Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study

Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study Kevin Schutzbach, Yann Corminboeuf, Beate Wild, Dieter Schellberg, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4058171/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Context: Palliative car aims to provide comprehensive care, since end of life can be marked by somatic, psycho-social and spiritual distress, requiring interdisciplinary care. However, interdiscoplinary care is costly, and palliative care services, as all other medical services, get under pressure to be as cost-effective as possible. Objectives To describe the case complexity of palliative care inpatients, to evaluate possible correlations between complexity and provision of care and to identifycomplexity subgroups. Methods Patients (N = 222) hospitalized in a specialized palliative care unit (Switzerland) were assessed regarding their biopsychosocial case complexity by means of the INTERMED. Based on a chart review, INTERMED scores were determined at admission and the end of hospitalization/death. Descriptive statistics and Pearson correlation coefficients were estimated for the association between biopsychosocial case complexity and amount and type of care provided. A principal component analysis (PCA) was conducted to explain variance and to identify patient subgroups. Results Almost all patients (98.7 %) qualified as complex as indicated by the INTERMED. Provision of care correlated positively (r=0.23, p=0.0008) with the INTERMED scores upon admission. The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p=0.0001). PCA performed with two factors explained 49% of the total variance and identified two subgroups which differed regarding the psychosocial item scores of the INTERMED. Conclusion Specialized palliative care inpatients show the highest complexity score of all populations assessed up to now with the INTERMED. Correlations between biopsychosocial complexity and care provided, and between care and decrease of complexity scores, can be considered as an indicator for care efficiency. Patient subgroups with specific needs (psychosocial burden) suggest that palliative care teams need specialized staff. Trial registration The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud (CER-VD 2023-01200). “INTERMED” “palliative care” “case complexity” “biopsychosocial” “interdisciplinary” “economicity” Figures Figure 1 Figure 2 Key message Provision of palliative care correlates with case complexity and is effective. Introduction Palliative care, based on the biopsychosocial model of disease ( 1 ), enlarged by the spiritual dimension ( 2 ), aims to provide holistic care ( 3 – 7 ). Since cure is no longer possible ( 7 , 8 ), palliative care patients evolve towards death ( 9 , 10 ), often affected by both somatic ( 11 – 15 ) and psychiatric morbidities ( 16 – 18 ), as well as by social problems ( 19 – 22 ). The vast majority of palliative care patients suffer from cancer ( 10 ) and the therapeutic objective is often limited to a temporary stabilization of their condition and relief of symptoms ( 23 ). Especially the end of life can be marked by somatic, psycho-social ( 20 ) and spiritual distress ( 16 ), often requiring hospitalization and interdisciplinary and interprofessional care ( 7 ). To the best of our knowledge, only one study using the INTERMED to assess the biopsychosocial case complexity has been conducted in the palliative care setting: conducted almost twenty years ago, this study included inpatients of a University hospital, for whom palliative care consultation were requested ( 24 ). The study showed biopsychosocial heterogeneity of the sample and concluded that the INTERMED could be a useful tool to comprehensively assess patients’ health care needs and to tailor interdisciplinary interventions. However, over the last twenty years, palliative care has evolved and has become - as any other medical discipline - pressured to be as cost-effective as possible. The ambition of a holistic approach of palliative care implies that care is based on an interdisciplinary and interprofessional approach, considered to respond to the needs of this patient population. The question, however, policy makers and insurance companies have raised is: is this expensive approach really needed and is it efficient ( 25 , 26 )? Moreover, there has been a call in a recent narrative review on the evidence of the economic value of end-of-life palliative care interventions for greater consistency in reporting outcome measures and costs associated with hospice care ( 27 ). This study has been conducted with this economic background issues in mind. Aim of the study: The main objective of this study was to describe the biopsychosocial complexity of specialized palliative care inpatients and to compare their complexity prevalence with other populations. Secondary objectives were to determine if a correlation exists between case complexity and amount of interdisciplinary care provided, and if complexity subgroups of patients with different health care needs can be identified. Methods Setting The Rive-Neuve specialized palliative care hospice, founded in 1988, is located in the French-speaking Canton of Vaud, in Western Switzerland, and can accommodate 20 inpatients. Admissions aredocumented in a file reviewed by a nurse, who is specialized in palliative care. Referrals are made by neighbouring hospitals or by the physicians of the mobile palliative home care team. Indications for hospitalization are the palliative situation of the patient, especially when symptoms are present, which are difficult to managesuch as pain, anxiety or dyspnea. In 2019, 222 patients were admitted; all of them were included in this study, since the documentation of all charts allowed the scoring with the INTERMED. The study period corresponds to the habitual situation, prior to the Covid pandemic. The staff consists of a multidisciplinary team of nurses, physiotherapists, an occupational therapist, an art therapist, a chaplain, about fifty volunteers, physicians, psychologists, psychiatrists, and administrative personal. The study was accepted by the ethics committee of the Canton of Vaud (CER-VD 2023 − 01200) - based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research. Given the aim of the study, no medical data were recorded. Comparison was intended only on a populational level or with regard to setting (e.g., palliative care patients versus patients affected by obesity). Since this is a descriptive study, we decided to include a whole year of admissions. Assessment instruments The study was based on a retrospective medical chart review. Sociodemographic and medical data, as well as patient symptom assessments with the ESAS (Edmonton Symptom Assessment System) were retrieved from the charts (28). Biopsychosocial case complexity was assessed by means of the INTERMED. The INTERMED is a reliable and valid instrument to evaluate patients’ case complexity by taking into account their biopsychosocial situation and the complexity of their interactions with the care system ( 29 , 30 ). The 20 items rated by the INTERMED are shown in the Appendix. Developed in 1995 ( 31 ), numerous studies have been conducted with the INTERMED in different countries, and different health care settings and patient populations. These studies have consistently shown - for example in low back pain ( 32 , 33 ), chronic shoulder pain ( 34 ), diabetes ( 35 ), or internal medicine ( 36 ) - that the INTERMED identifies complex patients who have a less favorable response to medical treatments ( 37 , 38 ). Moreover, early and targeted psychosocial interventions in complex patients identified by means of the INTERMED have demonstrated beneficial effects with regard to medical and psychological outcomes, as well as health care utilization ( 39 , 40 ). The INTERMED can be scored by means of a semi-structured interview, a self-assessment or retrospectively based on patient charts ( 41 ). Retrospective chart-based rating has been proved to be reliable: in a previous study: interrater reliability of retrospective ratings reached an intra class correlation (ICC) of 0.91 (41). The INTERMED is composed of three columns for each domain (biological, psychological, social and healthcare system domain) (see Fig. 1 ). The first column refers to the past (history), the second to the present (current state) and the third to the future (prognosis). Two items in the past and present domains and one items in the future domain are rated with a score ranging from 0 (no complexity) to 3 (indicating the highest level of complexity). Each domain can thus reach a score of 15, with a total INTERMED score of 60. A score ≥ 21 is considered as indicating biopsychosocial complexity ( 42 ). The amount of interdisciplinary palliative care interventions – without the care provided by medical doctors and nurses – was documented by the routine registration of minutes per patient spent by the different care professionals for 211 of the 222 patients (for 11 patients data were missing). All patients in Rive-Neuve are equally cared for by physicians and nurses, as in other medical settings. Therefore, care minutes calculated in this study only relates to the additional support provided by psychologists and psychiatrists, the chaplain, physiotherapists and occupational therapists, dietitians, social workers, hypnotherapy nurses, and others. The time spent with patients by volunteers was not collected and is therefore not taken into account in the calculations. Statistical Analysis Initially, descriptive statistics for the INTERMED total and domain scores were conducted for admission and the end of the stay (death or end of hospitalization). Differences between groups were analyzed using t-tests for independent or dependent groups. Percentages were calculated to estimate the prevalence of patients with complex health care needs. Correlations between the INTERMED change scores calculated by INTERMED T2-T1 and amount of palliative care provision were estimated by calculating Pearson’s correlation coefficients. Hierarchical cluster analysis was conducted, to investigate if the sample might consist of clearly distinct subgroups. It was worked out thoroughly using several criteria to check for the existence of more than one main cluster. However, cluster analysis - as a relatively rough method to determine clusters - did not result in easily separable groups. To further investigate the main sources of variance with respect to the INTERMED items, we conducted a principal component analysis (PCA). Results identified two factors with an Eigenvalue > 1 with one main factor ( 1 ) explaining 35.5% and the second factor ( 2 ) explaining 13.5% of the variance. For all 20 items of the INTERMED, the factor loadings were calculated. Items with a high positive factor loading on the main Factor 1 were related to psychological or social health care needs (see Appendix). Results All charts allowed to score the INTERMED items at admission and discharge (N = 62) or death (N = 160). Sociodemographic and administrative data Table 1 shows the sociodemographic and administrative data of the sample. Table 1 Sociodemographic and administrative data N % Gender Female 112 50.45 Male 110 49.55 Outcome Discharged Home 62 27.93 Died 160 72.07 Number of stays One stay 209 94.14 Two stays 12 5.4 Three stays 1 0.46 Mean Value (SD) [Range] Age 69 [31–100] Length of stay (days) 22.4 [1–115] Patients’ case complexity Mean INTERMED score at admission was 31 (standard deviation, 5; range 19–46), and 31 (standard deviation, 5; range 13–43) at discharge or death. INTERMED scores at admission did not differ significantly between discharged patients and patients who died (t(220)= -1.13; p = 026). Nearly all patients (n = 219, 98.7%) had an INTERMED score ≥ 21 and thus qualified as complex. Regarding the INTERMED domain scores (biological, psychological, social, health care system), 42.5% of the total score was due to the biological, 23% to the social, 19% to the psychological, and 15.5% to the health care domain. Provided health care Of the 222 patients, 11 had missing data and 4 stayed so shortly that they could not receive specific palliative care (there are no therapists at weekends apart from the nurses and the physicians on duty), which reduces the sample, regarding care interventions to 207 patients. Information regarding additional care for patients (number of patients) and amount of care per patient (in minutes) is provided in Table 2 . “Interviews (staff)” relates to time taken by nurses during their working hours to talk with patients who wished specifically to talk. Table 2 Number of patients benefiting from additional car and amount of care per patient Interventions Number of Patients Average Duration (minutes) Duration Range (minutes) Total Care 207 388 5–2876 Psychotherapists 201 152 5–1111 Physiotherapists 136 169 5–905 Chaplain 153 65 5–735 Interviews (staff) 186 44 5–425 Dietitians 132 47 5–245 Social Workers 17 89 10–315 Nurse hypnosis 3 145 60–195 Others 17 23 5–75 Provided amount of care correlated significantly with the total INTERMED score at admission (r = 0.23, p = 0.0008): patients with higher biopsychosocial complexity received more interdisciplinary care. The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p = 0.0001). Identification of subgroups PCA revealed two factors with one main factor explaining a high amount of variance. For all patients, an individual score for this main factor 1 was computed resulting in either a score ≤ 0 or > 0. Subsequently, the patients were divided in two subgroups according to this score: subgroup 1 includes n = 121 patients and is related to a factor 1 score > 0 (red points) whereas patients of subgroup 2 (n = 101) have a factor score ≤ 0 (blue points, see Fig. 2 ). According to the factor loadings patients with a score > 0 should be psychosocially more burdened compared to patients with a score ≤ 0. Figure 2 shows the mean values of these two subgroups for each of the INTERMED items. Mean values are similar in the two subgroups regarding items 1, 2, 7, 9, 13, 15, 16, 17. However, regarding items 3, 4, 6, 12, and 18, subgroup 2 shows consistently lower mean values compared to subgroup 1. All these items reflect the past, current, or future psychological or social complexity of the patients. Subgroup 1 could thus be described as highly complex with a heavy psychosocial burden, whereas subgroup 2 as highly complex regarding biological (somatic) aspects and less psychosocially burdened. The total amount of received interdisciplinary care differed significantly between the two groups (subgroup 1: mean = 452.6, SD = 463.8; subgroup 2: 293.6, SD = 277.5; t 209 = 2.94; p < 0.0001). Specifically, the amount of received additional psychiatric and social care was significantly higher for subgroup 1 compared to subgroup 2 (psychiatric care: mean = 181.1 (205.2) vs.101.8 (121.6), t 209 = 3.32, p < 0.0001; social care: mean = 48.9 (65.9) vs. 27.0 (25.8), t 209 = 3.06; p < 0.0001). Discussion We will first discuss the results and then situate our study within the literature on economic aspects of palliative care. While patient populations may differ between palliative care inpatient units, the mortality rate of our study population is similar to those of other palliative care inpatient units ( 43 ). Regarding the prevalence of case complexity, almost all patients showed an INTERMED score above 21, which is a three times higher prevalence than the prevalence found in patients with chronic disease ( 38 , 41 ). This population’s extraordinarily high biopsychosocial complexity, which remains stable over the course of the hospital stay, justifies interdisciplinary care and associated human resources. There is no significant difference in complexity scores at admission between patients who will be discharged and those who will die, which indicates that care cannot be guided by means of the INTERMED or targeted upon admission, as suggested in the discussion of the first study using the INTERMED in a population referred to palliative care consultations ( 24 ). Regarding specific domains of complexity, the somatic symptom burden (biological domain) unsurprisingly contributes most to the total case complexity. However, the social and psychological complexity domain equal together the contribution of the biological domain, which again demonstrates the need for interdisciplinary care taking into account the psychosocial suffering of patients in need of palliative care. Moreover, there is a correlation between the INTERMED, and the amount of care provided, which increases with increased case complexity of the patients. Moreover, changes in the INTERMED scores correlate negatively with provided care. Care thus reduced health care needs during stay, demonstrating that interdisciplinary interventions seem to be efficient. Our first approach to identify different patient groups by means of a cluster analysis did not lead to a statistically good fitting cluster result. Only when applying the more sophisticated PCA two factors were identified, with one main factor explaining a high amount of variance and the two subgroups differing markedly regarding the amount of psychosocial burden. The finding that the psychosocially heavy burdened subgroup received significantly more psychosocial care underlines again the need of an interdisciplinary team with specialists such as psychiatrists and psychologists, social workers, chaplains and physiotherapists, occupational and art therapists. Our study is situated within the body of studies investigating economic aspects of palliative care. A recent study has shown that palliative care intervention at the end of life reduces healthcare costs, mostly when it is home-based; however hospice-based intervention significantly reduces costs ( 27 ). Another study attempted to quantify these costs ( 25 ): the greatest savings were made when a palliative care program was implemented in inpatients. We therefore consider that our study contributes in that is shows, that palliative inpatient care cannot only reduce costs, but is also a cost-effective way to reduce costs. Conclusion In a time of increasing financial pressure on the health care system, which does not spare palliative care, this study shows that the extremely high prevalence of case complexity of palliative care inpatients and justifies the interdisciplinary care approach. The effectiveness of the care interventions in this setting provides additional arguments for the need of human resources for this most vulnerable population, which deserves the attention of medicine and society. Declarations Ethics approval and consent to participate: The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud (CER-VD 2023-01200) - based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research. Consent for publication: All parties accepting to participate in the study and writing of the manuscript accepted to publish the results of the study. Availability of data and materiels: The data that support the findings of this study are available from the correponding author (KS), upon reasonable request. Competing interest: The authors declare that they have no conflict of interest or competing interests. Funding: The authors did not receive funding for realizing this study. Author’s contribution: KS wrote the manuscript and collected the data. FS is the thesis director and accompanied KS throughout the whole process of the study (from design to submission of the manuscript). YC trained KS in using INTERMED, discussed design methodology and supervised chart review; he also reviewed the manuscript. BW and DS analyzed the data, summerized the statistics and corrected the methodology and results section and reviewed the manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4058171","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284081427,"identity":"343753a6-4a9f-464f-99bb-a6783b30543c","order_by":0,"name":"Kevin Schutzbach","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYBACCSA+AGIYADEzECfwg0QeABlEaGGGaJFsAIokENDCgKLFAGQCPi2S7T2GhwsY6uTNJfIPfy6oscszvpF7EGiLXR4uLdI8ZwwOz2A4bLhzRjKD8YxjycVmN/ISgFqSi3FpkZNISzjMA3S8wY1khmQetgOJ227kGAC1HEhswKVF/hlISx1Yy2GefwcSN88goEVagvkAUAszSAtjM2/bgcQNEgS0SPYkA7UYHDbccOaxMfPMvuTEGWfeALUYJOPUInH8YPNnnoo6eYPjiY8/F3yzS+xvzzH+8KHCDqcWCDAgQmQUjIJRMApGAQkAAJ6JXToDDQLXAAAAAElFTkSuQmCC","orcid":"","institution":"University of Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Schutzbach","suffix":""},{"id":284081428,"identity":"34a711a1-d1f0-4113-b90d-4c951856ea49","order_by":1,"name":"Yann Corminboeuf","email":"","orcid":"","institution":"Rive-Neuve","correspondingAuthor":false,"prefix":"","firstName":"Yann","middleName":"","lastName":"Corminboeuf","suffix":""},{"id":284081431,"identity":"28d5c407-e6c9-4bf7-8a07-148cf8ad0f7e","order_by":2,"name":"Beate Wild","email":"","orcid":"","institution":"University Hospital Heidelberg","correspondingAuthor":false,"prefix":"","firstName":"Beate","middleName":"","lastName":"Wild","suffix":""},{"id":284081433,"identity":"028fc8cd-cc0e-4ed6-97a6-5db5a81f6179","order_by":3,"name":"Dieter Schellberg","email":"","orcid":"","institution":"University Hospital Heidelberg","correspondingAuthor":false,"prefix":"","firstName":"Dieter","middleName":"","lastName":"Schellberg","suffix":""},{"id":284081435,"identity":"55d60f36-521b-4db6-90b4-90b608701b7d","order_by":4,"name":"Friedrich Stiefel","email":"","orcid":"","institution":"University Hospital of Lausanne","correspondingAuthor":false,"prefix":"","firstName":"Friedrich","middleName":"","lastName":"Stiefel","suffix":""}],"badges":[],"createdAt":"2024-03-09 16:17:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4058171/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4058171/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53666632,"identity":"f80fd3ca-9c9a-436b-9ce9-af471a45d976","added_by":"auto","created_at":"2024-03-28 16:58:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":95158,"visible":true,"origin":"","legend":"\u003cp\u003eINTERMED grid, from Huyse et al. 1997\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4058171/v1/f7e9357a4d59e60c4d98ed75.jpg"},{"id":53666634,"identity":"2fca0a7d-9a9a-4fa9-8b77-b6bbdc66cd9d","added_by":"auto","created_at":"2024-03-28 16:58:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43342,"visible":true,"origin":"","legend":"\u003cp\u003ePrincipal component analysis (PCA) with one main factor explaining a high amount of variance\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4058171/v1/4afe9d798889d08d3e9d8556.jpg"},{"id":56038675,"identity":"1828ad45-0280-4d29-adae-f5de5c0e926a","added_by":"auto","created_at":"2024-05-07 19:05:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":494727,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4058171/v1/7a0b9e5d-ee3b-426b-b5c8-b593b7c31cf0.pdf"},{"id":53666633,"identity":"a69aac4b-7c9b-4312-ba35-20b37a693c5c","added_by":"auto","created_at":"2024-03-28 16:58:32","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":27814,"visible":true,"origin":"","legend":"","description":"","filename":"ECSPAppendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4058171/v1/2c74c3c4e741cfb3bbbce32b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study","fulltext":[{"header":"Key message","content":"\u003cp\u003eProvision of palliative care correlates with case complexity and is effective.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePalliative care, based on the biopsychosocial model of disease (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), enlarged by the spiritual dimension (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), aims to provide holistic care (\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Since cure is no longer possible (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), palliative care patients evolve towards death (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), often affected by both somatic (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and psychiatric morbidities (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), as well as by social problems (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The vast majority of palliative care patients suffer from cancer (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and the therapeutic objective is often limited to a temporary stabilization of their condition and relief of symptoms (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Especially the end of life can be marked by somatic, psycho-social (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and spiritual distress (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), often requiring hospitalization and interdisciplinary and interprofessional care (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, only one study using the INTERMED to assess the biopsychosocial case complexity has been conducted in the palliative care setting: conducted almost twenty years ago, this study included inpatients of a University hospital, for whom palliative care consultation were requested (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The study showed biopsychosocial heterogeneity of the sample and concluded that the INTERMED could be a useful tool to comprehensively assess patients\u0026rsquo; health care needs and to tailor interdisciplinary interventions.\u003c/p\u003e \u003cp\u003eHowever, over the last twenty years, palliative care has evolved and has become - as any other medical discipline - pressured to be as cost-effective as possible. The ambition of a holistic approach of palliative care implies that care is based on an interdisciplinary and interprofessional approach, considered to respond to the needs of this patient population. The question, however, policy makers and insurance companies have raised is: is this expensive approach really needed and is it efficient (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)? Moreover, there has been a call in a recent narrative review on the evidence of the economic value of end-of-life palliative care interventions for greater consistency in reporting outcome measures and costs associated with hospice care (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This study has been conducted with this economic background issues in mind.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eAim of the study:\u003c/h2\u003e \u003cp\u003eThe main objective of this study was to describe the biopsychosocial complexity of specialized palliative care inpatients and to compare their complexity prevalence with other populations.\u003c/p\u003e \u003cp\u003eSecondary objectives were to determine if a correlation exists between case complexity and amount of interdisciplinary care provided, and if complexity subgroups of patients with different health care needs can be identified.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eSetting\u003c/h2\u003e\n \u003cp\u003eThe Rive-Neuve specialized palliative care hospice, founded in 1988, is located in the French-speaking Canton of Vaud, in Western Switzerland, and can accommodate 20 inpatients. Admissions aredocumented in a file reviewed by a nurse, who is specialized in palliative care. Referrals are made by neighbouring hospitals or by the physicians of the mobile palliative home care team. Indications for hospitalization are the palliative situation of the patient, especially when symptoms are present, which are difficult to managesuch as pain, anxiety or dyspnea. In 2019, 222 patients were admitted; all of them were included in this study, since the documentation of all charts allowed the scoring with the INTERMED. The study period corresponds to the habitual situation, prior to the Covid pandemic. The staff consists of a multidisciplinary team of nurses, physiotherapists, an occupational therapist, an art therapist, a chaplain, about fifty volunteers, physicians, psychologists, psychiatrists, and administrative personal. The study was accepted by the ethics committee of the Canton of Vaud \u003cem\u003e(CER-VD 2023\u0026thinsp;\u0026minus;\u0026thinsp;01200)\u003c/em\u003e - based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research. Given the aim of the study, no medical data were recorded. Comparison was intended only on a populational level or with regard to setting (e.g., palliative care patients versus patients affected by obesity). Since this is a descriptive study, we decided to include a whole year of admissions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eAssessment instruments\u003c/h2\u003e\n \u003cp\u003eThe study was based on a retrospective medical chart review. Sociodemographic and medical data, as well as patient symptom assessments with the ESAS (Edmonton Symptom Assessment System) were retrieved from the charts (28).\u003c/p\u003e\n \u003cp\u003eBiopsychosocial case complexity was assessed by means of the INTERMED. The INTERMED is a reliable and valid instrument to evaluate patients\u0026rsquo; case complexity by taking into account their biopsychosocial situation and the complexity of their interactions with the care system (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The 20 items rated by the INTERMED are shown in the Appendix. Developed in 1995 (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e), numerous studies have been conducted with the INTERMED in different countries, and different health care settings and patient populations. These studies have consistently shown - for example in low back pain (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e), chronic shoulder pain (\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e), diabetes (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e), or internal medicine (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e) - that the INTERMED identifies complex patients who have a less favorable response to medical treatments (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). Moreover, early and targeted psychosocial interventions in complex patients identified by means of the INTERMED have demonstrated beneficial effects with regard to medical and psychological outcomes, as well as health care utilization (\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe INTERMED can be scored by means of a semi-structured interview, a self-assessment or retrospectively based on patient charts (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). Retrospective chart-based rating has been proved to be reliable: in a previous study: interrater reliability of retrospective ratings reached an intra class correlation (ICC) of 0.91 (41).\u003c/p\u003e\n \u003cp\u003eThe INTERMED is composed of three columns for each domain (biological, psychological, social and healthcare system domain) (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The first column refers to the past (history), the second to the present (current state) and the third to the future (prognosis). Two items in the past and present domains and one items in the future domain are rated with a score ranging from 0 (no complexity) to 3 (indicating the highest level of complexity). Each domain can thus reach a score of 15, with a total INTERMED score of 60. A score\u0026thinsp;\u0026ge;\u0026thinsp;21 is considered as indicating biopsychosocial complexity (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe amount of interdisciplinary palliative care interventions \u0026ndash; without the care provided by medical doctors and nurses \u0026ndash; was documented by the routine registration of minutes per patient spent by the different care professionals for 211 of the 222 patients (for 11 patients data were missing). All patients in Rive-Neuve are equally cared for by physicians and nurses, as in other medical settings. Therefore, care minutes calculated in this study only relates to the additional support provided by psychologists and psychiatrists, the chaplain, physiotherapists and occupational therapists, dietitians, social workers, hypnotherapy nurses, and others. The time spent with patients by volunteers was not collected and is therefore not taken into account in the calculations.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eInitially, descriptive statistics for the INTERMED total and domain scores were conducted for admission and the end of the stay (death or end of hospitalization). Differences between groups were analyzed using t-tests for independent or dependent groups. Percentages were calculated to estimate the prevalence of patients with complex health care needs. Correlations between the INTERMED change scores calculated by INTERMED T2-T1 and amount of palliative care provision were estimated by calculating Pearson\u0026rsquo;s correlation coefficients. Hierarchical cluster analysis was conducted, to investigate if the sample might consist of clearly distinct subgroups. It was worked out thoroughly using several criteria to check for the existence of more than one main cluster. However, cluster analysis - as a relatively rough method to determine clusters - did not result in easily separable groups. To further investigate the main sources of variance with respect to the INTERMED items, we conducted a principal component analysis (PCA). Results identified two factors with an Eigenvalue\u0026thinsp;\u0026gt;\u0026thinsp;1 with one main factor (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) explaining 35.5% and the second factor (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) explaining 13.5% of the variance. For all 20 items of the INTERMED, the factor loadings were calculated. Items with a high positive factor loading on the main Factor 1 were related to psychological or social health care needs (see Appendix).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAll charts allowed to score the INTERMED items at admission and discharge (N\u0026thinsp;=\u0026thinsp;62) or death (N\u0026thinsp;=\u0026thinsp;160).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and administrative data\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sociodemographic and administrative data of the sample.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and administrative data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarged Home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNumber of stays\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo stays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThree stays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Value (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[Range]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[31\u0026ndash;100]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e[1\u0026ndash;115]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; case complexity\u003c/h2\u003e \u003cp\u003eMean INTERMED score at admission was 31 (standard deviation, 5; range 19\u0026ndash;46), and 31 (standard deviation, 5; range 13\u0026ndash;43) at discharge or death. INTERMED scores at admission did not differ significantly between discharged patients and patients who died (t(220)= -1.13; p\u0026thinsp;=\u0026thinsp;026).\u003c/p\u003e \u003cp\u003eNearly all patients (n\u0026thinsp;=\u0026thinsp;219, 98.7%) had an INTERMED score\u0026thinsp;\u0026ge;\u0026thinsp;21 and thus qualified as complex.\u003c/p\u003e \u003cp\u003eRegarding the INTERMED domain scores (biological, psychological, social, health care system), 42.5% of the total score was due to the biological, 23% to the social, 19% to the psychological, and 15.5% to the health care domain.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eProvided health care\u003c/h2\u003e \u003cp\u003eOf the 222 patients, 11 had missing data and 4 stayed so shortly that they could not receive specific palliative care (there are no therapists at weekends apart from the nurses and the physicians on duty), which reduces the sample, regarding care interventions to 207 patients. Information regarding additional care for patients (number of patients) and amount of care per patient (in minutes) is provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. \u0026ldquo;Interviews (staff)\u0026rdquo; relates to time taken by nurses during their working hours to talk with patients who wished specifically to talk.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of patients benefiting from additional car and amount of care per patient\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAverage Duration (minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDuration Range (minutes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e388\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;2876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychotherapists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;1111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiotherapists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChaplain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterviews (staff)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietitians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026ndash;315\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse hypnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u0026ndash;195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eProvided amount of care correlated significantly with the total INTERMED score at admission (r\u0026thinsp;=\u0026thinsp;0.23, p\u0026thinsp;=\u0026thinsp;0.0008): patients with higher biopsychosocial complexity received more interdisciplinary care.\u003c/p\u003e \u003cp\u003eThe change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIdentification of subgroups\u003c/h2\u003e \u003cp\u003ePCA revealed two factors with one main factor explaining a high amount of variance. For all patients, an individual score for this main factor 1 was computed resulting in either a score\u0026thinsp;\u0026le;\u0026thinsp;0 or \u0026gt;\u0026thinsp;0. Subsequently, the patients were divided in two subgroups according to this score: subgroup 1 includes n\u0026thinsp;=\u0026thinsp;121 patients and is related to a factor 1 score\u0026thinsp;\u0026gt;\u0026thinsp;0 (red points) whereas patients of subgroup 2 (n\u0026thinsp;=\u0026thinsp;101) have a factor score\u0026thinsp;\u0026le;\u0026thinsp;0 (blue points, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). According to the factor loadings patients with a score\u0026thinsp;\u0026gt;\u0026thinsp;0 should be psychosocially more burdened compared to patients with a score\u0026thinsp;\u0026le;\u0026thinsp;0.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the mean values of these two subgroups for each of the INTERMED items. Mean values are similar in the two subgroups regarding items 1, 2, 7, 9, 13, 15, 16, 17. However, regarding items 3, 4, 6, 12, and 18, subgroup 2 shows consistently lower mean values compared to subgroup 1. All these items reflect the past, current, or future psychological or social complexity of the patients. Subgroup 1 could thus be described as highly complex with a heavy psychosocial burden, whereas subgroup 2 as highly complex regarding biological (somatic) aspects and less psychosocially burdened. The total amount of received interdisciplinary care differed significantly between the two groups (subgroup 1: mean\u0026thinsp;=\u0026thinsp;452.6, SD\u0026thinsp;=\u0026thinsp;463.8; subgroup 2: 293.6, SD\u0026thinsp;=\u0026thinsp;277.5; t\u003csub\u003e209\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;2.94; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Specifically, the amount of received additional psychiatric and social care was significantly higher for subgroup 1 compared to subgroup 2 (psychiatric care: mean\u0026thinsp;=\u0026thinsp;181.1 (205.2) vs.101.8 (121.6), t\u003csub\u003e209\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;3.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; social care: mean\u0026thinsp;=\u0026thinsp;48.9 (65.9) vs. 27.0 (25.8), t\u003csub\u003e209\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;3.06; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe will first discuss the results and then situate our study within the literature on economic aspects of palliative care.\u003c/p\u003e \u003cp\u003eWhile patient populations may differ between palliative care inpatient units, the mortality rate of our study population is similar to those of other palliative care inpatient units (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Regarding the prevalence of case complexity, almost all patients showed an INTERMED score above 21, which is a three times higher prevalence than the prevalence found in patients with chronic disease (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This population\u0026rsquo;s extraordinarily high biopsychosocial complexity, which remains stable over the course of the hospital stay, justifies interdisciplinary care and associated human resources. There is no significant difference in complexity scores at admission between patients who will be discharged and those who will die, which indicates that care cannot be guided by means of the INTERMED or targeted upon admission, as suggested in the discussion of the first study using the INTERMED in a population referred to palliative care consultations (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Regarding specific domains of complexity, the somatic symptom burden (biological domain) unsurprisingly contributes most to the total case complexity. However, the social and psychological complexity domain equal together the contribution of the biological domain, which again demonstrates the need for interdisciplinary care taking into account the psychosocial suffering of patients in need of palliative care. Moreover, there is a correlation between the INTERMED, and the amount of care provided, which increases with increased case complexity of the patients. Moreover, changes in the INTERMED scores correlate negatively with provided care. Care thus reduced health care needs during stay, demonstrating that interdisciplinary interventions seem to be efficient.\u003c/p\u003e \u003cp\u003eOur first approach to identify different patient groups by means of a cluster analysis did not lead to a statistically good fitting cluster result. Only when applying the more sophisticated PCA two factors were identified, with one main factor explaining a high amount of variance and the two subgroups differing markedly regarding the amount of psychosocial burden. The finding that the psychosocially heavy burdened subgroup received significantly more psychosocial care underlines again the need of an interdisciplinary team with specialists such as psychiatrists and psychologists, social workers, chaplains and physiotherapists, occupational and art therapists.\u003c/p\u003e \u003cp\u003eOur study is situated within the body of studies investigating economic aspects of palliative care. A recent study has shown that palliative care intervention at the end of life reduces healthcare costs, mostly when it is home-based; however hospice-based intervention significantly reduces costs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Another study attempted to quantify these costs (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e): the greatest savings were made when a palliative care program was implemented in inpatients. We therefore consider that our study contributes in that is shows, that palliative inpatient care cannot only reduce costs, but is also a cost-effective way to reduce costs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn a time of increasing financial pressure on the health care system, which does not spare palliative care, this study shows that the extremely high prevalence of case complexity of palliative care inpatients and justifies the interdisciplinary care approach. The effectiveness of the care interventions in this setting provides additional arguments for the need of human resources for this most vulnerable population, which deserves the attention of medicine and society.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud \u003cem\u003e(CER-VD 2023-01200)\u0026nbsp;\u003c/em\u003e- based on a request for authorization under Article 34 LRH (no need for consent) - under the condition that no patient had explicitly stated his or her disagreement for using his or her routine medical data for research.\u003c/p\u003e\n\u003cp\u003eConsent for publication: All parties accepting to participate in the study and writing of the manuscript accepted to publish the results of the study.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materiels: The data that support the findings of this study are available from the correponding author (KS), upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interest: The authors declare that they have no conflict of interest or competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: The authors did not receive funding for realizing this study.\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s contribution: KS wrote the manuscript and collected the data. FS is the thesis director and accompanied KS throughout the whole process of the study (from design to submission of the manuscript). YC trained KS in using INTERMED, discussed design methodology and supervised chart review; he also reviewed the manuscript. BW and DS analyzed the data, summerized the statistics and corrected the methodology and results section and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: The first author would like to thank the Rive-Neuve Foundation for letting us use their data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEngel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977 Apr 8;196:129\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eSwami M, Case A. Effective palliative care: What is involved? [Internet]. 2018. Available from: https://www.cancernetwork.com/view/effective-palliative-care-what-involved \u003c/li\u003e\n\u003cli\u003eFernando G, Hughes S. Team approaches in palliative care: A review of the literature. International Journal of Palliative Nursing. 2019 Sept 2;25(9):444\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eArrieira IC de O, Thofehrn MB, Porto AR, Moura PMM, Martins CL, Jacondino MB. Spirituality in palliative care: experiences of an interdisciplinary team. Revista da Escola de Enfermagem da USP. 2018 Apr 12;52.\u003c/li\u003e\n\u003cli\u003eLeclerc BS, Blanchard L, Cantinotti M, Couturier Y, Gervais D, Lessard S, et al. The effectiveness of interdisciplinary teams in end-of-life palliative care: A Systematic review of comparative studies. Journal of Palliative Care. 2014 Mar 1;30(1):44\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eJanssen DJ, Spruit MA, Alsemgeest TP, Does JD, Schols JM, Wouters EF. A patient-centred interdisciplinary palliative care programme for end-stage chronic respiratory diseases. International Journal of Palliative Nursing. 2010 Apr;16(4):189\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eRoth AR, Canedo AR. Introduction to Hospice and Palliative Care. Primary Care: Clinics in Office Practice. 2019 Sep 1;46(3):287\u0026ndash;302. \u003c/li\u003e\n\u003cli\u003eHughes MT, Smith TJ. The Growth of Palliative Care in the United States. Annual Review of Public Health. 2014 Mar 18;35(1):459\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eJordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Edwards HL, Chapman EJ, Deliens L, Bennett M.I. Duration of palliative care before death in international routine practice: A systematic review and meta-analysis. BMC Medecine. 2020 Nov 26;18:368. \u003c/li\u003e\n\u003cli\u003eBennett MI, Ziegler L, Allsop M, Daniel S, Hurlow A. What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city. BMJ Open. 2016 Dec 9;6(12). \u003c/li\u003e\n\u003cli\u003eSmith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American society of clinical oncology provisional clinical opinion: The integration of palliative care into standard oncology care. Journal of Clinical Oncology. 2012 Oct 3;30(8):880\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eIyer AS, Sullivan DR, Lindell KO, Reinke LF. The role of palliative care in COPD. CHEST. 2022 May 1;161(5):1250\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eKavalieratos D, Gelfman LP, Tycon LE, Riegel B, Bekelman DB, Ikejiani DZ Goldstein N, Kimmel SE, Bakitas MA, Arnold RM. Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. Journal of American College of Cardiology. 2017 Oct 10;70(15):1919\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eRogers JG, Patel CB, Mentz RJ, Granger BB, Steinhauser KE, Fiuzat M, Adams PA, Speck A, Johnson KS, Krishnamoorthy A, Yang H, Anstrom KJ, Dodson GC, Taylor DH, Kirchner JL, Mark DB, O\u0026apos;Connor CM, Tulsky JA. Palliative care in heart failure: The PAL-HF randomized, controlled clinical trial. Journal of American College of Cardiology. 2017 Jul 18;70(3):331\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eRobinson MT, Holloway RG. Palliative Care in Neurology. Mayo Clinic Proceedings. 2017 Oct 1;92(10):1592\u0026ndash;601. \u003c/li\u003e\n\u003cli\u003eWong PTP, Yu TTF. Existential suffering in palliative care: An existential positive psychology perspective. Medicina. 2021 Sep 1;57(9):924. \u003c/li\u003e\n\u003cli\u003eMitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. The Lancet Oncology. 2011 Feb 1;12(2):160\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eAnn-Yi S, Bruera E, Wu J, Liu DD, Agosta M, Williams JL, et al. Characteristics and outcomes of psychology referrals in a palliative care department. Journal of Pain and Symptom Management. 2018 Sep 1;56(3):344\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eBradley N, Dowrick C, Lloyd-Williams M. A survey of hospice day services in the United Kingdom \u0026amp; Republic of Ireland: How did hospices offer social support to palliative care patients, pre-pandemic? BMC Palliative Care. 2022 Oct 5;21:170. \u003c/li\u003e\n\u003cli\u003eBradley N, Lloyd‐Williams M, Dowrick C. Effectiveness of palliative care interventions offering social support to people with life‐limiting illness\u0026mdash;A systematic review. European Journal of Cancer Care (Engl). 2018 Mar 24;27(3). \u003c/li\u003e\n\u003cli\u003eReese DJ, Raymer M. Relationships between social work involvement and hospice outcomes: results of the National Hospice Social Work Survey. Social Work. 2004 Jul 1;49(3):415\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eTaels B, Hermans K, Van Audenhove C, Cohen J, Hermans K, Declercq A. Development of an intervention (PICASO) to optimise the palliative care capacity of social workers in Flanders: A study protocol based on phase I of the Medical Research Council framework. BMJ Open. 2022 Oct 11;12(10). \u003c/li\u003e\n\u003cli\u003eKittelson SM, Elie MC, Pennypacker L. Palliative Care Symptom Management. Critical Care Nursing Clinics of North America. 2015 Sep 1;27(3):315\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eMazzocato C, Stiefel F, de Jonge P, Levorato A, Ducret S, Huyse FJ. Comprehensive assessment of patients in palliative care: A descriptive study utilizing the INTERMED. Journal of Pain and Symptom Management. 2000 Feb 1;19(2):83\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eYadav S, Heller IW, Schaefer N, Salloum RG, Kittelson SM, Wilkie DJ, Huo J. The health care cost of palliative care for cancer patients: A systematic review. Support Care Cancer. 2020 Oct 1;28(10):4561\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eGardiner C, Ryan T, Gott M. What is the cost of palliative care in the UK? A systematic review. BMJ Supportive \u0026amp; Palliative Care. 2018 Apr 13;8(3):250\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eLuta X, Ottino B, Hall P, Bowden J, Wee B, Droney J, et al. Evidence on the economic value of end-of-life and palliative care interventions: A narrative review of reviews. BMC Palliative Care. 2021 Jun 23;20(1):89. \u003c/li\u003e\n\u003cli\u003eHui D, Bruera E. The Edmonton Symptom Assessment System 25 years later: Past, present, and future developments. Journal of Pain and Symptom Management. 2017 Mar;53(3):630\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eHuyse FJ, Lyons JS, Stiefel FC, Slaets JPJ, de Jonge P, Fink P, Gans RO, Guex P, Herzog T, Lobo A, Smith GC, van Schijndel RS. \u0026ldquo;INTERMED\u0026rdquo;: a method to assess health service needs. I. Development and reliability. General Hospital Psychiatry. 1999 Jan-Feb;21(1):39\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eStiefel FC, de Jonge P, Huyse FJ, Guex P, Slaets JP, Lyons JS, Spagnoli J, Vannotti M. \u0026lsquo;INTERMED\u0026rsquo;: a method to assess health service needs. II. Results on its validity and clinical use. General Hospital Psychiatry. 1999 Jan-Feb;21(1):49\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eStiefel FC, Huyse FJ, S\u0026ouml;llner W, Slaets JPJ, Lyons JS, Latour CHM, van der Wal N, de Jonge P. Operationalizing integrated care on a clinical level: the INTERMED project. Medical Clinics of North America. 2006 Jul;90(4):713\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eStiefel FC, de Jonge P, Huyse FJ, Slaets JPJ, Guex P, Lyons JS, Vannotti M, Fritsch C, Moeri R, Leyvraz PF, So A, Spagnoli J. INTERMED-an assessment and classification system for case complexity: Results in patients with low back pain. Spine (Phila Pa 1976). 1999 Feb 15;24(4):378\u0026ndash;84; discussion 385. \u003c/li\u003e\n\u003cli\u003eScerri M, de Goumo\u0026euml;ns P, Fritsch C, Van Melle G, Stiefel FC, So A. The INTERMED questionnaire for predicting return to work after a multidisciplinary rehabilitation program for chronic low back pain. Joint Bone Spine. 2006 Dec;73(6):736\u0026ndash;41. Epub 2006 Jul 7. \u003c/li\u003e\n\u003cli\u003eWolfensberger A, Vuistiner P, Konzelmann M, Plomb-Holmes C, L\u0026eacute;ger B, Luthi F. Clinician and patient-reported outcomes are associated with psychological factors in patients with chronic shoulder pain. Clinical Orthopaedics and Related Research. 2016 Sep;474(9):2030\u0026ndash;9. Epub 2016 Jun 29. \u003c/li\u003e\n\u003cli\u003eFischer CJ, Stiefel FC, de Jonge P, Guex P, Troendle A, Bulliard C Huyse FJ, Gaillard R, Ruiz J. Case complexity and clinical outcome in diabetes mellitus. A prospective study using the INTERMED. Diabetes Metabolism. 2000 Sep;26(4):295\u0026ndash;302. \u003c/li\u003e\n\u003cli\u003ede Jonge P, Huyse FJ, Stiefel FC, Slaets JPJ, Gans RO. INTERMED\u0026mdash;a clinical instrument for biopsychosocial assessment. Psychosomatics. 2001 Mar-Apr;42(2):106\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHuyse FJ, Lyons JS, Stiefel FC, Slaets J, de Jonge P, Latour C. Operationalizing the biopsychosocial model: the INTERMED. Psychosomatics. 2001 Jan-Feb;42(1):5\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eStiefel FC, Zdrojewski C, Bel Hadj FB, Boffa D, Dorogi Y, So A, Ruiz J, de Jonge P. Effects of a multifaceted psychiatric intervention targeted for the complex medically ill: A randomized controlled trial. Psychotherapy and psychosomatics. 2008;77(4):247\u0026ndash;56. Epub 2008 Apr 28. \u003c/li\u003e\n\u003cli\u003eWild B, Lechner S, Herzog W, Maatouk I, Wesche D, Raum E, M\u0026uuml;ller H, Brenner H, Slaets J, Huyse F, S\u0026ouml;llner W. Reliable integrative assessment of health care needs in elderly persons: The INTERMED for the Elderly (IM-E). Journal of Psychosomatic Research. 2011 Feb;70(2):169\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eWild B, Heider D, Maatouk I, Slaets J, K\u0026ouml;nig HH, Niehoff D, Saum KU, Brenner H, S\u0026ouml;llner W, Herzog W. Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study. Psychosomatic Medicine. 2014 Sep;76(7):497-502. \u003c/li\u003e\n\u003cli\u003eCorminboeuf Y, Wild B, Zdrojewski C, Schellberg D, Favre L, Suter M, Stiefel FC. BMI course over 10 years after bariatric surgery and biopsychosocial complexity assessed with the INTERMED: A retrospective study. Obesity Surgery. 2021 May 12;31(9):3996\u0026ndash;4004. \u003c/li\u003e\n\u003cli\u003eHuyse FJ. Farewell to C-L? Time for a change? Journal of Psychosomatic Research. 2009 Jun;66(6):541\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eKnupp, R., Benninger, E. and Vontobel, R.G. Daten der Zertifizierten Institutionen (2021) - palliative, Schweizerischer Bericht zu den Palliative-Care-Versorgungsstrukturen 2021. [Internet]. (2022). Available at: https://www.palliative.ch/public/dokumente/was_ist_palliative_care/palliative_care_schweiz/palliative.ch_Strukturdaten_2021_Bericht_D.pdf. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"“INTERMED”, “palliative care”, “case complexity”, “biopsychosocial”, “interdisciplinary”, “economicity”","lastPublishedDoi":"10.21203/rs.3.rs-4058171/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4058171/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eContext:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePalliative car aims to provide comprehensive care, since end of life can be marked by somatic, psycho-social and spiritual distress, requiring interdisciplinary care. However, interdiscoplinary care is costly, and palliative care services, as all other medical services, \u0026nbsp;get under pressure to be as cost-effective as possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo describe the case complexity of palliative care inpatients, to evaluate possible correlations between complexity and provision of care and to identifycomplexity subgroups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients (N = 222) hospitalized in a specialized palliative care unit (Switzerland) were assessed regarding their biopsychosocial case complexity by means of the INTERMED. Based on a chart review, INTERMED scores were determined at admission and the end of hospitalization/death. Descriptive statistics and Pearson correlation coefficients were estimated for the association between biopsychosocial case complexity and amount and type of care provided. A principal component analysis (PCA) was conducted to explain variance and to identify patient subgroups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlmost all patients (98.7 %) qualified as complex as indicated by the INTERMED. Provision of care correlated positively (r=0.23, p=0.0008) with the INTERMED scores upon admission. The change of INTERMED score during stay correlated negatively with provided care (r=-0.27, p=0.0001). PCA performed with two factors explained 49% of the total variance and identified two subgroups which differed regarding the psychosocial item scores of the INTERMED.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecialized palliative care inpatients show the highest complexity score of all populations assessed up to now with the INTERMED. Correlations between biopsychosocial complexity and care provided, and between care and decrease of complexity scores, can be considered as an indicator for care efficiency. Patient subgroups with specific needs (psychosocial burden) suggest that palliative care teams need specialized staff.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was accepted August 24, 2023 by the ethics committee of the Canton of Vaud \u003cem\u003e(CER-VD 2023-01200).\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"Complexity in palliative care inpatients: prevalence and relationship with provision of care, a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-28 16:58:27","doi":"10.21203/rs.3.rs-4058171/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85f41d01-2e8d-49d5-8d5d-728edcf77aef","owner":[],"postedDate":"March 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-07T18:48:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-28 16:58:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4058171","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4058171","identity":"rs-4058171","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}