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  1. 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. 2. Financial Disclosure Statement <ul><li>Dr. Quill has no relevant financial relationships to disclose </li></ul>
  3. 3. Palliative Care: A Definition <ul><li>Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness and their families. </li></ul><ul><li>Palliative care is provided simultaneously with all other appropriate medical treatment. </li></ul><ul><li>Palliative care is distinct from hospice care which is medical care toward the end of life devoted exclusively to palliation </li></ul><ul><ul><li>Capitated payment system </li></ul></ul><ul><ul><li>Multidisciplinary team </li></ul></ul><ul><ul><li>Home primarily, but also nursing home and facility back-up </li></ul></ul><ul><ul><li>Very highly regarded, but a very hard transition at first </li></ul></ul>
  4. 4. As Illness Progresses… An Increasing Emphasis on Palliation
  5. 5. Age Distribution of US population 10,000 people/day http://www:metlife.com
  6. 9. Where more can be less
  7. 10. Regional Variation in Health Care costs Fisher,E. NEJM 2-26-09 5% 4% 3% 2.4%
  8. 11. Regional Variation in Health Care Costs <ul><li>No evidence that differences in costs are explained by differences in health </li></ul><ul><li>Access to technology similar </li></ul><ul><li>Unlikely that physicians in low-cost areas consciously denying their patients needed care (quality outcomes are actually better) </li></ul><ul><li>How physicians respond to the availability of resources, treatments important. </li></ul>
  9. 12. Spending at the EOL <ul><li>$2.1 Trillion 2006 HC </li></ul><ul><li>$735 billion Medicare </li></ul><ul><ul><li>$220 billion attributable to 5% of beneficiaries who die each year </li></ul></ul><ul><li>$66 billion in last month of life </li></ul><ul><ul><li>Most costs in acute care </li></ul></ul>
  10. 14. Health Care Costs in the Last week of Life: Associations with EOL Conversations <ul><li>627 patients with terminal cancer interviewed at baseline (~6 mo) and followed up through death </li></ul><ul><li>Controlled for age, sex, religion, marital status, race, health insurance status </li></ul><ul><li>“ Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?” </li></ul><ul><ul><ul><ul><ul><li>Zhang. Arch Intern Med,March 9, 2009 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  11. 16. Two Recent Palliative Care Studies Relevant to Cost, Quality, and Mortality
  12. 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
  13. 18. Methods <ul><li>Design: Non-blinded RCT of early outpatient palliative care integrated with standard oncologic care compared with standard oncologic care alone. </li></ul><ul><li>All participants received standard oncologic care, but half also received palliative care from diagnosis. </li></ul><ul><li>Setting: Massachusetts General Hospital </li></ul><ul><li>Inclusion Criteria: Pathologically confirmed metastatic NSCLC diagnosis within last 8 weeks, ECOG 0-2, English speaking </li></ul>
  14. 19. Key Findings: QOL and Mood <ul><li>PC patients had 2.3 point increase in mean QOL compared to standard care patients who had 2.3 decrease in QOL (p=.04) </li></ul><ul><li>PC group had lower rates of depression </li></ul><ul><ul><ul><li>Standard Care Early PC p </li></ul></ul></ul><ul><ul><li>HADS-D 38% 16% .01 </li></ul></ul><ul><ul><li>PHQ-9 17% 4% .04 </li></ul></ul>
  15. 20. Key Findings: End-of-Life Care <ul><li>Standard care patients </li></ul><ul><ul><li>more likely to receive aggressive care (54% vs. 33%, p=.05) </li></ul></ul><ul><ul><li>less likely to have resuscitation preferences documented (28% vs. 53%, p=.05) </li></ul></ul><ul><li>PC patients had longer median survival (11.6 vs. 8.9 months, p=.02) </li></ul>
  16. 21. Key Results <ul><li>Early palliative care provided at the same time as life-sustaining treatments for patients with metastatic NSCLC has multiple benefits </li></ul><ul><ul><li>Improved mood </li></ul></ul><ul><ul><li>Improved QOL </li></ul></ul><ul><ul><li>Less use of aggressive therapies </li></ul></ul><ul><ul><li>Improved survival </li></ul></ul><ul><li>Results don’t explain why </li></ul>
  17. 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
  18. 23. Methods <ul><li>Retrospective analysis of hospital administrative and cost-accounting data </li></ul><ul><li>Four structurally diverse urban New York State hospitals in one large and two mid-size cities </li></ul><ul><li>All sites had mature palliative care consultation teams </li></ul><ul><li>Adult Medicaid beneficiaries with advanced illness receiving palliative care matched by propensity score to usual care patients </li></ul><ul><li>Calendar years 2004-2007 </li></ul>
  19. 24. Palliative Care and Cost Outcomes <ul><li>* p<.05; + p<.01; ++ p<.001; N/A Not Applicable </li></ul>
  20. 25. Cost/Day For Patients Discharged Alive
  21. 26. Implications <ul><li>Hospital costs among Medicaid beneficiaries were significantly lower when they had consultations with the palliative care team </li></ul><ul><li>Palliative care team consultations may reduce expenditures, while helping to ensure quality care consistent with patient wishes, for hospitalized Medicaid beneficiaries. </li></ul><ul><li>New payment mechanisms aimed at improving quality and efficiency would benefit from inclusion of palliative care teams. </li></ul>
  22. 27. Bottom Line <ul><li>Palliative care improves quality of care </li></ul><ul><ul><li>Pain and symptom management </li></ul></ul><ul><ul><li>More informed decision making </li></ul></ul><ul><ul><li>Added patient and family support </li></ul></ul><ul><li>Palliative care probably improves cost of care </li></ul><ul><ul><li>Better informed consent; more realistic expectations </li></ul></ul><ul><ul><li>Less expensive, near futile treatment </li></ul></ul><ul><ul><li>More timely and appropriate transition to hospice care </li></ul></ul><ul><li>Palliative care may improve actual mortality and/or mortality rates </li></ul><ul><ul><li>If introduced early along side disease-directed therapy </li></ul></ul><ul><ul><li>By preventing near futile aggressive treatment that might shorten life </li></ul></ul><ul><ul><li>By facilitating earlier and more appropriate referral to hospice </li></ul></ul>
  23. 28. Primary vs Specialty Palliative Care <ul><li>Basic palliative care for all primary care/specialist physicians </li></ul><ul><ul><li>Basic pain and symptom management </li></ul></ul><ul><ul><li>Assistance with difficult decision-making </li></ul></ul><ul><ul><li>Follow through when aggressive, disease-directed care is finished </li></ul></ul><ul><ul><li>Key role for primary care physicians </li></ul></ul><ul><li>Specialty level palliative care </li></ul><ul><ul><li>Daunting gaps in availability and training </li></ul></ul><ul><ul><li>Can’t possibly manage all the potential need </li></ul></ul><ul><ul><li>Reserved for the more difficult cases </li></ul></ul><ul><ul><ul><li>Difficult pain and symptom management </li></ul></ul></ul><ul><ul><ul><li>Challenging or conflictual decision-making </li></ul></ul></ul>
  24. 29. References <ul><li>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. </li></ul><ul><li>2.Morrison, R.S., et al., Palliative care consultation cut hospital costs for Medicaid beneficiaries. Health Affairs. 2011. 30(3): p. 454-63. </li></ul><ul><li>3.Morrison, R.S. and D.E. Meier, Clinical Practice: Palliative Care. N Engl J Med, 2004. 351: p. 1148-1149. </li></ul><ul><li>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. </li></ul><ul><li>  </li></ul>