Palliative Care: Can we really improve quality, save money and prolong life? Timothy E. Quill M.D. Center for Ethics, Humanities and Palliative Care University of Rochester Medical Center
Financial Disclosure Statement
Dr. Quill has no relevant financial relationships to disclose
Palliative Care: A Definition
Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness and their families.
Palliative care is provided simultaneously with all other appropriate medical treatment.
Palliative care is distinct from hospice care which is medical care toward the end of life devoted exclusively to palliation
Capitated payment system
Home primarily, but also nursing home and facility back-up
Very highly regarded, but a very hard transition at first
As Illness Progresses… An Increasing Emphasis on Palliation
Age Distribution of US population 10,000 people/day http://www:metlife.com
Where more can be less
Regional Variation in Health Care costs Fisher,E. NEJM 2-26-09 5% 4% 3% 2.4%
Regional Variation in Health Care Costs
No evidence that differences in costs are explained by differences in health
Access to technology similar
Unlikely that physicians in low-cost areas consciously denying their patients needed care (quality outcomes are actually better)
How physicians respond to the availability of resources, treatments important.
Spending at the EOL
$2.1 Trillion 2006 HC
$735 billion Medicare
$220 billion attributable to 5% of beneficiaries who die each year
$66 billion in last month of life
Most costs in acute care
Health Care Costs in the Last week of Life: Associations with EOL Conversations
627 patients with terminal cancer interviewed at baseline (~6 mo) and followed up through death
Controlled for age, sex, religion, marital status, race, health insurance status
“ Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?”
Zhang. Arch Intern Med,March 9, 2009
Two Recent Palliative Care Studies Relevant to Cost, Quality, and Mortality
Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ N Engl J Med 2010 363:733-42
Design: Non-blinded RCT of early outpatient palliative care integrated with standard oncologic care compared with standard oncologic care alone.
All participants received standard oncologic care, but half also received palliative care from diagnosis.
Setting: Massachusetts General Hospital
Inclusion Criteria: Pathologically confirmed metastatic NSCLC diagnosis within last 8 weeks, ECOG 0-2, English speaking
Key Findings: QOL and Mood
PC patients had 2.3 point increase in mean QOL compared to standard care patients who had 2.3 decrease in QOL (p=.04)
PC group had lower rates of depression
Standard Care Early PC p
HADS-D 38% 16% .01
PHQ-9 17% 4% .04
Key Findings: End-of-Life Care
Standard care patients
more likely to receive aggressive care (54% vs. 33%, p=.05)
less likely to have resuscitation preferences documented (28% vs. 53%, p=.05)
PC patients had longer median survival (11.6 vs. 8.9 months, p=.02)
Early palliative care provided at the same time as life-sustaining treatments for patients with metastatic NSCLC has multiple benefits
Less use of aggressive therapies
Results don’t explain why
Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries R. Sean Morrison, Jessica Dietrich, Susan Ladwig, Timothy Quill, Joseph Sacco, John Tangeman, Diane E. Meier Health Affairs 2011;30:454-453
Retrospective analysis of hospital administrative and cost-accounting data
Four structurally diverse urban New York State hospitals in one large and two mid-size cities
All sites had mature palliative care consultation teams
Adult Medicaid beneficiaries with advanced illness receiving palliative care matched by propensity score to usual care patients
Calendar years 2004-2007
Palliative Care and Cost Outcomes
* p<.05; + p<.01; ++ p<.001; N/A Not Applicable
Cost/Day For Patients Discharged Alive
Hospital costs among Medicaid beneficiaries were significantly lower when they had consultations with the palliative care team
Palliative care team consultations may reduce expenditures, while helping to ensure quality care consistent with patient wishes, for hospitalized Medicaid beneficiaries.
New payment mechanisms aimed at improving quality and efficiency would benefit from inclusion of palliative care teams.
Palliative care improves quality of care
Pain and symptom management
More informed decision making
Added patient and family support
Palliative care probably improves cost of care
Better informed consent; more realistic expectations
Less expensive, near futile treatment
More timely and appropriate transition to hospice care
Palliative care may improve actual mortality and/or mortality rates
If introduced early along side disease-directed therapy
By preventing near futile aggressive treatment that might shorten life
By facilitating earlier and more appropriate referral to hospice
Primary vs Specialty Palliative Care
Basic palliative care for all primary care/specialist physicians
Basic pain and symptom management
Assistance with difficult decision-making
Follow through when aggressive, disease-directed care is finished
Key role for primary care physicians
Specialty level palliative care
Daunting gaps in availability and training
Can’t possibly manage all the potential need
Reserved for the more difficult cases
Difficult pain and symptom management
Challenging or conflictual decision-making
1.Temel, J.S., et al., Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine. 2010. 363(8): p. 733-42.
2.Morrison, R.S., et al., Palliative care consultation cut hospital costs for Medicaid beneficiaries. Health Affairs. 2011. 30(3): p. 454-63.
3.Morrison, R.S. and D.E. Meier, Clinical Practice: Palliative Care. N Engl J Med, 2004. 351: p. 1148-1149.
4. Zhang B., et al., Healthcare costs in the last week of life: Associations with end of life conversations . Arch Int Med, 2009. 169(5): p. 480-88.