• Corita R Grudzen, Nina Siman, Allison M Cuthel, Oluwaseun Adeyemi, Rebecca Liddicoat Yamarik, Keith S Goldfeld, PRIM-ER Investigators, Benjamin S Abella, Fernanda Bellolio, Sorayah Bourenane, Abraham A Brody, Lauren Cameron-Comasco, Joshua Chodosh, Julie J Cooper, Ashley L Deutsch, Marie Carmelle Elie, Ahmed Elsayem, Rosemarie Fernandez, Jessica Fleischer-Black, Mauren Gang, Nicholas Genes, Rebecca Goett, Heather Heaton, Jacob Hill, Leora Horwitz, Eric Isaacs, Karen Jubanyik, Sangeeta Lamba, Katharine Lawrence, Michelle Lin, Caitlin Loprinzi-Brauer, Troy Madsen, Joseph Miller, Ada Modrek, Ronny Otero, Kei Ouchi, Christopher Richardson, Lynne D Richardson, Matthew Ryan, Elizabeth Schoenfeld, Matthew Shaw, Ashley Shreves, Lauren T Southerland, Audrey Tan, Julie Uspal, Arvind Venkat, Laura Walker, Ian Wittman, and Erin Zimny.
• Division of Supportive and Acute Care Services, Memorial Sloan Kettering Cancer Center, New York, New York.
• JAMA. 2025 Jan 15.

ImportanceThe emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness.ObjectiveTo assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness.Design, Setting, And ParticipantsCluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded.InterventionA multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff.Main Outcome And MeasuresThe primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months.ResultsThere were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]).Conclusions And RelevanceThis multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness.Trial RegistrationClinicalTrials.gov Identifier: NCT03424109.

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