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  • 1. 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
  • 2. Financial Disclosure Statement
    • Dr. Quill has no relevant financial relationships to disclose
  • 3. 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
      • Multidisciplinary team
      • Home primarily, but also nursing home and facility back-up
      • Very highly regarded, but a very hard transition at first
  • 4. As Illness Progresses… An Increasing Emphasis on Palliation
  • 5. Age Distribution of US population 10,000 people/day
  • 6.  
  • 7.  
  • 8.  
  • 9. Where more can be less
  • 10. Regional Variation in Health Care costs Fisher,E. NEJM 2-26-09 5% 4% 3% 2.4%
  • 11. 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.
  • 12. 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
  • 13.  
  • 14. 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
  • 15.  
  • 16. Two Recent Palliative Care Studies Relevant to Cost, Quality, and Mortality
  • 17. 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
  • 18. Methods
    • 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
  • 19. 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
  • 20. 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)
  • 21. Key Results
    • Early palliative care provided at the same time as life-sustaining treatments for patients with metastatic NSCLC has multiple benefits
      • Improved mood
      • Improved QOL
      • Less use of aggressive therapies
      • Improved survival
    • Results don’t explain why
  • 22. 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
  • 23. Methods
    • 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
  • 24. Palliative Care and Cost Outcomes
    • * p<.05; + p<.01; ++ p<.001; N/A Not Applicable
  • 25. Cost/Day For Patients Discharged Alive
  • 26. Implications
    • 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.
  • 27. Bottom Line
    • 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
  • 28. 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
  • 29. References
    • 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.