1 Best Practices: Hospice and Palliative Care in Advanced Cancer J. Cameron Muir, MD, FAAHPM EVP, Quality and Access, Capital Caring Clinical Scholar,

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Best Practices: Hospice and Palliative Care in Advanced Cancer

J. Cameron Muir, MD, FAAHPM

EVP, Quality and Access, Capital Caring

Clinical Scholar, Georgetown Center for Bioethics

Assistant Clinical Professor, Johns Hopkins Oncology

Past President, Am. Academy of Hospice and Palliative Medicine

J. Cameron Muir, MD, FAAHPM

EVP, Quality and Access, Capital Caring

Clinical Scholar, Georgetown Center for Bioethics

Assistant Clinical Professor, Johns Hopkins Oncology

Past President, Am. Academy of Hospice and Palliative Medicine

Presentation Outline:

National Framework(s)

Hospice AND Palliative Care – Unique Solutions

Quality OutcomesCare Transitions across the ContinuumPositive Impact on Bottom Line

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ASCO - 1Cancer Care During the Last Phase of

Life JCO 5:1986-1996, 1998Longstanding & continuous relationship –

training and interest in end-of-life careResponsive to patient’s wishesTruthful, sensitive, empathic communication

with patient and familyOptimizes QOL throughout the course of the

illness

ASCO - 2

Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps JCO 27: 3052-3058, 2009

Changes are needed in current policy, drug availability, education, quality improvement, and research for integration of PC throughout the experience of cancer

The need for palliative cancer care is greater than ever

Vision: PC integrated into CCC by 2020

National Priorities PartnershipConvened by the National Quality Forum (NQF)

Engage patients and families in managing their health and making decisions about their care

Improve the health of the populationImprove the safety and reliability of America’s healthcare

systemEnsure patients receive well-coordinated care within and

across all healthcare organizations, settings, and levels of care

Guarantee appropriate and compassionate care for patients with life-limiting illnesses

Eliminate overuse while ensuring the delivery of appropriate care

http://www.nationalprioritiespartnership.org/uploadedFiles/NPP/About_NPP/ExecSum_no_ticks.pdf 5

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NQF Framework for Quality Palliative Care Eight Domains

1. Structure and Process of Care2. Physical Aspects of Care3. Psychological and Psychiatric Aspects of

Care4. Social Aspects of Care5. Spiritual, Religious and Existential Aspects

of Care6. Cultural Aspects of Care7. Care of the Imminently Dying Patient8. Ethical and Legal Aspects of Care

http://www.nationalconsensusproject.org/AboutGuidelines.asp

NQF: Core Elements of Palliative CareDebilitating chronic or life-threatening illness,

condition or injury Patient- and family-centered care Begins at the time of diagnosis of a life-

threatening or debilitating condition Comprehensive care Interdisciplinary teamAttention to relief of suffering Communication skills Skill in care of the dying and the bereaved Continuity of care across settings

http://www.nationalconsensusproject.org/Guidelines_Download.asp 7

ASCO - 3ASCO Statement: Toward

Individualized Care for Patients with Advanced Cancer JCO 28:1-

6, 2011 Individualized approach to discussing and

providing disease-directed and supportive care throughout the continuum of care

Discussion of patient’s goals and preferences improves patient care

Oncologists should curtail the use of ineffective therapy and ensure a focus on palliative care

The “problem”90% of us will die from a chronic, progressive

illness

85% of us want to be at “home”

75% of us will die in an institution50% die in hospitals25% die in a nursing facility

Will not die “well”SUPPORT studyCancer and AIDS symptom burden studies

Sites of Death

Death in the USCensus:

19902000

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Historically (400 BC-1950 AD) - At home with family

Framework for Continuum of Care

Palliative Care

Disease Modifying Treatments

Hospice

DiagnosisTreatments to Relieve Suffering/Improve QOL

6Mo Death

Bereavement

Mean survival: “advanced” diseaseDementia: years (x = 11 years)CHF: 3 years (x from EF <20%)COPD: yearsBreast CA (bone mets only): 3 yearsLung CA (IIIb/IV): 12-14 months

Multiple hospitalizations

Symptom = first indication of advanced disease

Hospice is “Gold Standard”Utilization increasing dramatically:

158,000 (1985)1,360,000 (2008)

NHPCO (2008)Average: 57 daysMedian: 22 days

Primary site = home

#1 feedback: “if only I’d known about your services earlier”

Palliative CareAcross continuum: 3 years across 57 days

through deathPhysicalPracticalEmotional Spiritual

Reduce suffering

Improve Quality of Life

Best Hospitals: Best PracticeTop 100 Hospitals (US News & World

Report)Has considered the presence of Hospice and

Palliative Care services as an indicator of excellence since 2001

All of the Top Ten have Palliative Care programs

46 of the Top 50 Cancer ProgramsSince 2001: ~20%/year Growth in US Hospital-

based Palliative Care

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Trends in Hospital-based Palliative Care Consultation:

http://www.capc.org/news-and-events/releases/04-05-10

125.8% increase from 2000-2008

H/PC becoming standard…Significant growth in past 5 years:

1486 hospital-based PC Programs (2008)59% of COTHs have PC Programs (2005)90 fellowship programs/54 Accredited (2008)ACGME recognition for training (7/06)ABMS Recognition as subspecialty (9/06)

Unique Opportunity

Integrate the best of: Acute careHospice CarePalliative Care

Further develop and enhance the continuum of care

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Palliative Care = Quality

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Quality Outcomes of Palliative Care…

Reduction of Pain & SymptomsImproves Quality of LifePatient and Family Satisfaction Nurse SatisfactionPhysician SatisfactionReduced Provider/Caregiver burden Care plan consistent with wishesIncreased Referral/LOS to Hospice

CAPC http://www.capc.org/research-and-references-for-palliative-care/citations/index_html#2

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Integrating Palliative Care into an Outpatient Private Practice Oncology Setting Private practice with 5 offices:

Primary office – 7 Medical Oncologists/4 NPs* Integrated PC consultation ½ day/week in April 2005

Secondary office – 2 Medical Oncologists Integrated PC consultation ½ day/week in August

2008Three additional offices begin summer 2011

3 Medical Oncologists /1 NP 2 Medical Oncologists 2 Medical Oncologists

Integrating Palliative Care into an Outpatient Private Practice Oncology Setting JC Muir, F Daly, M Davis, et al, JPSM 40(1):126-135, 2010

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Pain (152 patients)

0

1

2

3

Initial Final

Moderate

Mild

None

Severe

Dyspnea (274 patients)

0

1

2

3

Initial Final

Severe

Moderate

Mild

None

Initial Consultation Symptoms

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96% = 3-5 Symptoms

JC Muir, F Daly, M Davis, et al, Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting. JPSM 40(1):126-135, 2010

Symptom Relief

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ESAS: Edmonton Symptom Assessment Scale/90 www.palliative.org


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Mean Median

Availability of Palliative Care Services:9.3 9

Accessibility of Palliative Care Services:9.3 9

Acceptability Of Palliative Care Services:8.4 8.5

Continuity of Palliative Care Services:8.4 9

Quality of Palliative Care Services:8.4 9

Cost Impact of Palliative Care Services:7.9 8.5

Physician Satisfaction


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Impact of Comprehensive Palliative Oncology in Partnered versus Non-Partnered Practices


Averag e P C R eferrals per P hys ic ian in Group

0

2

4

6

8

10

12

14

16

18

2003 2004 2005 2006 2007 A NNL

F NV HO/F (8)

F NV HO/O (17)

Other MedOnc (75)

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600

3600

0 720 840

3960

9720

0

2000

4000

6000

8000

10000

Estimated Time (min) Saved 2006 EstimatedTime (min) Saved 2007

Estimated FNVHO/F MD* Productive Time Expanded Using Outpatient Palliative Care Services

Referring Physician

Min

ute

s

Average of 170 minutes of provider time saved per referral to PC

ASCO QOPI “Palliative Subset” (Core Measures)Pain Assessment

3. Pain assessed by the second office visit (%) 4. Pain intensity quantified by the second office visit (%) 5. For patients with moderate to severe pain, documentation that pain

was addressed (%) Narcotic analgesic assessment 6. Effectiveness of pain medication assessed on visit following new

narcotic prescription (%) 7. Constipation assessed at time of or at first visit following new

narcotic analgesic prescription (%) Psychosocial support (Test) 21. Chart documents patient’s emotional well-being was assessed

within one month of first visit to office (%) 22. For patients identified with a problem with emotional well-being,

the chart documents that action was taken within one month of first visit to office (%)

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ASCO QOPI “Palliative Subset” (Care at End of Life Measures)

Pain assessed and documented near the end of life 35. Pain assessed on the second to last or last visit before death (%) 36. Pain intensity quantified on second to last or last visit before death (%)

Dyspnea assessed near the end of life 37. Dyspnea assessed on second to last or last office visit before death (%) 38. Action taken to ease dyspnea on second to last or last office visit before death

(%) Timing of hospice enrollment

39. Patient enrolled in hospice before death (%) 40. Patient enrolled in hospice/referred for palliative care services before death (%) 41. Patient enrolled in hospice within 3 days of death (%) (Lower Score - Better) 42. Patient enrolled in hospice within 1 week of death (%) (Lower Score - Better) 43. For patients not referred in last 2 months of life, hospice/palliative care

discussed (%) Timing of chemotherapy administration before death

44. Chemotherapy administered within the last two weeks of life (%) (Lower Score -Better)

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PC = Improved SurvivalThe New England Journal of Medicine - original

articleEarly Palliative Care for Patients with Metastatic

Non–Small-Cell Lung CancerRCT – standard care vs standard plus PCImproved QOLDecreased resource utilization (33% vs. 54%, P = 0.05)Lived 3 months longer (11.6 months vs. 8.9 months,

P = 0.02)

J. Temel, et al., n engl j med 363(8): 733-742 (august 19, 2010)

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Palliative Care = Positive Bottom Line

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60 Minutes Nov. 22, 2009

The Cost of Dying: Patients' Last Two Months of Life Cost Medicare $50 Billion Last Year; Is There a Better Way?More than the budget of the

Department of Homeland Security or the Department of Education

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PC Cost Savings…• Palliative Care Consultation

• Hospital-based (8 Hospitals)

• 2900 patients matched to 18,000 “usual care”

• 2400 died matched to 2100 “usual care”

• D/C - $1696 cost reduction (p=0.004)

$279/day (p<0.001)

• Died - $4908 cost reduction (p=0.003)

$374/day (p<0.001)Morrison, S, et al, Arch Intern Med.168(16):1783-90, 2008

Palliative Care Benchmarking…PC Unit: Saves $1Million/year

White, K, et al, Nonclinical Outcomes of Hospital-based Palliative Care. J Healthcare Mgt 51(4):260-274, 2006

UHC: w “hi-mortality dx” (cancer, CHF, HIV, COPD/vent)PC Consultation:

4Reduction of average costs/pt/day: $2204Higher % Key Performance Measures4“PC Bundle”: higher quality/lower cost and

shorter LOS

Cassel, B, Smith, T, et al, PC Benchmarks from AMCs, JPM, 2006

Palliative Care Benchmarking…4“PC Bundle”: higher quality/lower cost and

shorter LOS (15.8 -> 15.6 -> 12.5)

Cassel, B, Smith, T, et al, PC Benchmarks from AMCs, JPM, 2006

Impact of Continuum of H/PC

Brumley, R, et al, JPallMed, 2003 (Kaiser Permanente)

SummaryUnprecedented opportunity:

High quality care

Care across an enhanced continuum

Reduce health care expenditures

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Documents

1 Best Practices: Hospice and Palliative Care in Advanced Cancer J. Cameron Muir, MD, FAAHPM EVP, Quality and Access, Capital Caring Clinical Scholar,