Evaluation of a continuous quality improvement initiative for end-of-life care for older noncancer patients.

OBJECTIVES The burden of suffering among patients with end-stage chronic diseases may be greater than those of cancer patients, as a result of longer duration of illness trajectory and high prevalence of symptoms, yet they may be less likely to receive palliative care services. To improve the quality of care of these patients, we carried out a continuous quality improvement initiative among medical and nursing staff of a convalescent facility. DESIGN Evaluation of a quality improvement initiative. SETTING Nonacute institution in Hong Kong SAR, China. PARTICIPANTS The participants were patients with advanced chronic diseases not opting for active treatment. INTERVENTION The intervention was a continuous quality improvement process carried out over a 3-month period, consisting of service reengineering, provision of guidelines and educational material, and interactive sessions to achieve culture change among staff. Evaluation before and after the intervention included patient symptoms checklist and quality-of-life measures for patients; quality-of-life and cost-of-care index for family members; quality-of-life and carer burden for staff; and use of various health care services. RESULTS There were 80 and 89 participants in the pre- and post-intervention phase. The initiative resulted in shorter duration of stay, fewer investigations, fewer transfers back to the affiliated acute care hospital, and more follow-up by the outreach team, with no significant difference in mortality after adjusting for age and comorbidity. Symptoms of pain and cough were reduced, while there was a trend toward more constipation but less dizziness. Family members' satisfaction improved. CONCLUSIONS It is possible to improve quality-of-life care for elderly patients with end-stage chronic diseases by staff education, and culture and system change, not only without additional resources, but likely savings were achieved in terms of reduced use of health care resources.