Home ventilation patients: associations of having advance care plans with end-of-life healthcare utilisation.

Background: The Home Ventilation and Respiratory Support Service (HVRSS) at Tan Tock Seng Hospital's (TTSH) in Singapore manages patients with chronic, progressive neurological diseases requiring home ventilation support nation-wide. We examined prevalence of advance care plans (ACPs) among a cohort of decedent patients, available ACP information, and the relationship of having completed an ACP with healthcare utilisation [acute hospital (AH) admissions, cumulative AH length of stay (LOS), emergency department (ED) and HVRSS home visits], 90 days prior-to-death. We hypothesised that some HVRSS patients had ACPs, and HVRSS patients with and without ACPs potentially have differences in end-of-life healthcare utilisation outcomes. Methods: This was a retrospective cohort study. Patients were deceased by 2019, were discharged home with ≥1 HVRSS encounter and sufficient electronic medical documentation. We extracted healthcare utilisation outcomes, in the 90 days prior-to-death period, of: AH admissions, cumulative AH LOS, ED and HVRSS home visits. We subsequently linked out dataset to another database of ACP information, using unique identifiers, to determine whether study participants had completed an ACP during their lifetime. The factor of having completed ACPs (with and without) was incorporated into multiple regression analysis of outcomes. Results: Among 118 patients, 75 (63.6%) were male and mostly Chinese (84.7%), who had a mean HVRSS enrolment-age was 64.2 years [standard deviation (SD) =16.1 years] and were mostly diagnosed with motor neuron disease (47.5%). The prevalence of ACPs was (44.1%), with more being doctor-facilitated discussions (67.3%). Most discussions were conducted with subjects with or without family members (82.7%). Mean ACP-to-death duration was 1.6 years (SD =1.6). Compared to participants without ACP, the cumulative hospital LOS in the 3 months prior-to-death was at least 55% lower for participants with a completed ACP [ACP: mean =5.8, SD =11.0; No-ACP: mean =14.9, SD =25.3; internal rate of return (IRR): 0.38-0.53; P<0.001]. However, the number of home care visits was up to 54% higher for those with completed ACPs (ACP: mean =5.3, SD =4.4; No-ACP: mean =4.0; SD =4.2; IRR =1.27-1.88; P<0.001). No significant between-group differences in hospitalization (P=0.79), and ED visits were detected (P=0.14). Conclusions: This was the first known examination of ACP uprate among a nationally representative multi-ethnic group of home ventilation patients. ACP uptake appeared to be lower than similar studies conducted in other countries. The completion of ACP with higher home visits by a homecare team may have supported end-of-life care and reduced hospital LOS at end-of-life. ACPs can potentially be an important service-planning consideration for home ventilation patients.