Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Dolores Clement

Second Advisor

Gloria Bazzoli

Third Advisor

Leslie Stratton

Fourth Advisor

Yongyun Shin

Fifth Advisor

Kenneth White


Hospital-based palliative care services aim to streamline medical care for patients with chronic and potentially life-limiting illnesses by focusing on individual patient needs, efficient use of hospital resources, and providing guidance for patients, patients’ families and clinical providers toward making optimal decisions concerning a patient’s care. This study examined the nature of palliative care provision in U.S. hospitals and its impact on selected organizational and patient outcomes, including hospital costs, length of stay, in-hospital mortality, and transfer to hospice. Hospital costs and length of stay are viewed as important economic indicators. Specifically, lower hospital costs may increase a hospital’s profit margin and shorter lengths of stay can enable patient turnover and efficiency of care. Higher rates of hospice transfers and lower in-hospital mortality may be considered positive outcomes from a patient perspective, as the majority of patients prefer to die at home or outside of the hospital setting.

Several data sources were utilized to obtain information about patient, hospital, and county characteristics; patterns of hospitals’ palliative care provision; and patients’ hospital costs, length of stay, in-hospital mortality, and transfer to hospice (if a patient survived hospitalization). The study sample consisted of 3,763,339 patients; 348 urban, general, short-term, acute care, non-federal hospitals; and 111 counties located in six states over a 5-year study (2007-2011). Hospital-based palliative care provision was measured by the presence of three palliative care services, including inpatient palliative care consultation services (PAL), inpatient palliative care units (IPAL), and hospice programs (HOSPC). Derived from Institutional Theory, Resource Dependence Theory, and Donabedian’s Structure Process-Outcome framework, 13 hypotheses were tested using a hierarchical (generalized) linear modeling approach.

The study findings suggested that hospital size was associated with a higher probability of hospital-based palliative care provision. Conversely, the presence of palliative care services through a hospital’s health system, network, or joint venture was associated with a lower probability of hospital-based palliative care provision. The study findings also indicated that hospitals with an IPAL or HOSPC incurred lower hospital costs, whereas hospitals with PAL incurred higher hospital costs. The presence of PAL, IPAL, and HOSPC was generally associated with a lower probability of in-hospital mortality and transfer to hospice. Finally, the effects of hospital-based palliative care services on length of stay were mixed, and further research is needed to understand this relationship.


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