crit Care Med 2021 Jul;22(7):595-602. doi: 10.1097/pcc.0000000000002726..
Keywords: Children/Adolescents, Chronic Conditions, Palliative Care, Inpatient Care
Lee K, Gani F, Canner JK
Racial disparities in utilization of palliative care among patients admitted with advanced solid organ malignancies.
The primary objective of this study was to describe racial differences in the use of inpatient palliative care consultations (IPCC) for patients with advanced cancer who are admitted to a hospital in the United States. Hospital admissions of patients with advanced cancers were identified through the National Inpatient Dataset. Findings showed that death during hospitalization was a significant modifier of the relationship between race and receipt of palliative care consultation. There were significant racial disparities in the utilization of IPCC for patients with advanced cancer.
AHRQ-funded; HS024736.
Citation: Lee K, Gani F, Canner JK .
Racial disparities in utilization of palliative care among patients admitted with advanced solid organ malignancies.
Am J Hosp Palliat Care 2021 Jun;38(6):539-46. doi: 10.1177/1049909120922779..
Keywords: Healthcare Cost and Utilization Project (HCUP), Palliative Care, Cancer, Disparities, Racial and Ethnic Minorities, Healthcare Utilization, Inpatient Care, Chronic Conditions
Sedhom R, Nudotor R, Freund KM
Can community health workers increase palliative care use for African American patients? A pilot study.
African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer. The investigators concluded that utilization of CHWs to address PC domains and social determinants of health was feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.
AHRQ-funded; HS024736.
Citation: Sedhom R, Nudotor R, Freund KM .
Can community health workers increase palliative care use for African American patients? A pilot study.
JCO Oncol Pract 2021 Feb;17(2):e158-e67. doi: 10.1200/op.20.00574..
Keywords: Palliative Care, Community-Based Practice, Racial and Ethnic Minorities
Orth J, Li Y, Simning A
End-of-life care among nursing home residents with dementia varies by nursing home and market characteristics.
This study’s objectives were to examine variations in end-of-life (EOL) care/outcomes among decedents with Alzheimer's disease/related dementias (ADRD) and to identify associations with nursing home (NH)/market characteristics. Findings showed that decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Recommendations included modifications to state Medicaid NH payments to promote better EOL care/outcomes and future research to understand NH care practices associated with presence of Alzheimer's units in order to identify mechanisms possibly promoting higher-quality EOL care.
AHRQ-funded; HS024923.
Citation: Orth J, Li Y, Simning A .
End-of-life care among nursing home residents with dementia varies by nursing home and market characteristics.
J Am Med Dir Assoc 2021 Feb;22(2):320-28.e4. doi: 10.1016/j.jamda.2020.06.021..
Keywords: Elderly, Palliative Care, Dementia, Nursing Homes, Long-Term Care
Kamal AH, Check DK, Bull J
Associations of patient characteristics and care setting with complexity of specialty palliative care visits.
Information routinely collected during a palliative care consultation request may help predict the level of complexity of that patient encounter. In this retrospective cohort analysis, the investigators examined whether patient and consultation characteristics, as captured in consultation requests, were associated with the number of unmet palliative care needs that emerge during consultation, as an indicator of complexity.
AHRQ-funded; HS023681.
Citation: Kamal AH, Check DK, Bull J .
Associations of patient characteristics and care setting with complexity of specialty palliative care visits.
J Palliat Med 2021 Jan;24(1):83-90. doi: 10.1089/jpm.2020.0149..
Keywords: Palliative Care
Quigley DD, McCleskey SG
Improving care experiences for patients and caregivers at end of life: a systematic review.
End-of-life care is increasing as the US population ages. Approaches to providing high-quality end-of-life care vary across setting, diseases, and populations. Several data collection tools measure patient and/or caregiver care experiences at end of life and can be used for quality improvement. Previous reviews examined palliative care improvements or available measures but none explicitly on improving care experiences. In this study, the researchers reviewed literature on improving patient and/or caregiver end-of-life care experiences.
AHRQ-funded; HS025920.
Citation: Quigley DD, McCleskey SG .
Improving care experiences for patients and caregivers at end of life: a systematic review.
Am J Hosp Palliat Care 2021 Jan;38(1):84-93. doi: 10.1177/1049909120931468..
Keywords: Palliative Care, Caregiving, Patient Experience, Quality Improvement, Quality of Care
Rhodes RL, Ukoha NCE, Williams KA
Understanding underuse of advance care planning among a cohort of African American patients with advanced cancer: formative research that examines gaps in intent to discuss options for care.
Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans. This study assessed the impact of stage of intent to discuss ACP options as key potential barriers. The investigators concluded that despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low.
AHRQ-funded; HS022418.
Citation: Rhodes RL, Ukoha NCE, Williams KA .
Understanding underuse of advance care planning among a cohort of African American patients with advanced cancer: formative research that examines gaps in intent to discuss options for care.
Am J Hosp Palliat Care 2019 Dec;36(12):1057-62. doi: 10.1177/1049909119843276..
Keywords: Cancer, Palliative Care, Patient-Centered Healthcare, Racial and Ethnic Minorities
Makam AN, Tran T, Miller ME
The clinical course after long-term acute care hospital admission among older Medicare beneficiaries.
Investigators sought to examine the clinical course after long-term acute care (LTAC) admission. They found that hospitalized older adults transferred to LTAC hospitals had poor survival, spent most of their remaining life as an inpatient, and frequently underwent life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and to prioritize healthcare needs for these adults. Given the exceedingly low rates of palliative care consultations, they recommend future research to examine unmet palliative care needs in this population.
AHRQ-funded; HS022418.
Citation: Makam AN, Tran T, Miller ME .
The clinical course after long-term acute care hospital admission among older Medicare beneficiaries.
J Am Geriatr Soc 2019 Nov;67(11):2282-88. doi: 10.1111/jgs.16106..
Keywords: Elderly, Medicare, Palliative Care, Patient-Centered Outcomes Research, Outcomes, Care Management, Healthcare Delivery
Kukulka K, Washington KT, Govindarajan R
Stakeholder perspectives on the biopsychosocial and spiritual realities of living with ALS: implications for palliative care teams.
The purpose of this study was to generate a rich description of the realities of living with amyotrophic lateral sclerosis (ALS), equipping palliative care teams with an in-depth understanding of the experiences and needs of patients with ALS and their family caregivers. Study findings illustrated the intricacies of living with ALS and the importance of eliciting individualized values when caring for patients with ALS and their families. The investigators concluded that the complex biopsychosocial needs experienced by patients and family caregivers suggested numerous opportunities for meaningful palliative care involvement.
AHRQ-funded; HS022140.
Citation: Kukulka K, Washington KT, Govindarajan R .
Stakeholder perspectives on the biopsychosocial and spiritual realities of living with ALS: implications for palliative care teams.
Am J Hosp Palliat Care 2019 Oct;36(10):851-57. doi: 10.1177/1049909119834493..
Keywords: Palliative Care, Patient-Centered Outcomes Research, Neurological Disorders, Patient-Centered Healthcare, Patient and Family Engagement, Caregiving
Iyer AS, Dionne-Odom JN, Ford SM
A formative evaluation of patient and family caregiver perspectives on early palliative care in chronic obstructive pulmonary disease across disease severity.
Investigators sought to identify patient and family caregiver early palliative care needs across stages of chronic obstructive pulmonary disease (COPD) severity. They conducted their study as part of the Medical Research Council Framework developmental phase for intervention development. Their results showed that patients with moderate to very severe COPD and their family caregivers found early palliative care acceptable and felt it should be integrated before end-stage. Of the five broad themes of early palliative care needs, coping with COPD and emotional symptoms were the highest priority, followed by respiratory symptoms, illness understanding, and prognostic awareness.
AHRQ-funded; HS023009.
Citation: Iyer AS, Dionne-Odom JN, Ford SM .
A formative evaluation of patient and family caregiver perspectives on early palliative care in chronic obstructive pulmonary disease across disease severity.
Ann Am Thorac Soc 2019 Aug;16(8):1024-33. doi: 10.1513/AnnalsATS.201902-112OC..
Keywords: Caregiving, Palliative Care, Respiratory Conditions
Kamal AH, Wolf SP, Troy J
Policy changes key to promoting sustainability and growth of the specialty palliative care workforce.
The authors used 2018 clinician survey data to model risk factors associated with palliative care clinicians leaving the field early. Their modeling revealed an impending "workforce valley." They recommended policies that support high-value, team-based palliative care through expansion in all segments of the specialty palliative care workforce, combined with payment reform to encourage the deployment of sustainable teams.
AHRQ-funded; HS023681.
Citation: Kamal AH, Wolf SP, Troy J .
Policy changes key to promoting sustainability and growth of the specialty palliative care workforce.
Health Aff 2019 Jun;38(6):910-18. doi: 10.1377/hlthaff.2019.00018..
Keywords: Palliative Care, Policy, Provider, Teams, Workforce
Armstrong MJ, Alliance S, Taylor A
End-of-life experiences in dementia with Lewy bodies: qualitative interviews with former caregivers.
This study examined the knowledge of former caregivers of patients with dementia with Lewy bodies (DLB) and the patients’ end of life (EOL) experiences. Telephone interviews were conducted with a total of 30 caregivers and family members of individuals who died with DLB in the last 5 years. The interviews revealed a lack of knowledge regarding what to expect, EOL time course, advance care planning, medications at the end of life, approaching end of life, and the death experience itself.
AHRQ-funded; HS024159.
Citation: Armstrong MJ, Alliance S, Taylor A .
End-of-life experiences in dementia with Lewy bodies: qualitative interviews with former caregivers.
PLoS One 2019 May 30;14(5):e0217039. doi: 10.1371/journal.pone.0217039..
Keywords: Palliative Care, Dementia, Neurological Disorders, Caregiving
Hadler RA, Goldstein NE, Bekelman DB
"Why would i choose death?": a qualitative study of patient understanding of the role and limitations of cardiac devices.
The aim of this study was to assess perceptions of cardiac devices in patients with heart failure and how these perceptions impacted advance care planning and future expectations. The investigators found that patients, in their sample, with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.
AHRQ-funded; HS022989.
Citation: Hadler RA, Goldstein NE, Bekelman DB .
"Why would i choose death?": a qualitative study of patient understanding of the role and limitations of cardiac devices.
J Cardiovasc Nurs 2019 May/Jun;34(3):275-82. doi: 10.1097/jcn.0000000000000565..
Keywords: Cardiovascular Conditions, Heart Disease and Health, Mortality, Palliative Care
Kamal AH, Bowman B, Ritchie CS
Identifying palliative care champions to promote high-quality care to those with serious illness.
This article discusses the shortage of palliative care specialists in the United States now and in the future. In 2010, the shortage quantified as anywhere from 6000 to 18,000 palliative care physicians. Projections to 2030 do not show that the workforce will increase by that time. The authors suggest the use of “Palliative Care Champions” who are physicians with basic palliative care training.
AHRQ-funded; HS023681.
Citation: Kamal AH, Bowman B, Ritchie CS .
Identifying palliative care champions to promote high-quality care to those with serious illness.
J Am Geriatr Soc 2019 May;67(S2):S461-s67. doi: 10.1111/jgs.15799..
Keywords: Palliative Care, Quality of Care, Provider: Clinician, Provider: Physician
Ray EM, Riedel RF, LeBlanc TW
Assessing the impact of a novel integrated palliative care and medical oncology inpatient service on health care utilization before hospice enrollment.
The goal of this retrospective cohort study was to assess the impact of integrating specialist palliative care (PC) on health care utilization among hospitalized cancer patients before hospice enrollment. Patients in the solid tumor inpatient unit who were discharged to hospice pre- and post-integration were compared on the following outcomes: intensive care unit days, invasive procedures, subspecialty consultations, radiographic studies, hospital length of stay, and use of chemotherapy or radiation. Health care utilization was relatively low in both groups, and researchers found no significant differences in utilization between the two groups. They conclude that PC integration may not impact health care utilization during the final hospitalization before discharge to hospice, which may reflect the greater benefits of integrating PC farther ‘upstream’ from the final hospitalization.
AHRQ-funded; HS000032.
Citation: Ray EM, Riedel RF, LeBlanc TW .
Assessing the impact of a novel integrated palliative care and medical oncology inpatient service on health care utilization before hospice enrollment.
J Palliat Med 2019 Apr;22(4):420-23. doi: 10.1089/jpm.2018.0235..
Keywords: Cancer, Healthcare Utilization, Inpatient Care, Palliative Care
Johnston FM, Neiman JH, Parmley LE
Stakeholder perspectives on the use of community health workers to improve palliative care use by African Americans with cancer.
This study focused on the issue of lack of palliative care for African-Americans with cancer. Stakeholder interviews and focus groups were conducted with cancer patients, caregivers, health care administrators, oncologists, and community health workers (CHWs). Participants felt that CHWs could play a central role in bridging patients with their providers, information and resources. They also felt that CHWs should either come from the community, or be familiar with the history, culture, and norms of the communities from which they operate.
AHRQ-funded; HS024736.
Citation: Johnston FM, Neiman JH, Parmley LE .
Stakeholder perspectives on the use of community health workers to improve palliative care use by African Americans with cancer.
J Palliat Med 2019 Mar;22(3):302-06. doi: 10.1089/jpm.2018.0366..
Keywords: Access to Care, Cancer, Healthcare Delivery, Healthcare Utilization, Cultural Competence, Disparities, Palliative Care, Racial and Ethnic Minorities
Armstrong MJ, Alliance S, Corsentino P
Cause of death and end-of-life experiences in individuals with dementia with Lewy bodies.
Researchers investigate the natural history, cause of death, and end-of-life experiences of individuals diagnosed with dementia with Lewy bodies (DLB). In the 20-question survey, respondents indicated that physicians rarely discussed what to expect at the end of life and that the caregiver usually initiated such conversations. Failure to thrive was the most common cause of death, followed by pneumonia and swallowing difficulties, other medical conditions, and complications from falling. The researchers conclude that the study results highlight a critical need for better prognostic counseling and education for persons and families living with DLB, and they recommended further study.
AHRQ-funded; HS024159.
Citation: Armstrong MJ, Alliance S, Corsentino P .
Cause of death and end-of-life experiences in individuals with dementia with Lewy bodies.
J Am Geriatr Soc 2019 Jan;67(1):67-73. doi: 10.1111/jgs.15608..
Keywords: Dementia, Neurological Disorders, Patient Experience, Palliative Care, Mortality, Elderly
Deutsch GB, Deneve JL, Al-Kasspooles MF
Intellectual equipoise and challenges: accruing patients with advanced cancer to a trial randomizing to surgical or nonsurgical management (SWOG S1316).
Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). In this paper, the authors report their experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. Accrual is ongoing. Experience gained from the S1316 study can aid future palliative care trials. They note that it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.
AHRQ-funded; HS021491.
Citation: Deutsch GB, Deneve JL, Al-Kasspooles MF .
Intellectual equipoise and challenges: accruing patients with advanced cancer to a trial randomizing to surgical or nonsurgical management (SWOG S1316).
Am J Hosp Palliat Care 2020 Jan;37(1):12-18. doi: 10.1177/1049909119851471..
Keywords: Cancer, Surgery, Comparative Effectiveness, Palliative Care
Knox-Rice T, Xuan L, Wadsworth H
Knox-Rice T, Xuan L, Wadsworth H, Halm EA, Rhodes RL. Examining the association between healthcare utilization and clinical characteristics among cancer patients in a safety net health system.
The goal of this study was to examine the association between available patient and clinical characteristics and healthcare utilization in a cohort of breast, lung, and colorectal cancer patients within a safety-net hospital system. The investigators found that some patient and clinical characteristics associated with increased ER visits and hospitalizations in this cohort included race/ethnicity, palliative care referral, markers of advanced disease, and number opioids prescribed.
AHRQ-funded; R24 HS022418.
Citation: Knox-Rice T, Xuan L, Wadsworth H .
Knox-Rice T, Xuan L, Wadsworth H, Halm EA, Rhodes RL. Examining the association between healthcare utilization and clinical characteristics among cancer patients in a safety net health system.
J Palliat Med 2019 Jan;22(1):80-83. doi: 10.1089/jpm.2018.0202..
Keywords: Cancer, Healthcare Utilization, Palliative Care, Hospitals
Wang D, Ing C, Blinderman CD
Latent class analysis of specialized palliative care needs in adult intensive care units from a single academic medical center.
The purpose of this study was to use latent class analysis to separate ICU patients into different classes of palliative care needs, and to determine if these classes differ in their resource requirements. Using information from ICU patients who received specialized palliative care, researchers extracted reason(s) for consultation from the initial note and entered it into a latent class analysis model to generate mutually exclusive patient classes. Four classes were identified: Pain and Symptom Management, Goals of Care and Advance Directives (GCAD), All Needsand Supportive Care. GCAD patients were least likely to be high utilizers.
AHRQ-funded; HS022941.
Citation: Wang D, Ing C, Blinderman CD .
Latent class analysis of specialized palliative care needs in adult intensive care units from a single academic medical center.
J Pain Symptom Manage 2019 Jan;57(1):73-78. doi: 10.1016/j.jpainsymman.2018.10.270..
Keywords: Care Management, Inpatient Care, Intensive Care Unit (ICU), Palliative Care