Why palliative care

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Why palliative care?

• 5. The fiscal imperative
• Population aging growth in numbers of patients
  in need effective new technologies antiquated
  payment system financial crisis for healthcare

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Wall Street Journal page 1Sept. 18, 2003
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Medical Spending in the US 1.7 trillion in
2004

• 15 GNP, rising to 20 by 2015
• U.S. has more per capita spending than anywhere
  else in the world, but ranks 20th in quality
  indices
• The costliest 5 account for 43 of Medicare
  spending
• Medicare Payment Policy Report to Congress.
  Medpac 2004 www.medpac.gov
• Health Affairs 200524903-14.
• CBO May 2005 High Cost Medicare Beneficiaries
  www.cbo.gov

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Palliative Care aims to improve
care in 3 domains

• Relieve physical and emotional suffering
• Improve patient-physician communication and
  decision-making
• Coordinate continuity of care across settings

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Benefits of Palliative Care The Evidence Base

• Reduction in symptom burden
• Improved patient and family satisfaction
• Reduced costs

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Does Palliative Care Improve Outcomes? Results
from Systematic Reviews

• Meta-analyses of all studies comparing
  hospice/palliative care teams (2 or more health
  care workers) with usual care
• 44 studies identified
• 17 from the UK, 9 from Europe, 12 from the U.S.
  and 6 from other countries
• 7 flawed RCTs level 1
• 10 prospective controlled trials level 2
• 27 retrospective, cross-sectional, observational
  studies level 3

Higginson et al, JPSM, 2003 Finlay et al, Ann
Oncol 2002 Higginson et al, JPSM 2002.
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Hospital Based Palliative Care Teams (HBPCT)

• 8 studies pooled from meta-analysis, 1 additional
  cluster randomized controlled trial
• Compared to conventional care, HBPCT were
  associated with significant improvements in
• Pain
• Non-pain symptoms
• Patient/family satisfaction (RCT)
• Hospital length of stay, in-hospital deaths (RCT)

Jordhay et al Lancet 2000
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Palliative Care Improves Quality

• Data demonstrate that palliative care
• Relieves pain and distressing symptoms
• Supports on-going re-evaluations of goals of care
  and difficult decision-making
• Improves quality of life, satisfaction for
  patients and their families
• Eases burden on providers and caregivers
• Helps patients complete life prolonging
  treatments
• Improves transition management

Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 UC Davis Health System News
2002 Carr et al, Vitas Healthcare, 1995
Franklin Health, 2001 Dartmouth Atlas, 2000
Micklethwaite, 2002 Du Pen et al, J Clin Oncol,
1999 Finn et al, ASCO, 2002 Francke, Pat Educ
Couns, 2000 Advisory Board, 2001, 2004
Portenoy, Seminars in Oncol, 1995 Ireland Cancer
Center, 2002 Von Roenn et al, Ann Intern Med,
1993 Finn J et al ASCO abstract. 2002 Manfredi
et al JPSM 2001 Schneiderman et al. JAMA 2003
Higginson et al JPSM 2002 2003 Smith et al.
JCO 2002, JPM 2003 Coyne et al. JPSM 2002
www.capc.org.
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Symptom Improvement for 3,707 Palliative Care
Patients at Mount Sinai Hospital (6/97-12/04)
Pain
Nausea
Severe
Severe
Mod.
Mod.
Mild
Mild
None
None
Shortness of Breath
Anxiety
Severe
Severe
Mod.
Mod.
Mild
Mild
None
None
Source Patient Interviews, Mount Sinai
Hospital, New York City
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High Satisfaction-Mount Sinai Hospital
DataPercent of Palliative Care Families
Satisfied or Very Satisfied Following their Loved
Ones Death with

• Control of pain - 95
• Control of non-pain symptoms - 92
• Support of patients quality of life - 89
• Support for family stress/anxiety - 84
• Manner in which you were told of patients
  terminal illness - 88
• Overall care provided by palliative care program-
  95

Source Post-Discharge/Death Family Satisfaction
Interviews, Mount Sinai Hospital, New York City
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Palliative Care Is Cost-Saving, supports
transitions to more appropriate care settings

• Palliative care lowers costs (for hospitals and
  payers) by reducing hospital and ICU length of
  stay, and direct (such as pharmacy) costs.
• Palliative care improves continuity between
  settings and increases hospice/homecare/nursing
  home referral by supporting appropriate
  transition management.

Lilly et al, Am J Med, 2000 Dowdy et al, Crit
Care Med, 1998 Carlson et al, JAMA, 1988
Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 Bruera et al, J Pall Med,
2000 Finn et al, ASCO, 2002 Goldstein et al,
Sup Care Cancer, 1996 Advisory Board 2002 Davis
et al J Support Oncol 2005 Smeenk et al Pat Educ
Couns 2000 Von Gunten JAMA 2002 Schneiderman et
al JAMA 2003 Campbell and Guzman, Chest 2003
Smith et al. JPM 2003 Smith, Hillner JCO 2002
www.capc.org Gilmer et al. Health Affairs 2005.
Campbell et al. Ann Int Med.2004 Health Care
Advisory Board. The New Medical Enterprise 2004.
Elsayem et al, JPM 2006 Fromme et al, JPM 2006
Penrod et al, JPM 2006 Gozalo and Miller, HSR
2006 White et al, JHCM 2006
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How Palliative Care Reduces Length of Stay and
Cost

• Palliative care
• Clarifies goals of care with patients and
  families
• Helps families to select medical treatments and
  care settings that meet their goals
• Assists with decisions to leave the hospital, or
  to withhold or withdraw death-prolonging
  treatments that dont help to meet their goals

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How does PC reduce costs?

• Better care coordination, more hospice
• Fewer deaths in hospital
• Presence in or good relationship with ED
• More admissions directly to PC not ICU, from ED
• Reduce severe symptoms
• More transfers out of, fewer into, ICUs
• Families, docs, nurses like the PC alternative
• Shorter LOS, especially in ICUs
• Change, clarify goals of care
• Less use of labs, radiology, hi pharmacy, blood
  products
• Higher quality, reduced variability, lower costs
• Specialization, volume, treatment algorithms

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Mount Sinai LOS Comparison Palliative Care vs.
Usual Care 2004
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Making the Financial Case Direct Costs Prior to
Death
All adult deaths (gt18 years) for calendar years
2002, 2003 Length of stay greater than 10 days
and less than 35 days 30 most frequent DRGs for
palliative care patients Palliative Care
(N368) Usual Care (N1036)
Median Day of First Palliative Care Consult
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Total Costs Before and After Palliative Care
Consultation
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Cost Drivers Behind that Pattern
VCU Medical Center