The Business Case for Palliative Care: Translating Research Into Program Development in the U.S

Developing a generic business case for an advanced chronic liver disease support service

Introduction

Liver disease deaths are rising, but specialist palliative care services for hepatology are limited. Expansion across the NHS is required.

Methods

We surveyed clinicians, patients and carers to design an 'ideal' service. Using standard NHS tariffs, we calculated the cost of this service. In hospitals where specialist palliative care was available for liver disease, patient-level costs and bed utilisation in last year of life (LYOL) were compared between those seen by specialist palliative care before death and those not.

Results

The 'ideal' service was described. Costs were calculated as whole time equivalent for a minimal service, which could be scaled up. From a hospital with an existing service, patients seen by specialist palliative care had associated costs of £14 728 in LYOL, compared with £18 558 for those dying without. Savings more than balanced the costs of introducing the service. Average bed days per patient in LYOL were reduced (19.4 vs 25.7) also intensive care unit bed days (1.1 vs 1.8). Despite this, time from first admission in LYOL to death was similar in both groups (6 months for the specialist palliative care group vs 5 for those not referred).

Conclusions

We have produced a template business case for an 'ideal' advanced liver disease support service, which self-funds and saves many bed days. The model can be easily adapted for local use in other trusts. We describe the methodology for calculating patient-level costs and the required service size. We present a financially compelling argument to expand a service to meet a growing need.

Impact of Community Palliative Care on Quality of Life among Cancer Patients in Bangladesh

Cancer, a leading cause of mortality worldwide, is often diagnosed at late stages in low- and middle-income countries, resulting in preventable suffering. When added to standard oncological care, palliative care may improve the quality of life (QOL) of these patients. A longitudinal observational study was conducted from January 2020 to December 2021. Thirty-nine cancer patients were enrolled in the Compassionate Narayanganj community palliative care group (NPC), where they received comprehensive palliative care in addition to oncological care. Thirty-one patients from the Dept. of Oncology (DO) at BSMMU received standard oncological care. In contrast to the DO group, the NPC group had a higher percentage of female patients, was older, and had slightly higher levels of education. At 10 to 14 weeks follow-up, a significant improvement in overall QOL was observed in the NPC group (p = 0.007), as well as in the psychological (p = 0.003), social (p = 0.002), and environmental domains (p = 0.15). Among the secondary outcomes, the palliative care group had reduced disability and neuropathic pain scores. Additionally, there were statistically significant reductions in pain, drowsiness, and shortness of breath, as well as an improvement in general wellbeing, based on the results of the Edmonton Symptom Assessment Scale-Revised. At the community level in Bangladesh, increased access to palliative care may improve cancer patient outcomes such as QOL and symptom burden.

Telehealth Palliative Care in Nursing Homes: A Scoping Review

OBJECTIVES

Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy.

DESIGN

Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review.

SETTINGS AND PARTICIPANTS

Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians.

METHODS

We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents.

RESULTS

The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden.

CONCLUSIONS AND IMPLICATIONS

Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.

The Declaration on Palliative Care in a Pandemic: report of the African Ministers of Health Meeting and the 7th International African Palliative Care Conference, held from the 24th to 26th August 2022 in Kampala, Uganda and virtually

The 7th International African Palliative Care Conference and the 4th African Ministers of Health Meeting were held in Kampala from the 24th to 26th August 2022. The theme of the conference - Palliative Care in a Pandemic - reflected the reality of palliative care provision on the continent, and the experience of patients and providers over the past 2 years. It was hosted by the African Palliative Care Association and the Worldwide Hospice Palliative Care Alliance with co-sponsors being the International Children's Palliative Care Network, the International Association of Hospice and Palliative Care, Global Partners in Care and Palliative care in Humanitarian Aid Situations and Emergencies. The conference was held in Kampala as a hybrid event, with a mix of in-person, pre-recorded and virtual presentations. The African Ministers of Health Meeting held on the 24^th August was attended by delegates from 25 Ministries of Health, with 92 participants in-person and 122 attending virtually. Hosted by the Minister of State for Primary Health Care in Uganda, the participants at the meeting endorsed a Declaration on Palliative Care in a Pandemic. The main conference, held on the 25th and 26th August, was attended by 334 delegates from 40 countries, 199 (60%) of whom attended in-person. Key themes discussed throughout the conference included: contagious compassion; building a business case and evidence for palliative care in Africa; palliative care policy, funding and sustainability; the importance of collaboration and global partnerships; palliative care for all ages, children through to the elderly, and all conditions; the need to be innovative and creative, embracing technology; and a feeling of hopefulness in the future of palliative care in the region as we go forward together. The impact of the pandemic has been significant on everyone. Despite this, and the limitations imposed by the pandemic, the African palliative care community has come through it stronger, is committed to continuing the development of palliative care across the region, working together and is hopeful for the future.

Quality indicators of palliative care for cardiovascular intensive care

Healthcare providers working for cardiovascular intensive care often face challenges and they play an essential role in palliative care and end-of-life care because of the high mortality rates in the cardiac intensive care unit. Unfortunately, there are several barriers to integrating palliative care, cardiovascular care, and intensive care. The main reasons are as follows: cardiovascular disease-specific trajectories differ from cancer, there is uncertainty associated with treatments and diagnoses, aggressive treatments are necessary for symptom relief, and there is ethical dilemma regarding withholding and withdrawal of life-sustaining therapy. Quality indicators that can iterate the minimum requirements of each medical discipline could be used to overcome these barriers and effectively practice palliative care in cardiovascular intensive care. Unfortunately, there are no specific quality indicators for palliative care in cardiovascular intensive care. A few indicators and their domains are useful for understanding current palliative care in cardiovascular intensive care. Among them, several domains, such as symptom palliation, patient- and family-centered decision-making, continuity of care, and support for health care providers that are particularly important in cardiovascular intensive care.

Historically, the motivation for using quality indicators is to summarize mechanisms for external accountability and verification, and formative mechanisms for quality improvement. Practically, when using quality indicators, it is necessary to check structural indicators in each healthcare service line, screen palliative care at the first visit, and integrate palliative care teams with other professionals. Finally, we would like to state that quality indicators in cardiovascular intensive care could be useful as an educational tool for practicing palliative care, understanding the minimum requirements, and as a basic structure for future discussions.

Palliative Care: A Survey of Program Benchmarking for Productivity and Compensation

Background: Palliative Care (PC) encompasses an integrated health care philosophy of care for individuals with serious illnesses and their families. Referrals to palliative care often come from other healthcare clinicians who lack the time and skill required to address the needs of the patient and their caregivers. At its heart, palliative care is individualized to the values, beliefs, and goals of the patient. The process of eliciting values, beliefs, and goals takes time and expertise, and corresnpondingly, palliative care is labor intensive. To date, there has been no concentrated focus on how to accurately capture the productivity or work of palliative care clinicians. As a result, there is not a universally accepted method of measuring the effort which includes impact, activity, composition, and productivity of a palliative care program. Objective: This paper reviews results obtained during a telephone survey of similar hospital-based palliative care programs on how they measure productivity. Currently, based on the survey, there are two focused methods for benchmarking: work relative value units (wRVU) and consult volume. This paper highlights the variability of wRVUs and the challenge of using them to compare different PC programs. Design: The design was an open-ended question telephone survey. Using the characteristics of our hospital program, the team created a composite of descriptions to consider for comparison. Then, various hospital-based palliative care teams were selected based on publicly reported data through Vizient, a national benchmarking organization. Based on a literature review, an open-ended question survey was created. These questions explored program composition, clinician productivity and performance benchmarks. Data was collected manually and stored in a confidential file. Result: Ninety-four programs were queried that met the following composite: (1) participated in Vizient program and (2) self-reported a hospital-based, inpatient palliative program. Forty-one programs responded to the request to participate. Of these, 32 programs consisted of facilities who had hospitalists who provided palliative care, but there was not a dedicated palliative care team. Nine programs had a dedicated palliative care team with clinicians who only practiced palliative medicine. Inquiry to these programs revealed that within these nine programs-two methods of capturing clinician productivity were used-five sites used a wRVU metric and four sites used a consult volume metric. Conclusion: Preliminary findings support the complexity of benchmarking PC programs against peer institutions with a standard productivity model based on the variability in program composition.

Underutilization of Palliative Care in Metastatic Foregut Cancer Patients Is Associated with Socioeconomic Disparities

BACKGROUND

Metastatic foregut cancers (MFC) are associated with debilitating symptoms that negatively impact patients' quality of life. Palliative care (PC) is effective in mitigating disease-, psychosocial-, and treatment-related effects and may improve survival in select cases. Our study characterizes PC utilization rates in MFC and identifies factors associated with PC receipt.

METHODS

We conducted a retrospective review of 228,027 National Cancer Database patients diagnosed with MFC between 2004 and 2016. Chi-squared tests were used to analyze differences between groups receiving and not receiving PC. Logistic regression was performed to assess the impact of factors on the likelihood of receiving PC.

RESULTS

Overall PC utilization was low (17.8%). A greater proportion of patients not receiving PC were in the lowest median income quartile of < $38,000/year versus those receiving PC (18.1% vs 17.8%, p < 0.0001). Higher education was associated with increased likelihood of receiving PC (OR 1.23 for communities with < 6.3% no high school degree vs ≥ 17.6%, p < 0.0001). Hispanics were significantly less likely to receive PC compared to Whites (OR 0.72, 95% CI 0.68-0.76). Patients treated at academic centers were also more likely to receive PC compared to those treated in the community (OR 1.10, 95% CI 1.05-1.14).

CONCLUSIONS

PC is a key component in improving quality of life among MFC patients. Despite slight increases in PC rates over time, PC remains drastically underutilized. Significant racial and socioeconomic disparities in patterns of PC delivery exist. Further studies are needed to understand these disparities in order to identify key targets for interventions aimed at improving equity.

Associations between informal care costs, care quality, carer rewards, burden and subsequent grief: the international, access, rights and empowerment mortality follow-back study of the last 3 months of life (IARE I study)

BACKGROUND

At the end of life, formal care costs are high. Informal care (IC) costs, and their effects on outcomes, are not known. This study aimed to determine the IC costs for older adults in the last 3 months of life, and their relationships with outcomes, adjusting for care quality.

METHODS

Mortality follow-back postal survey.

SETTING

Palliative care services in England (London), Ireland (Dublin) and the USA (New York, San Francisco).

PARTICIPANTS

Informal carers (ICrs) of decedents who had received palliative care.

DATA

ICrs reported hours and activities, care quality, positive aspects and burdens of caregiving, and completed the Texas Revised Inventory of Grief (TRIG).

ANALYSIS

All costs (formal, informal) were calculated by multiplying reported hours of activities by country-specific costs for that activity. IC costs used country-specific shadow prices, e.g. average hourly wages and unit costs for nursing care. Multivariable logistic regression analysis explored the association of potential explanatory variables, including IC costs and care quality, on three outcomes: positive aspects and burdens of caregiving, and subsequent grief.

RESULTS

We received 767 completed surveys, 245 from London, 282 Dublin, 131 New York and 109 San Francisco. Most respondents were women (70%); average age was 60 years. On average, patients received 66-76 h per week from ICrs for 'being on call', 52-55 h for ICrs being with them, 19-21 h for personal care, 17-21 h for household tasks, 15-18 h for medical procedures and 7-10 h for appointments. Mean (SD) IC costs were as follows: USA $32,468 (28,578), England $36,170 (31,104) and Ireland $43,760 (36,930). IC costs accounted for 58% of total (formal plus informal) costs. Higher IC costs were associated with less grief and more positive perspectives of caregiving. Poor home care was associated with greater caregiver burden.

CONCLUSIONS

Costs to informal carers are larger than those to formal care services for people in the last three months of life. If well supported ICrs can play a role in providing care, and this can be done without detriment to them, providing that they are helped. Improving community palliative care and informal carer support should be a focus for future investment.

PALLiON - PALLiative care Integrated in ONcology: study protocol for a Norwegian national cluster-randomized control trial with a complex intervention of early integration of palliative care

Background

Several publications have addressed the need for a systematic integration of oncological care focused on the tumor and palliative care (PC) focused on the patient with cancer. The exponential increase in anticancer treatments and the high number of patients living longer with advanced disease have accentuated this. Internationally, there is now a persuasive argument that introducing PC early during anticancer treatment in patients with advanced disease has beneficial effects on symptoms, psychological distress, and survival.

Methods

This is a national cluster-randomized trial (C-RCT) in 12 Norwegian hospitals. The trial investigates effects of early, systematic integration of oncology and specialized PC in patients with advanced cancer in six intervention hospitals compared with conventional care in six. Hospitals are stratified on the size of local catchment areas before randomization. In the intervention hospitals, a three-part complex intervention will be implemented. The backbone of the intervention is the development and implementation of patient-centered care pathways that contain early, compulsory referral to PC and regular and systematic registrations of symptoms. An educational program must be completed before patient inclusion. A total of 680 patients with advanced cancer and one caregiver per patient are included when patients come for start of last line of chemotherapy, defined according to national treatment guidelines. Data registration, clinical variables, and patient- and caregiver-reported outcomes take place every 2 months for 1 year or until death. The primary outcome is use of chemotherapy in the last 3 months of life by comparing the proportion of patients who receive this in the intervention and control groups. Primary outcome is use of chemotherapy in the last 3 months before death, i.e. number of patients. Secondary outcomes are initiation, discontinuation and number of cycles, last 3 months of life, administration of other medical interventions in the last month of life, symptom burden, quality of life (QoL), satisfaction with information and follow-up, and caregiver health, QoL, and satisfaction with care.

Discussion

Results from this C-RCT will be used to raise the awareness about the positive outcomes of early provision of specialized palliative care using pathways for patients with advanced cancer receiving medical anticancer treatment. The long-term clinical objective is to integrate these patient-centered pathways in Norwegian cancer care. The specific focus on the patient and family and the organization of a predictable care trajectory is consistent with current Norwegian strategies for cancer care.

Trial registration

ClinicalTrials.gov, NCT03088202. Registered on 23 March 2017.

Effects of a Population Health Community-Based Palliative Care Program on Cost and Utilization

Background: New population health community-based models of palliative care can result in more compassionate, affordable, and sustainable high-quality care. Objectives: We evaluated utilization and cost outcomes of a standardized, population health community-based palliative care program provided by nurses and social workers. Design: We conducted a retrospective propensity-adjusted study to quantify cost savings and resource utilization associated with a community-based palliative care program. We analyzed claims data from a Medicare Advantage (MA) plan and used a proprietary predictive model to identify 804 members at high risk for overmedicalized end-of-life care. We enrolled 204 members in the palliative care program and compared them with 600 who received standard, telephonic, health plan case management. We excluded members with fewer than two months of enrolled experience or those with insufficient data for analysis, leaving 176 members in the study group and 570 in the control group for evaluation. We compared differences in utilization and costs (medical and pharmacy), hospital admissions, bed days (acute and intensive care unit [ICU]), and emergency department visits. Setting/Subjects: A 30,000-member MA plan and a health system in Central Ohio between October 2015 and June 2016. Results: Members who received community-based palliative care showed a statistically significant 20% reduction in total medical costs ($619 per enrolled member per month), 38% reduction in ICU admissions, 33% reduction in hospital admissions, and 12% reduction in hospital days. Conclusion: A structured nurse and social work model of community-based palliative care using a predictive model to identify MA candidates for intervention can reduce utilization and medical costs.

Hospital palliative care consult improves value-based purchasing outcomes in a propensity score-matched cohort

BACKGROUND

Hospital-based palliative care consultation is consistently associated with reduced hospitalization costs and more importantly with improved patient quality of life. As healthcare systems move toward value-based purchasing rather than fee-for-service models, understanding how palliative care consultation is associated with value-based purchasing metrics can provide evidence for expanded health system support for a greater palliative care presence.

AIM

To understand how a palliative care consultation impacts rates of patient readmission and hospital-acquired infections associated with value-based purchasing metrics.

DESIGN

Retrospective propensity-matched case-control study evaluating the impact of palliative care consultation on hospital charges, hospital and intensive care unit length of stay, readmission rates, and rates of hospital-acquired conditions.

SETTING/PARTICIPANTS

All adult patients admitted to a two hospital healthcare system over a 2-year period from 1 April 2015 to 31 March 2017. The palliative care team involved three physicians, five advanced practice providers, a social worker, and a chaplain during the study period.

RESULTS

A total of 3415 patients receiving a palliative consult were propensity matched to 25,028 controls. Compared to controls, cases had decreased charges per day and decreased rates of 7-, 30-, and 90-day readmissions.

CONCLUSION

Through value-based purchasing, hospitals have 3% of their Medicare reimbursements at risk based on readmission rates. By clarifying prognosis and patient goals, palliative care consultation reduces readmission rates. Hospital systems may want to invest in larger palliative care programs as part of their efforts to reduce hospital readmissions.

Models of Outpatient Palliative Care Clinics for Patients With Cancer

PURPOSE:

Early integration of outpatient palliative care (OPC) benefits patients with advanced cancer and also the health care systems in which these patients are seen. Successful development and implementation of models of OPC require attention to the needs and values of both the patients being served and the institution providing service.

SUMMARY:

In the 2016 clinical guideline, ASCO recommended integrating palliative care early in the disease trajectory alongside cancer-directed treatment. Despite strong endorsement and robust evidence of benefit, many patients with cancer lack access to OPC. Here we define different models of care delivery in four successful palliative care clinics in four distinct health care settings: an academic medical center, a safety net hospital, a community health system, and a hospice-staffed clinic embedded in a community cancer center. The description of each clinic includes details on setting, staffing, volume, policies, and processes.

CONCLUSION:

The development of robust and capable OPC clinics is necessary to meet the growing demand for these services among patients with advanced cancer. This summary of key aspects of functional OPC clinics will enable health care institutions to evaluate their specific needs and develop programs that will be successful within the environment of an individual institution.

A Conceptual Framework of Palliative Care across the Continuum of Advanced Kidney Disease

Kidney palliative care is a growing discipline within nephrology. Kidney palliative care specifically addresses the stress and burden of advanced kidney disease through the provision of expert symptom management, caregiver support, and advance care planning with the goal of optimizing quality of life for patients and families. The integration of palliative care principles is necessary to address the multidimensional impact of advanced kidney disease on patients. In particular, patients with advanced kidney disease have a high symptom burden and experience greater intensity of care at the end of life compared with other chronic serious illnesses. Currently, access to kidney palliative care is lacking, whether delivered by trained kidney care professionals or by palliative care clinicians. These barriers include a gap in training and workforce, policies limiting access to hospice and outpatient palliative care services for patients with ESKD, resistance to integrating palliative care within the nephrology community, and the misconception that palliative care is synonymous with end-of-life care. As such, addressing kidney palliative care needs on a population level will require not only access to specialized kidney palliative care initiatives, but also equipping kidney care professionals with the skills to address basic kidney palliative care needs. This article will address the role of kidney palliative care for patients with advanced kidney disease, describe models of care including primary and specialty kidney palliative care, and outline strategies to improve kidney palliative care on a provider and system level.

Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution

Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.

Palliative Care in Lung Cancer: When to Start

PURPOSE OF REVIEW

Despite recent advances in the care of patients with advanced non-small cell lung cancer (NSCLC), significant morbidity and mortality remains. Symptoms caused by the cancer and its treatments can be profoundly debilitating. Palliative care aims to reduce this burden. In this review, we discuss the definition, purpose, benefits, and optimal timing of palliative care in advanced NSCLC.

RECENT FINDINGS

Several studies evaluating the value of early palliative care for patients with advanced NSCLC and other advanced malignancies have identified benefits for patients, caregivers, and health systems. For patients with advanced NSCLC, introduction of palliative care early in the disease course improves quality of life and even overall survival. Early institution of palliative care should become standard of care for patients with advanced NSCLC.

Facilitators and Barriers to Interdisciplinary Communication between Providers in Primary Care and Palliative Care

BACKGROUND

Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined.

OBJECTIVE

The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC.

METHODS

This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings.

RESULTS

Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC.

CONCLUSIONS

Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.

A Framework to Guide Economic Analysis of Advance Care Planning

BACKGROUND

Advance care planning (ACP) is fundamental to guiding medical care at the end of life. Understanding the economic impact of ACP is critical to implementation, but most economic evaluations of ACP focus on only a few actors, such as hospitals.

OBJECTIVE

To develop a framework for understanding and quantifying the economic effects of ACP, particularly its distributional consequences, for use in economic evaluations.

DESIGN

Literature review of economic analyses of ACP and related costs to estimate magnitude and direction of costs and benefits for each actor and how data on these costs and benefits could be obtained or estimated.

RESULTS

ACP can lead to more efficient allocation of resources by reducing low-value care and reallocating resources to high-value care, and can increase welfare by aligning care to patient preferences. This economic framework considers the costs and benefits of ACP that accrue to or are borne by six actors: the patient, the patient's family and caregivers, healthcare providers, acute care settings, subacute and home care settings, and payers. Program implementation costs and nonhealthcare costs, such as time costs borne by patients and caregivers, are included. Findings suggest that out-of-pocket costs for patients and families will likely change if subacute or home care is substituted for acute care, and subacute care utilization is likely to increase while primary healthcare providers and acute care settings may experience heterogeneous effects.

CONCLUSIONS

A comprehensive economic evaluation of ACP should consider how costs and benefits accrue to different actors.

Emerging Models of Providing Oncology Palliative Care

OBJECTIVE

To describe palliative care integration into oncology, including several models that facilitate this integration, important considerations when initiating a program, special oncologic populations that would benefit from palliative care, and challenges to consider.

DATA SOURCES

Palliative care and oncology literature over the past decade.

CONCLUSION

Multiple models exist to facilitate the integration of palliative care based on the needs of the providers or payers. There are several special populations that would benefit from early integration of palliative care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a critical role in identifying patients, providing early primary palliative care, and facilitating collaborative relationships with and referring to specialist palliative care.

A Process Evaluation of an Outpatient Palliative Care Program: A Quality Improvement Project

Palliative care has evolved from providing care for patients near end of life into a specialized discipline focused on addressing the physical, emotional, social, and spiritual needs of patients throughout the trajectory of an illness. For patients with metastatic cancer, timely referrals to palliative care are essential in order to have a meaningful impact on their quality of life. Recommendations for screening patients for palliative care have been offered by professional organizations; however, screening all patients with metastatic cancer poses many challenges. This quality improvement project conducted a process evaluation of an outpatient palliative care program and evaluated the feasibility of utilizing a screening tool in an effort to readily identify patients with metastatic cancer who have palliative care needs in an outpatient cancer center. Although nurses' compliance with the screening tool was less than expected, screening for palliative care needs in this setting resulted in more referrals to palliative care compared with physician referrals. Improvements in quality of life were found in patients who received a palliative care consultation, and patients were very satisfied with the care provided by palliative care. The potential for financial improvements was observed as a result of this project.

A National Strategy For Palliative Care

In 2014 the World Health Organization called for palliative care to be integrated as an essential element of the health care continuum. Yet in 2017 US palliative care services are found largely in hospitals, and hospice care, which is delivered primarily in the home, is limited to people who are dying soon. The majority of Americans with a serious illness are not dying; are living at home, in assisted living facilities, or in nursing homes; and have limited access to palliative care. Most health care providers lack knowledge about and skills in pain and symptom management, communication, and care coordination, and both the public and health professionals are only vaguely aware of the benefits of palliative care and how and when to access it. The lack of policy supports for palliative care contributes to preventable suffering and low-value care. In this article we outline the need for a national palliative care strategy to ensure reliable access to high-quality palliative care for Americans with serious medical illnesses. We review approaches employed by other countries, list the participants needed to develop and implement an actionable strategy, and identify analogous US national health initiatives to inform a process for implementing the strategy.

Aligning policy objectives and payment design in palliative care

BACKGROUND

Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system.

AIM

To propose optimal payment arrangements for palliative care.

APPROACH

Review of relevant literature on funding mechanisms in health care generally and palliative care in particular.

RESULTS

Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting.

CONCLUSIONS

If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.

Earlier Initiation of Community-Based Palliative Care Is Associated With Fewer Unplanned Hospitalizations and Emergency Department Presentations in the Final Months of Life: A Population-Based Study Among Cancer Decedents

CONTEXT

Although community-based palliative care (CPC) is associated with decreased acute care use in the lead up to death, it is unclear how the timing of CPC initiation affects this association.

OBJECTIVES

We aimed to explore the association between timing of CPC initiation and hospital use, over the final one, three, six, and 12 months of life.

METHODS

We conducted a retrospective, population-based study in Perth, Western Australia. Linked administrative data including cancer registry, mortality, hospital admissions, emergency department (ED), and CPC records were obtained for cancer decedents from 1 January, 2001 to 31 December, 2011. The exposure was month of CPC initiation; outcomes were unplanned hospitalizations, ED presentations, and associated costs.

RESULTS

Of 28,331 decedents residing in the CPC catchment area, 16,439 (58%) accessed CPC, mostly (64%) in the last three months of life. Initiation of CPC before the last six months of life was associated with a lower mean rate of unplanned hospitalizations in the last six months of life (1.4 vs. 1.7 for initiation within six months of death); associated costs were also lower ($(A2012) 12,976 vs. $13,959, comparing the same groups). However, those initiating CPC earlier did show a trend toward longer time in hospital when admitted, compared to those initiating in the final month of life.

CONCLUSIONS

When viewed at a population level, these results argue against temporally restricting access to CPC, as earlier initiation may pay dividends in the final few months of life in terms of fewer unplanned hospitalizations and ED presentations.

End-of-Life Care Planning in Accountable Care Organizations: Associations with Organizational Characteristics and Capabilities

OBJECTIVE

To measure the extent to which accountable care organizations (ACOs) have adopted end-of-life (EOL) care planning processes and characterize those ACOs that have established processes related to EOL.

DATA SOURCES

This study uses data from three waves (2012-2015) of the National Survey of ACOs. Respondents were 397 ACOs participating in Medicare, Medicaid, and commercial ACO contracts.

STUDY DESIGN

This is a cross-sectional survey study using multivariate ordered logit regression models. We measured the extent to which the ACO had adopted EOL care planning processes as well as organizational characteristics, including care management, utilization management, health informatics, and shared decision-making capabilities, palliative care, and patient-centered medical home experience.

PRINCIPAL FINDINGS

Twenty-one percent of ACOs had few or no EOL care planning processes, 60 percent had some processes, and 19.6 percent had advanced processes. ACOs with a hospital in their system (OR: 3.07; p = .01), and ACOs with advanced care management (OR: 1.43; p = .02), utilization management (OR: 1.58, p = .00), and shared decision-making capabilities (OR: 16.3, p = .000) were more likely to have EOL care planning processes than those with no hospital or few to no capabilities.

CONCLUSIONS

There remains considerable room for today's ACOs to increase uptake of EOL care planning, possibly by leveraging existing care management, utilization management, and shared decision-making processes.

Economic Evaluation of a Hospital-Based Palliative Care Program

PURPOSE

Establish costs of an inpatient palliative care unit (PCU) and conduct a threshold analysis to estimate the maximum possible costs for the PCU to be considered cost effective.

METHODS

We used a hospital perspective to determine costs on the basis of claims from administrative data from Johns Hopkins PCU between March 2013 and March 2014. Using existing literature, we estimated the number of quality-adjusted life years (QALYs) that the PCU could generate. We conducted a threshold analysis to assess the maximum costs for the PCU to be considered cost effective, incorporating willingness to pay ($180,000 per QALY). Three types of costs were considered, which included variable costs alone, contribution margin (ie, revenue minus variable costs), and PCU cost savings compared with usual care (from a separate publication).

RESULTS

The data showed that there were 153 patient encounters (PEs), variable costs of $1,050,031 ($1,343 per PE per day), a contribution margin of $318,413 ($407 per PE per day), and savings compared with usual care of $353,645 ($452 savings per PE per day). On the basis of the literature, the program could generate 3.11 QALYs from PEs (0.05 QALY) and caregivers (3.06 QALYs). The threshold analysis determined that the maximum variable cost required to be cost effective was $559,800 (an additional $716 per PE per day could be spent).

CONCLUSION

According to variable costs, the PCU was not cost effective; however, when considering savings of the PCU compared with usual care, the PCU was cost saving. The contribution margin showed that the PCU was cost saving. This study supports efforts to expand PCUs, which enhance care for patients and their caregivers and can generate hospital savings. Future research should prospectively explore the cost utility of PCUs.

Funding models in palliative care: Lessons from international experience

BACKGROUND

Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them.

AIM

To assess national models and methods for financing and reimbursing palliative care.

DESIGN

Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms.

RESULTS

Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs.

CONCLUSION

Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.

Impact of a New Palliative Care Program on Health System Finances: An Analysis of the Palliative Care Program Inpatient Unit and Consultations at Johns Hopkins Medical Institutions

PURPOSE

Palliative care inpatient units (PCUs) can improve symptoms, family perception of care, and lower per-diem costs compared with usual care. In March 2013, Johns Hopkins Medical Institutions (JHMI) added a PCU to the palliative care (PC) program. We studied the financial impact of the PC program on JHMI from March 2013 to March 2014.

METHODS

This study considered three components of the PC program: PCU, PC consultations, and professional fees. Using 13 months of admissions data, the team calculated the per-day variable cost pre-PCU (ie, in another hospital unit) and after transfer to the PCU. These fees were multiplied by the number of patients transferred to the PCU and by the average length of stay in the PCU. Consultation savings were estimated using established methods. Professional fees assumed a collection rate of 50%.

RESULTS

The total positive financial impact of the PC program was $3,488,863.17. There were 153 transfers to the PCU, 60% with cancer, and an average length of stay of 5.11 days. The daily loss pretransfer to the PCU of $1,797.67 was reduced to $1,345.34 in the PCU (-25%). The PCU saved JHMI $353,645.17 in variable costs, or $452.33 per transfer. Cost savings for PC consultations in the hospital, 60% with cancer, were estimated at $2,765,218. $370,000 was collected in professional fees savings.

CONCLUSION

The PCU and PC program had a favorable impact on JHMI while providing expert patient-centered care. As JHMI moves to an accountable care organization model, value-based patient-centered care and increased intensive care unit availability are desirable.

Implementing Evidence-Based Palliative Care Programs and Policy for Cancer Patients: Epidemiologic and Policy Implications of the 2016 American Society of Clinical Oncology Clinical Practice Guideline Update

The American Society of Clinical Oncology (ASCO) recently convened an Ad Hoc Palliative Care Expert Panel to update a 2012 provisional clinical opinion by conducting a systematic review of clinical trials in palliative care in oncology. The key takeaways from the updated ASCO clinical practice guidelines (CPGs) are that more people should be referred to interdisciplinary palliative care teams and that more palliative care specialists and palliative care-trained oncologists are needed to meet this demand. The following summary statement is based on multiple randomized clinical trials: "Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs" (J Clin Oncol. 2017;35(1):96). This paper addresses potential epidemiologic and policy interpretations and implications of the ASCO CPGs. Our review of the CPGs demonstrates that to have clinicians implement these guidelines, there is a need for support from stakeholders across the health-care continuum, health system and institutional change, and changes in health-care financing. Because of rising costs and the need to improve value, the need for coordinated care, and change in end-of-life care patterns, many of these changes are already underway.

The Influence of Palliative Care Consultation on Health-Care Resource Utilization During the Last 2 Months of Life: Report From an Integrated Palliative Care Program and Review of the Literature

BACKGROUND

We reviewed 104 consecutive deaths of veterans receiving care in the Dayton VA Medical Center from October 10, 2015 to April 11, 2016. The purpose of our study was to test our hypothesis that palliative care consultation would be associated with reduced health care resource utilization for individuals approaching end of life.

METHODS

Medical records were reviewed and data entry recorded on a spreadsheet. Non-parametric statistical methods were used to compare four outcome variables from veterans with palliative care consultation (PCC) vs. those without PCC. These variables included the number of ED visits, hospitalizations, hospital days, and ICU days all during the last two months of life. Predictor variables included PCC vs. no PCC and PCC before vs. PCC during the last two months of life. The study sample was comprised of 102 patients after excluding two outlier cases with ethical challenges in surrogate decision-making.

RESULTS

Of the 102 consecutive veteran deaths, palliative care consultation was associated with a lower number of ICU days during the last two months of life. For 96 veterans with PCC, the frequency of ED visits and acute care hospitalizations, as well as the number of ICU and hospital days, were all significantly less after PCC compared to before PCC during the last two months of life. The timing of PCC had no effect on the outcomes of interest.

CONCLUSION

Palliative care consultation has a notable effect on health care resource utilization during the last two months of life.

Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.

Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs

Objectives

To evaluate the nonclinical outcomes of a proactive palliative care program funded and operated by a health system for Medicare Advantage plan beneficiaries.

Design

Observational, retrospective study using propensity‐based matching.

Setting

A health system in southern California.

Participants

Individuals who received the intervention between 2007 and 2014 (n = 368) were matched with 1,075 comparison individuals within each of four disease groups: cancer, chronic obstructive pulmonary disease, heart failure, and dementia. All were known to be dead at the time of the retrospective study, were Medicare Advantage beneficiaries, and had 2 years of usage data before death. Median age at death for each disease group was older than 80.

Intervention

Home‐ and clinic‐based palliative care (PC) services provided by a multidisciplinary team.

Measurements

Outcomes included hospital costs, other healthcare costs, readmission rates, hospital admissions and bed days, intensive care unit use in final 30 days of life, and death within 30 days of an admission.

Results

Intervention participants in all four disease groups had less hospital use and lower hospital costs nonintervention participants, which drove lower overall healthcare costs. In the final 6 months of life, healthcare costs for the intervention groups stayed largely the same from month to month, whereas costs for comparison participants increased dramatically.

Conclusion

In the context of an alternative payment model in which the provider was “at risk” of bearing the costs of care, a proactive PC program helped to avoid the escalation in hospital use and costs commonly seen in the final months of life.

Phase I Cancer Trials and Palliative Care: Antagonism, Irrelevance, or Synergy?

This article synthesizes the presentations and conclusions of an international symposium on Phase 1 oncology trials, palliative care, and ethics held in 2014. The purpose of the symposium was to discuss the intersection of three independent trends that unfolded in the past decade. First, large-scale reviews of hundreds of Phase I trials have indicated there is a relatively low risk of serious harm and some prospect of clinical benefit that can be meaningful to patients. Second, changes in the design and analysis of Phase I trials, the introduction of "targeted" investigational agents that are generally less toxic, and an increase in Phase I trials that combine two or more agents in a novel way have changed the conduct of these trials and decreased fears and apprehensions about participation. Third, the field of palliative care in cancer has expanded greatly, offering symptom management to late-stage cancer patients, and demonstrated that it is not mutually exclusive with disease-targeted therapies or clinical research. Opportunities for collaboration and further research at the intersection of Phase 1 oncology trials and palliative care are highlighted.

Analyzing the Impact of Palliative Care Interventions on Cost of Hospitalization: Practical Guidance for Choice of Dependent Variable

CONTEXT

Multiple cost analyses of hospital-based palliative care have been published in recent years, but there are important differences between studies in their choice of dependent variable, complicating interpretation of results.

OBJECTIVES

The purpose of this article was to compare three different established approaches to estimating treatment effect on hospital costs, to highlight that different approaches yield different results, and to provide some practical guidelines for investigators performing hospital cost analysis in future.

METHODS

A simple example is developed using simulated cost data for four hospitalized patients, one of whom receives usual care only and three of whom receive different interventions. The impacts of the interventions are calculated and compared for three different dependent variables: cost of hospitalization, mean daily costs, and "before-and-after" costs.

RESULTS

Both the magnitude of an intervention's cost-saving effect and the relative impact of different interventions vary according to which dependent variable is used. Cost of hospitalization provides the most useful results of the three options for evaluating an intervention's impact on resource use. Alternative approaches visible in the literature can be misleading with respect to cost effects. Where the intervention is first administered to different patients at different points in a hospital admission, incorporating intervention timing is essential to maximize accuracy of cost-effect estimates.

CONCLUSION

Investigators evaluating the impact of palliative care programs on hospital costs ought to use cost of hospitalization as the dependent variable in primary analysis unless the research question specifically justifies an alternative approach. Mean daily costs and "before-and-after" costs should be used only to address relevant research questions, and results must be interpreted carefully. Analyses should also incorporate timing of the intervention where appropriate.

The Palliative-Supportive Care Unit in a Comprehensive Cancer Center as Crossroad for Patients' Oncological Pathway

Aim

The aim of this study was to assess how an admission to an acute palliative-supportive care unit (APSCU), may influence the therapeutic trajectory of advanced cancer patients.

Methods

A consecutive sample of advanced cancer patients admitted to APCU was assessed. The following parameters were collected: patients demographics, including age, gender, primary diagnosis, marital status, and educational level, performance status and reasons for and kind of admission, data about care-givers, recent anticancer treatments, being on/off treatment or uncertain, the previous care setting, who proposed the admission to APSCU. Physical and psychological symptoms were evaluated at admission and at time of discharge. The use of opioids was also recorded. Hospital staying was also recorded. At time of discharge the parameters were recorded and a follow-up was performed one month after discharge.

Results

314 consecutive patients admitted to the APSCU were surveyed. Pain was the most frequent reason for admission. Changes of ESAS were highly significant, as well as the use of opioids and breakthrough pain medications (p <0.0005). A significant decrease of the number of “on therapy” patients was reported, and concomitantly a significant number of “off-therapy” patients increased. At one month follow-up, 38.9% patients were at home, 19.7% patients were receiving palliative home care, and 1.6% patients were in hospice. 68.5% of patients were still living.

Conclusion

Data of this study suggest that the APSCU may have a relevant role for managing the therapeutic trajectory of advanced cancer patients, limiting the risk of futile and aggressive treatment while providing an appropriate care setting.

Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities

Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.