Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial.
Courtright KR, Madden V, Bayes B, Chowdhury M, Whitman C, Small DS, Harhay MO, Parra S, Cooney-Zingman E, Ersek M, Escobar GJ, Hill SH, Halpern SD
- DOI
- 10.1001/jama.2023.25092
- Record issued
- 2026-08-16
- Engine
- 7.39.0
- Exported
- 2026-09-20
Prepared by Alpha1. This document is confidential: it is intended for the recipient it was shared with and must not be redistributed. The live record at alpha1science.com/verify/4999641a-75fb-49ac-8b41-9bb777cbbfd2 is authoritative.
How this rating was calculated
- IntegrityIntegrity concern ×2−1★
- ReportingStatistical analysis partially met−0.25★
- ReportingData & code availability partially met−0.25★
- ReportingReporting transparency partially met−0.25★
- CitationsUnresolved reference−0.25★
- Statistics were not checked: no recomputable values were found in this text — no test statistic reported with its degrees of freedom, no effect estimate printed with both a 95% CI and a p-value, and no percentage printed with both its count and its denominator.
This Kaimen Rigor review uses Kaimen Rigor reviewers trained on a curated corpus of high-fidelity and retracted papers, with expert supervision and curation. It can still make mistakes; verify each finding against the source before relying on it.
This policy report card is methodologically sound for its descriptive purpose, with a clear premise and transparent limitations. However, it lacks a data availability statement, does not name statistical software or tests for its inferential claim, and has minor copyedit issues including a duplicated glossary entry and an internal inconsistency in the appendix table.
All three reviewers classified the study as 'other' (policy report card/descriptive surveillance), and this classification is adopted. Five dimensions (study design, biological variables, ethical approvals, key resources, statistical analysis partially) were rated not applicable because the report does not involve experimental design, biological subjects, or inferential statistics beyond a single claim.
Numerical inconsistencies
1 finding · worst lowValues that contradict each other or are impossible for the stated sample: recomputed p-values and test statistics, GRIM/GRIMMER checks on summary numbers, percentages against their own counts, totals against their parts, and estimates against their own confidence intervals.
- Internal contradictions in the reported numbersAssessed
- lowinternal contradictionThe report states that 72% of hospitals with 50+ beds have palliative care, but the Appendix Table shows a national prevalence of 71.5% (1723/2409). The difference may be due to rounding or different denominators, but it is not explained.
As of 2019, 72% of hospitals with fifty or more beds report a palliative care team, up from 67% in 2015 and 7% in 2001. ... NATIONAL B 71.5 (1723/2409)
Resultsreviewer’s wording - lowinternal contradictionIn the Appendix Table, for several states the sum of the subgroup counts (by hospital type) does not equal the total number of hospitals, suggesting overlapping categories or missing data that are not explained.
“New Jersey A 91.8 (56/61) 96.2 (51/53) 71.4 (5/7) 0.0 (0/1) 0.0 (0/0) 96.5 (28/29) 0.0 (0/0)”
Supplementary material
Overstated conclusions
None foundConclusions that reach past what the paper's own results support — including a significance claim that no longer holds when the statistic is recomputed, and efficacy resting on an unvalidated surrogate endpoint.
Checked — nothing surfaced.
8 major claims checked against the paper's own evidence: all adequately supported.
- supportedReviewers 1, 2, 372% of hospitals with fifty or more beds report a palliative care team as of 2019.The claim is supported by the data in the Appendix Table showing 71.5% (1723/2409), which rounds to 72%.Evidence: Appendix Table shows national prevalence of 71.5% (1723/2409).
“As of 2019, 72% of hospitals with fifty or more beds report a palliative care team, up from 67% in 2015 and 7% in 2001.”
Results - supportedReviewers 1, 2, 3Three-quarters of states now have a grade of A or B.The claim is supported by the grade distribution shown in Graph B, which indicates 21 A's and 18 B's out of 51 (including DC), totaling 39, which is 76.5%.Evidence: Graph B shows 21 A's and 18 B's.
“Three-quarters of states now have a grade of A or B.”
Results - supportedReviewers 1, 3Only 17% of rural hospitals with fifty or more beds report palliative care programs.The claim is supported by the data presented in the report, though the specific source table is not shown in the excerpt.Evidence: The report states this statistic directly.
“Only 17% of rural hospitals with fifty or more beds report palliative care programs.”
Results - supportedReviewers 1, 3For-profit hospitals are significantly less likely to provide palliative care services than nonprofit or public hospitals.The claim is supported by the data in Graph D and the text, showing 35% of for-profit vs 82% nonprofit and 60% public.Evidence: Graph D and text provide these percentages.
“Eighty-two percent of nonprofit hospitals, 60% of public hospitals, and only 35% of for-profit hospitals (up from 23% in 2015) report palliative care programs.”
Results - supportedReviewer 1Palliative care reduces symptoms and improves quality of life for both the patient and their family caregivers.The claim is supported by citations to recent studies, though the report does not provide detailed evidence within this document.Evidence: Citations 9-15 are referenced.
“Recent studies have shown that palliative care reduces symptoms and improves quality of life for both the patient and their family caregivers.”
Introduction - supportedReviewer 2Palliative care reduces costs and improves quality of life.The claim is supported by citations to multiple studies, though the report does not provide original data.Evidence: The report cites studies showing reduced symptoms, improved quality of life, and cost savings.
“Recent studies have shown that palliative care reduces symptoms and improves quality of life for both the patient and their family caregivers.”
Introduction - supportedReviewer 2Access to palliative care is lower in for-profit hospitals.The claim is supported by the data presented in Graph D and the text.Evidence: The report states '82% of nonprofit hospitals, 60% of public hospitals, and only 35% of for-profit hospitals report palliative care programs.'
“Eighty-two percent of nonprofit hospitals, 60% of public hospitals, and only 35% of for-profit hospitals (up from 23% in 2015) report palliative care programs.”
Results - supportedReviewer 3Palliative care consultation is associated with reductions in direct hospital costs of more than $3,000 per admission.The claim is supported by a cited study, though the report does not provide the original data.Evidence: The report cites reference 16 for this statistic.
“On average, palliative care consultation is associated with reductions in direct hospital costs of more than $3,000 per admission, and for the sickest patients with four or more diagnoses, these cost savings are closer to $4,800 per admission.”
Introduction
Data authenticity concerns
None foundAn adversarial read for patterns associated with data that may not be genuine: results that look too clean, implausibly large effects, duplicated data or images, and methods that do not match the results reported.
Checked — nothing surfaced.
Reporting gaps
3 findings · worst highRequired detail the manuscript never states — study design, biological variables, ethics approval and consent, key resources, statistical reporting, data and code availability, and overall transparency.
- Statistical reporting gaps (tests, assumptions, effect sizes)Assessed
- Data/code availability incompleteAssessed
- Reporting/transparency gapsAssessed
The introduction cites prior research, national statistics, and a Commonwealth Fund report to establish the problem. It clearly links the premise to the report's objectives and acknowledges limitations of prior reports. The rationale is logical and well-supported.
“Comparisons across Report Cards should be made with caution, as previous Report Cards did not include children’s general medical and surgical hospitals or children’s cancer hospitals.”
“The goal is both to inform and to help the public and policymakers increase the availability of palliative care for the millions of people in need.”
“As in our prior reports (2001, 2008, 2011, and 2015), this report describes the prevalence and locations of hospital palliative care programs across the fifty states and the District of Columbia”
“As with our previous Report Cards, the 2019 State-by-State Report Card did not examine timeliness, reach, or quality of hospital-based palliative care programs.”
“Recent studies have shown that palliative care reduces symptoms and improves quality of life for both the patient and their family caregivers.”
“As with our previous Report Cards, the 2019 State-by-State Report Card did not examine timeliness, reach, or quality of hospital-based palliative care programs.”
The report uses existing survey and registry data to describe prevalence. There is no randomization, blinding, power analysis, or experimental controls. The methodology is described in the appendix, but it is not a study design in the traditional sense.
“Analyses were limited to nongovernmental, general medical and surgical, children’s general medical and surgical, cancer, children’s cancer, heart, and obstetrics and gynecology hospitals within the fifty states and the District of Columbia.”
“Analyses were limited to nongovernmental, general medical and surgical, children’s general medical and surgical, cancer, children’s cancer, heart, and obstetrics and gynecology hospitals within the fifty states and the District of Columbia.”
“Analyses were limited to nongovernmental, general medical and surgical, children’s general medical and surgical, cancer, children’s cancer, heart, and obstetrics and gynecology hospitals within the fifty states and the District of Columbia.”
The unit of analysis is hospitals, not organisms or human subjects. There are no sex, age, weight, or health status variables to report.
Data sources are the AHA Annual Survey, National Palliative Care Registry, and CAPC's Mapping initiative, which are aggregate hospital-level data. No patient-level or identifiable data are used.
“Data on hospital characteristics were obtained from the American Hospital Association (AHA) Annual Survey Database ™ for the data year 2017 and supplemented with data from 2016 for nonresponders.”
“Data on hospital characteristics were obtained from the American Hospital Association (AHA) Annual Survey Database ™ for the data year 2017 and supplemented with data from 2016 for nonresponders.”
The analysis relies on existing databases and standard statistical software. No antibodies, cell lines, organisms, or reagents are used.
The report uses descriptive statistics (percentages, counts) and mentions 'statistically different' without providing tests or p-values. No statistical software is identified. The appendix table contains some internal inconsistencies (e.g., subgroup counts not summing to totals) that are not explained. However, the report is primarily descriptive and does not rely heavily on inferential statistics.
“Only 40% of sole community provider hospitals reported a palliative care team in 2019, a number that was not statistically different from our finding in 2015.”
“Only 40% of sole community provider hospitals reported a palliative care team in 2019, a number that was not statistically different from our finding in 2015.”
“New Jersey A 91.8 (56/61) 96.2 (51/53) 71.4 (5/7) 0.0 (0/1) 0.0 (0/0) 96.5 (28/29) 0.0 (0/0)”
“Only 40% of sole community provider hospitals reported a palliative care team in 2019, a number that was not statistically different from our finding in 2015.”
The report names the data sources (AHA Annual Survey, National Palliative Care Registry, CAPC Mapping) but does not provide a data availability statement or a repository deposit. The data are not publicly downloadable, and no code is shared.
“Data on hospital characteristics were obtained from the American Hospital Association (AHA) Annual Survey Database ™ for the data year 2017 and supplemented with data from 2016 for nonresponders.”
“Data on hospital characteristics were obtained from the American Hospital Association (AHA) Annual Survey Database ™ for the data year 2017 and supplemented with data from 2016 for nonresponders.”
“Data on hospital characteristics were obtained from the American Hospital Association (AHA) Annual Survey Database ™ for the data year 2017 and supplemented with data from 2016 for nonresponders.”
Methods are described in the appendix, limitations are discussed, and conclusions are generally proportional. However, no reporting guideline (e.g., STROBE) is referenced, and funding sources are acknowledged but not in a formal COI statement.
“As with our previous Report Cards, the 2019 State-by-State Report Card did not examine timeliness, reach, or quality of hospital-based palliative care programs.”
“The publication of this report was made possible by the generous support of the Gordon and Betty Moore Foundation.”
“As with our previous Report Cards, the 2019 State-by-State Report Card did not examine timeliness, reach, or quality of hospital-based palliative care programs.”
“The publication of this report was made possible by the generous support of the Gordon and Betty Moore Foundation.”
“As with our previous Report Cards, the 2019 State-by-State Report Card did not examine timeliness, reach, or quality of hospital-based palliative care programs.”
“The publication of this report was made possible by the generous support of the Gordon and Betty Moore Foundation.”
No trial/study registration detected. Reporting guideline cited: CARE.
Broken references and links
1 finding · worst lowReferences checked against Crossref, OpenAlex and Retraction Watch for retractions and resolvability, plus declared data and code links probed for whether they resolve to content matching the paper.
- References not resolvable to a published paperRecomputed
Checked 25 references by DOI: 14 verified — 1 DOI unresolved, 10 no DOI (shown, not verified).
- UNRESOLVED10.1016/jpainsymman.2017.12.045Impact of specialist palliative care on re-admissions: a “competing risks” analysis to take mortality into accountCited DOI does not resolve to any Crossref record.
- NO DOIHigh-need, high-cost patients: who are they and how do they use health care? A population-based comparison of demographics, health care use, and expendituresNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIOlder people projected to outnumber children for first time in U.S. historyNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIMultiple Chronic Conditions in the United StatesNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIBeing seriously ill in America todayNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIPublic Opinion Strategies pollNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIKey facts about the uninsured populationNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIWhat has the biggest impact on hospital readmission ratesNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIWorkforce Data and ReportsNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIAdvanced Certified Hospice and Palliative Nurse (ACHPN®) Computer Based ExaminationNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
- NO DOIThe impact of a home-based palliative care program in an accountable care organizationNo DOI in the reference — shown for manual review; not independently verifiable (not a fabrication signal).
5 data/code links checked; 5 live.
- datahttps://registry.capc.orgLIVEHTTP 200Resolves, but the content could not be matched to the paper.
- datahttps://mapping.capc.orgLIVEHTTP 200Resolves, but the content could not be matched to the paper.
- datahttps://www.capc.orgLIVEHTTP 200Resolves, but the content could not be matched to the paper.
- datahttps://www.npcrc.orgLIVEHTTP 200Resolves, but the content could not be matched to the paper.
- datahttps://reportcard.capc.orgLIVEHTTP 200Resolves, but the content could not be matched to the paper.
Copyediting
8 minorWording, consistency and formatting errors that need correcting before submission.
No major wording or formatting errors. 8 minor suggestions below.
8 copyedit issues flagged: mostly typo, consistency, clarity.
- MINORtypoGlossary, page 36“An Accountable Care Organizations is a group”→ Change to 'An Accountable Care Organization is a group'Subject-verb agreement error.
- MINORconsistencyAppendix Table, page 38“Hospitals with less than 50 beds”→ Change to 'fewer than 50 beds' for consistency with the rest of the report.Inconsistent use of 'less' vs 'fewer'.
- MINORclarityGlossary, page 36“Sole community provider: Hospitals that are designated by Medicare because they are located more than thirty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.thirty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.”→ Remove the duplicated sentence fragment.Duplicated text in the glossary entry.
- MINORtypoGlossary, Sole community provider definition“thisty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.thirty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.”→ Remove the duplicated sentence fragment.The definition is repeated verbatim.
- MINORconsistencyAppendix Table, New Jersey row“New Jersey A 91.8 (56/61) 96.2 (51/53) 71.4 (5/7) 0.0 (0/1) 0.0 (0/0) 96.5 (28/29) 0.0 (0/0)”→ Verify that the subgroup counts sum to the total (56/61 vs 51/53+5/7+0/1+0/0+28/29+0/0).Subgroup counts do not sum to the total; may be due to overlapping categories.
- MINORtypoPage 36, Glossary“An Accountable Care Organizations is a group”→ Change to 'An Accountable Care Organization is a group'Subject-verb agreement error.
- MINORconsistencyPage 36, Glossary“thisty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.thirty-five miles from other hospitals, or they are the sole providers of health care services for a region due to limitations in local topography or prolonged severe weather conditions.”→ Remove duplicated phrase.Duplicated text in the definition of sole community provider.
- MINORclarityPage 14, Findings and Analysis“Æ PUBLIC AND SOLE COMMUNITY PROVIDER HOSPITALS are often the only option for people lacking health care coverage (10% of the population 19 ) or for those who are geographically isolated.”→ Consider rephrasing for clarity, e.g., 'Public and sole community provider hospitals are often the only option...'The use of the symbol 'Æ' is unconventional.
The published report is robust for its descriptive purpose, but an informed reader should weigh the lack of a data availability statement, the absence of statistical method details for the one inferential claim, and the internal inconsistency in the appendix table. These issues do not invalidate the main findings but warrant a correction or clarification.
- 1.HIGHdata codeAdd a formal data availability statement in the Appendix specifying how the underlying hospital-level dataset can be accessed or requested, including any conditions.Without a data availability statement, readers cannot verify or replicate the findings, which is a key transparency requirement.
- 2.HIGHstatisticsIn the Methodology section, name the statistical software (e.g., SAS, Stata, R) and version used for the analysis.Identifying the software is essential for reproducibility and is a standard reporting expectation.
- 3.HIGHstatisticsClarify the statistical methods used to determine 'statistically different' findings, including the specific tests and thresholds, and provide exact p-values or confidence intervals.The report makes an inferential claim without any methodological detail, which undermines reproducibility and reader trust.
- 4.HIGHreportingAdd a formal conflicts of interest statement, even if it is a simple declaration of no conflicts, in the front matter or acknowledgments.A formal COI statement is a standard transparency requirement that is currently missing.
- 5.HIGHreportingReference a reporting guideline such as STROBE or a relevant checklist for surveillance reports in the Methodology section.Referencing a reporting guideline improves completeness and transparency of the report.
- 6.HIGHreportingClarify the internal inconsistencies in the Appendix Table (e.g., subgroup counts not summing to totals) by adding footnotes explaining overlaps or exclusions.The inconsistency may confuse readers and could indicate a data handling error that needs explanation.
- 7.MEDIUMdata codeConsider depositing the aggregated state-level data in a public repository (e.g., Zenodo, Figshare) with a DOI to facilitate transparency and reuse.Depositing the data enhances reproducibility and allows independent verification of the reported percentages.
- 8.MEDIUMdata codeIf custom analysis code was used to generate grades or figures, share it in a public repository (e.g., GitHub) with versioning and documentation.Sharing code allows others to reproduce the grading methodology and figures exactly.
- 9.MEDIUMreportingProvide a breakdown of the data validation process for hospitals identified as having palliative care programs, as described in the Appendix, to enhance methodological transparency.Describing the validation process helps readers assess the reliability of the data.
- 10.MEDIUMreportingInclude a statement on how missing data (e.g., nonresponders to AHA survey) were handled in the analysis.Handling of missing data is a key methodological detail that affects the validity of the results.
- 11.MEDIUMreportingClarify the definition of 'grade' and the thresholds used for letter grades in the Methodology section.The grading criteria are not explicitly defined, which limits interpretability of the report card.
- 12.LOWcopyeditFix the subject-verb agreement error in the Glossary: change 'An Accountable Care Organizations is a group' to 'An Accountable Care Organization is a group'.This is a minor typo that detracts from the professionalism of the report.
- 13.LOWcopyeditFix the duplicated sentence fragment in the Glossary definition of 'Sole community provider'.The duplicated text is a clear copyediting error that should be corrected.
- 14.LOWcopyeditChange 'Hospitals with less than 50 beds' to 'Hospitals with fewer than 50 beds' for consistency with the rest of the report.Consistency in language ('less' vs 'fewer') improves readability and professionalism.
- 15.LOWcopyeditConsider rephrasing the sentence on page 14 that begins with the symbol 'Æ' for clarity.The unconventional symbol may confuse readers and should be replaced with standard text.
The star rating is the report’s one-glance summary. Every paper starts at 5★ and loses stars for the concrete problems the review finds — so a rating is never a vague average, it’s a running total you can read line by line under “How this rating was calculated.”
- Reporting — 8 dimensionseach dimension that fully fails−½★
- each dimension partially met−¼★
- Statistics · Integrity · Claimseach serious problem−1★
- each medium problem−½★
- Citationseach retracted or unverifiable reference−¼★
- Copyeditonly when the manuscript needs a full edit−½★
The rating never drops below 1★, and a demonstrable critical failure (an impossible statistic, a proven ethics violation) caps it at 1★ on its own — so the stars can never look healthy when the verdict is CRITICAL.
The rating draws on a panel of agents. Three independent Kaimen Rigor reviewers grade the eight dimensions below across several independent passes (the shown verdict is their majority vote — steadier than any single run), isolate the paper’s major claims and check its own evidence backs them, and flag integrity concerns. Alongside them, a citation agent resolves every reference against Crossref, OpenAlex, and Retraction Watch; a statistics agent recomputes reported tests; and rule-based checks verify that declared data/code links actually resolve. Full text is required — an abstract-only submission is not analyzed.
Graded against NIH, MDAR, ARRIVE 2.0, CONSORT, EQUATOR, and RRID guidelines. A dimension that doesn’t apply to the study type is skipped, never penalized.
This Kaimen Rigor review is model-assisted and is not a substitute for formal expert review. It complements human evaluation by surfacing potential methodological concerns — verify each finding against the source.