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Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
Financial Disclosure Statement
Dr. Quill has no relevant financial
relationships to disclose
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
As Illness Progresses…An Increasing Emphasis on Palliation
Center for Ethics, Humanities and Palliative Care
Age Distribution of US population Age Distribution of US population
10,000 people/day
http://www:metlife.comhttp://www:metlife.com
Center for Ethics, Humanities and Palliative Care
Center for Ethics, Humanities and Palliative Care
Center for Ethics, Humanities and Palliative Care
Center for Ethics, Humanities and Palliative Care
Where more can be less
Center for Ethics, Humanities and Palliative Care
Fisher,E. NEJM 2-26-09
5%
4%
3%
2.4%
Regional Variation in Health Care costs
Center for Ethics, Humanities and Palliative Care
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.
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
Center for Ethics, Humanities and Palliative 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
Center for Ethics, Humanities and Palliative Care
Center for Ethics, Humanities and Palliative Care
Two Recent Palliative Care Studies Relevant to Cost, Quality, and Mortality
Center for Ethics, Humanities and Palliative Care
Early Palliative Care for Patients withMetastatic Non-Small-Cell Lung Cancer
Temel JS, Greer JA, Muzikansky A, GallagherER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJN Engl J Med 2010 363:733-42
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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)
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
Palliative Care and Cost Outcomes
* p<.05; + p<.01; ++ p<.001; N/A Not Applicable
Center for Ethics, Humanities and Palliative Care
Cost/Day For Patients Discharged Alive
Center for Ethics, Humanities and Palliative Care
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.
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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
Center for Ethics, Humanities and Palliative Care
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.
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