Reducing unnecessary hospital admissions for end-of-life patients in lower and middle-income countries

Dear Editor,

We read the article “How do Primary Care Clinicians Approach Hospital Admission Decisions for People in the Final Year of Life?” by Davies et al. with great interest. ¹ Although the review considered studies mainly from high-income countries, we found some parallels between its findings and our experiences in rural teaching hospitals in Kenya. Conversations around death are often avoided, and the treatment preferences of terminally ill patients are rarely considered. ² Caregivers frequently request clinicians to conceal terminal diagnoses from patients, hence alienating them from the decision-making process. ³ Therefore, many patients are frequently subjected to non-beneficial hospital stays with a lack of personalized care in overcrowded wards. ⁴

The economic challenges in many developing countries greatly influence admission decisions for end-of-life patients. Unlike in many developed countries, inpatient care can sometimes be cheaper for Kenyan families insured by the Social Health Insurance Fund (SHIF), which covers most basic hospital expenses for as low as three US dollars monthly. ⁵ Admitting terminal patients offsets recurrent costs, including medications, meals, and transport to and from hospitals for caregivers. Unfortunately, unnecessary admissions also cause systemic wastage and avoidable physical and psychological complications. ⁶ Besides, end-of-life patients are frequently subjected to prolonged inpatient stays by hospitals to minimize losses, as financial compensation from SHIF is in fixed per diem payments. ⁷

Reduced quality of care in primary health centers contributes to the high demand for inpatient care in secondary and tertiary hospitals. In Kenya, SHIF only covers outpatient costs for primary care facilities. ⁷ Although this was meant to shield secondary and tertiary institutions from high patient volumes and promote community-oriented care, it has struggled in this mainly because most primary care facilities are under-equipped, and their clinicians undertrained to meet palliative patients’ outpatient needs comprehensively. ⁸ Consequently, many patients prefer seeking care in higher-tier facilities that rely on out-of-pocket payments for their outpatient services, forcing caregivers to request admissions to minimize direct costs.

To address this, it is necessary to equip primary healthcare centers with the necessary resources and to train their staff to effectively identify and meet the needs of end-of-life patients. In PCEA Chogoria Hospital, we integrated the Supportive and Palliative Care Indicator Tool (SPICT-low-income setting) into the electronic health records system to allow junior clinicians to identify terminally ill patients and link them to the necessary care, which often includes holistic and home-based interventions. ⁹ Having tested that SPICT is feasible to use as a screening tool in a busy general hospital in Africa, it will be feasible to train workers to use SPICT in the local health centers and dispensaries to identify patients with palliative care needs that might be addressed in the community rather than admitted routinely to the hospital.

The SPICT is available to download free at www.spict.org.uk