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Palliative Care – A Palliative Care – A Luxury you cannot Luxury you cannot
afford?afford?
James Hallenbeck, MDJames Hallenbeck, MDAssistant Professor of MedicineAssistant Professor of Medicine
Director, Palliative Care Director, Palliative Care ServicesServices
VA Palo Alto HCSVA Palo Alto HCS
AgendaAgenda
Review data regarding where veterans Review data regarding where veterans die, associated costs and correlationsdie, associated costs and correlations
Encourage you to think about barriers to Encourage you to think about barriers to the expansion of palliative care in VAthe expansion of palliative care in VA
Challenge the assumption that palliative Challenge the assumption that palliative care is a luxury we cannot affordcare is a luxury we cannot afford
Palliative Care in the VAPalliative Care in the VA
VA is the largest unified healthcare system VA is the largest unified healthcare system in the countryin the country
28% of Americans dying each year are 28% of Americans dying each year are veterans (more than die from all cancers veterans (more than die from all cancers annually)annually)
VA is a potential model for universal VA is a potential model for universal healthcare of an aged, chronically ill healthcare of an aged, chronically ill populationpopulation
Unified database for analysisUnified database for analysis
Important to study Important to study because…because…
Annual Veteran Annual Veteran DeathsDeaths
A small percentage of veterans die as inpatients in VA facilities
Questions for VA and for YouQuestions for VA and for You
Should VA invest in palliative care?Should VA invest in palliative care? Is such care “cost-effective”?Is such care “cost-effective”? Could adequate dollars be cost-shifted or Could adequate dollars be cost-shifted or
avoided to justify such an investment? avoided to justify such an investment? Why is there such variance across VA Why is there such variance across VA
regions and facilities? regions and facilities?
Is palliative care is luxury the VA cannot afford, or can the VA not
afford not to have palliative care?
Good News Good News Establishment of hospice treating Establishment of hospice treating
specialty 2002specialty 2002 Interprofessional Palliative Care Interprofessional Palliative Care
Fellowship 2002Fellowship 2002 Mandated palliative care consult teams Mandated palliative care consult teams
20032003 Accelerated Administrative and Clinical Accelerated Administrative and Clinical
Training (AACT) initiative 2002-Training (AACT) initiative 2002- Establishment of Hospice-Veteran Establishment of Hospice-Veteran
Partnerships (HVPs) 2002-Partnerships (HVPs) 2002-
Examples of Palliative Care Examples of Palliative Care InterventionsInterventions
Palliative care consultation teams Palliative care consultation teams Palliative care clinicsPalliative care clinics Nursing home hospice programsNursing home hospice programs Active management of home hospice Active management of home hospice
programsprograms Palliative care training programs for Palliative care training programs for
students, residents, palliative care students, residents, palliative care fellowshipsfellowships
ChallengesChallenges
Assumption: Assumption: Something “nice” like Something “nice” like palliative care must be a luxury we palliative care must be a luxury we cannot affordcannot afford
Zero-Sum Game and Life-Boat TriageZero-Sum Game and Life-Boat Triage To spend more on palliative care in the To spend more on palliative care in the
short run means to spend less on short run means to spend less on something else something else
Competing missions Competing missions Institutional Inertia Institutional Inertia
Management Argument: Management Argument: “We cannot afford palliative “We cannot afford palliative
care”care”
Assumptions-Assumptions- We have no choice as to where veterans We have no choice as to where veterans
die or how much it costsdie or how much it costs Palliative care services would just be an Palliative care services would just be an
additional expense without true cost additional expense without true cost savingssavings Even if it would be “nice” to have…Even if it would be “nice” to have…
SHOW ME DATA!SHOW ME DATA!
The skeptical The skeptical manager says…manager says…
Initial Questions:Initial Questions: What do people What do people wantwant toward the end-of- toward the end-of-
life?life? What constitutes good care? What do they What constitutes good care? What do they getget
Where do people die?Where do people die? What do they die from?What do they die from? How much does it cost?How much does it cost? How much variability exists in the above How much variability exists in the above
parameters parameters And what accounts for this variability?And what accounts for this variability?
WHAT DO PEOPLE WHAT DO PEOPLE WANT?WANT?
What would be most What would be most important to you?important to you?
Steinhauser K et. al. , Factors considered important at the end Steinhauser K et. al. , Factors considered important at the end of life by patients, family, physicians, and other care providers of life by patients, family, physicians, and other care providers
JAMA, 2000; 284(19):.2476-2482JAMA, 2000; 284(19):.2476-2482
Where do people Where do people die?die?
Major Site: Acute Care Major Site: Acute Care HospitalHospital
Traditionally, people died in their homes. Only Traditionally, people died in their homes. Only a few decades ago, the hospital was a few decades ago, the hospital was considered the “place where people went to considered the “place where people went to die,” and was avoided by many, including the die,” and was avoided by many, including the dying, for that very reason. Now, perhaps dying, for that very reason. Now, perhaps ironically, that the hospital is seen as being ironically, that the hospital is seen as being for short-term care, people enter more for short-term care, people enter more readily – and die there more often.readily – and die there more often.
Richard A. KalishRichard A. Kalish
Honoring Veterans’ Honoring Veterans’ Preferences at the Preferences at the
End-of-LifeEnd-of-Life
Patient Preferences for Site of DeathPatient Preferences for Site of DeathHome vs. Hospital or Nursing HomeHome vs. Hospital or Nursing Home
Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient preferences and local health system characteristics on the place preferences and local health system characteristics on the place
of death. SUPPORT Investigators. Study to Understand of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Prognoses and Preferences for Risks and Outcomes of
Treatment." Treatment." J Am Geriatr SocJ Am Geriatr Soc 46 46(10): 1242-50.(10): 1242-50.
“Whether people die in the hospital or not is powerfully influenced by
characteristics of the local health system but not by patient preferences or other
patient characteristics.”
Palliative and End-Palliative and End-of-Life Care in the of-Life Care in the
VAVAEarly FindingsEarly Findings
Patient Demographics VA Patient Demographics VA Inpatient Deaths FY00Inpatient Deaths FY00
47% over age 7547% over age 75
45% married45% married
Median annual income < $10,000Median annual income < $10,000 25% no reported income25% no reported income
35% Service Connected 35% Service Connected
Many veterans dying as inpatients have poor social support structures
Average Cost per Day for Average Cost per Day for Terminal Admissions FY00Terminal Admissions FY00
$0$100$200$300$400$500$600$700$800$900
$1,000
Palo Alto AcuteCare
Other Facility 1 Other Facility 2 Palo AltoHospice Care
Center
Non-Hospice Percent Total Costs Non-Hospice Percent Total Costs Acute Care VA Palo Alto FY00Acute Care VA Palo Alto FY00
Non-Hospice Percent Total Costs
Pharmacy8%
MedProc21%
Nursing55%
MH0%
Other16%
0% 0% MentMental al HealtHealthh
21% 21% Medical Medical ProceduProceduresres
Palo Alto Hospice Costs FY00 Palo Alto Hospice Costs FY00
Hospice Percent of Total Costs
Pharmacy7% MedProc
2%
Nursing75%
MH13%
Other3%
13% 13% Mental Mental HealthHealth
2% 2% Medical Medical ProcedurProcedureses
NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR PIEPIE
Palo Alto VA: Acute/ICU Deaths: 30 pts Discharge Diagnoses FY00
41%
10%7%3%
3%
21%
3%
3%
3%
3%
3%
Met cancer
Cirrhosis
End-stage renal
Hip fx
Stroke
Heart dx
COPD
Aneurism
Pericarditis
Sepsis
Head injury
MOST CAUSES OF DEATH IN ACUTE CARE PREDICTABLE AND NOT SIGNIFICANTLY DIFFERENT
FROM HOSPICE
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
National Palo Alto Lebanon Dayton
National vs three stations with palliative care units
FY 2000 Inpatient Deaths by Location
ICU (all)
General Medicine
Intermediate Medicine
Nursing Home
Responses from Managers…Responses from Managers…
““Doesn’t prove anything”Doesn’t prove anything” – differences – differences may have arisen from:may have arisen from: Referral and selection biases: (hospice Referral and selection biases: (hospice
patients more end-stage, preferred less patients more end-stage, preferred less aggressive/expense care)aggressive/expense care)
““You don’t know our patients - they want You don’t know our patients - they want more aggressive care based on… different more aggressive care based on… different illnesses, age, ethnicity etc.”illnesses, age, ethnicity etc.”
Background Message:Background Message:
‘‘Immutable patient variables Immutable patient variables predominantly determine where predominantly determine where patients die and how much it costs’patients die and how much it costs’
Implication: Changing the system will make Implication: Changing the system will make little differencelittle difference
And thus status-quo is And thus status-quo is maintainedmaintained
Patient vs. System VariablesPatient vs. System Variables
Patient variablesPatient variables AgeAge GenderGender RaceRace IncomeIncome Diseases (DRG)Diseases (DRG) Proximity/Proximity/
distance to care distance to care venuesvenues
Preferences for Preferences for carecare
System variablesSystem variables Total hospital bedsTotal hospital beds ICU bedsICU beds Nursing Home bedsNursing Home beds Availability of Availability of
Palliative Care Palliative Care Consult TeamConsult Team
Dedicated PC bedsDedicated PC beds Geographic Geographic
locations of locations of hospitals and PC hospitals and PC unitsunits
Demographics and Associated Demographics and Associated Costs of Dying for Enrolled Costs of Dying for Enrolled
VeteransVeteransPreliminary FindingsPreliminary Findings
James Hallenbeck, MDJames Hallenbeck, MD
James Breckenridge, PhDJames Breckenridge, PhD
Co-Principal InvestigatorsCo-Principal Investigators
VA Palo Alto HCSVA Palo Alto HCS
Susan Ettner, PhD, UCLA, Susan Ettner, PhD, UCLA,
Karl Lorenz, MD, UCLAKarl Lorenz, MD, UCLA
David Draper, PhD. U.C. Santa Cruz David Draper, PhD. U.C. Santa Cruz
Co-investigators Co-investigators Funded by the Robert Wood Johnson Funded by the Robert Wood Johnson
FoundationFoundation
Study PurposesStudy Purposes
Archeological – A “dig” in VA databasesArcheological – A “dig” in VA databases Where veterans dieWhere veterans die Demographic and system correlates with terminal venueDemographic and system correlates with terminal venue Patterns of care across venuesPatterns of care across venues
Economic – Examining relationship between care Economic – Examining relationship between care patterns and cost of carepatterns and cost of care Costs of care in different venuesCosts of care in different venues Instrumental variable analysis: comparing costs of Instrumental variable analysis: comparing costs of
deaths in dedicated palliative care beds to deaths deaths in dedicated palliative care beds to deaths elsewhereelsewhere
MethodologyMethodology Population: Population: All veterans during FY 00-02 All veterans during FY 00-02
with at least one institutional staywith at least one institutional stay: 849,489 : 849,489 individualsindividuals
Veterans who died Veterans who died during this time periodduring this time period:: 172,086 172,086 (20%)(20%)
Last institutional venue:Last institutional venue: ICU, Acute Care (non-ICU), Nursing Home, ICU, Acute Care (non-ICU), Nursing Home,
Other, Dedicated Palliative Care Bed Other, Dedicated Palliative Care Bed Analyze associated demographics and Analyze associated demographics and
costscosts
In Hospital DeathsIn Hospital Deaths
Dartmouth Atlas: Dartmouth Atlas: www.dartmouthatlas.org/ www.dartmouthatlas.org/
VA Institutional Deaths by VISN
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23
VISN
Pe
rce
nt
by
ve
nu
e
OTHER/PSCH
NHC/INT
Acute
ICU
41% of Acute Care Deaths in 41% of Acute Care Deaths in ICUICU
39% of acute care deaths for 39% of acute care deaths for Pts 65+ Pts 65+
n = n = 79,38979,389
Controlling for Charlson Co-morbidity Controlling for Charlson Co-morbidity Index, HCUP/CCS Diagnosis-based Risk Index, HCUP/CCS Diagnosis-based Risk adjustment, Age, Sex, Race and Distance adjustment, Age, Sex, Race and Distance Nearest VANearest VA
p = .002, r = p = .002, r = -.64-.64
Plots facility nursing home deaths per 1000 patients in the Plots facility nursing home deaths per 1000 patients in the study population against ICU deaths as a percentage of all study population against ICU deaths as a percentage of all institutional deaths and deaths within 30 days of dischargeinstitutional deaths and deaths within 30 days of discharge
r= -.52, r= -.52, p=000p=000
What do people die What do people die from in ICUs?from in ICUs?
ICU Terminal Stay ICD9 ICU Terminal Stay ICD9 CodesCodes
Diagnosis Freq Diagnosis Freq % %
Diagnosis Freq Diagnosis Freq % %SUBENDO INFARCT, INITIAL 467 2.19
AMI NOS, INITIAL 459 2.15FOOD/VOMIT PNEUMONITIS 424 1.98CRNRY ATHRSCL NATVE VSSL 407 1.9CARDIAC ARREST 368 1.72ACUTE RENAL FAILURE NOS 339 1.59ALCOHOL CIRRHOSIS LIVER 331 1.55GASTROINTEST HEMORR NOS 246 1.15MAL NEO UPPER LOBE LUNG 229 1.07MAL NEO BRONCH/LUNG NOS 206 0.96INTRACEREBRAL HEMORRHAGE 184 0.86URIN TRACT INFECTION NOS 181 0.85ATRIAL FIBRILLATION 174 0.81HYPOVOLEMIA 171 0.8OTHER PULMONARY INSUFF 170 0.8STAPH AUREUS PNEUMONIA 168 0.79SHOCK W/O TRAUMA NEC 164 0.77CRBL ART OCL NOS W INFRC 162 0.76ACUTE PANCREATITIS 158 0.74STAPH AUREUS SEPTICEMIA 155 0.73AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58
AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58CVA 121 0.57PNEUMOCOCCAL PNEUMONIA 117 0.55CHR AIRWAY OBSTRUCT NEC 115 0.54PULM EMBOL/INFARCT NEC 103 0.48CIRRHOSIS OF LIVER NOS 102 0.48AORTIC VALVE DISORDER 98 0.46MAL NEO LOWER LOBE LUNG 97 0.45PLEURAL EFFUSION NOS 94 0.44PSEUDOMONAL PNEUMONIA 93 0.44INTESTINAL OBSTRUCT NOS 92 0.43ACT MYL LEUK W/O RMSION 91 0.43RUPT ABD AORTIC ANEURYSM 91 0.43HEMATEMESIS 87 0.41POSTINFLAM PULM FIBROSIS 78 0.36HYPOTENSION NOS 77 0.36ANOXIC BRAIN DAMAGE 76 0.36ATH EXT NTV ART GNGRENE 76 0.36CHRONIC RENAL FAILURE 76 0.36SEPTICEMIA NEC 73 0.34AMI ANTEROLATERAL, INIT 72 0.34
How much does it How much does it cost?cost?
Cost per Day Terminal StaysCost per Day Terminal Stays
AverageAverage MedianMedian Average Average LOSLOS
ICUICU $1624$1624 $1406$1406 10.710.7
AcuteAcute $641$641 $536$536 10.310.3
NHCNHC $253$253 $230$230 **
Palliative Palliative
CareCare
$278$278 $262$262 2424
n = 79,389n = 79,389
Direct Costs of Care for Last Six Direct Costs of Care for Last Six Months and Last Year of LifeMonths and Last Year of Life
Institutional Institutional CostsCosts
Outpatient & Outpatient & Fee CostsFee Costs
TotalTotal
Direct CostsDirect Costs
Six Six MonthsMonths
$743,162,000$743,162,000 $159,604,000$159,604,000 $902,766,000$902,766,000
One One
YearYear
$966,439,000$966,439,000 $204,832,000$204,832,000 $1,172,237,000$1,172,237,000
> 10% VA clinical budget spent for > 10% VA clinical budget spent for <1.5% VA enrolled population in the <1.5% VA enrolled population in the
last year of life…last year of life…
Costs of Terminal StaysCosts of Terminal Stays
Percentage total cost by venue
38%
29%
18%
4%
11%ICU Deaths
Acute Care Deaths
NHC Deaths
Ded. Palliative CareDeaths
Other Setting
Annual direct DSS costs of terminal admits:Annual direct DSS costs of terminal admits: $387,367,000 $387,367,000
67% of costs in acute care67% of costs in acute care
Total Inpatient Costs in Last Six Months for All Deaths and the Percentage of Deaths in Intensive Care by VA Facility
y = 14504e2.3383x
R2 = 0.3286
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
0% 10% 20% 30% 40% 50% 60% 70%
Percentage Dying in Intensive Care
Six
Mon
th T
otal
Cos
ts
How can we put this How can we put this all together?all together?
National Trends Affecting National Trends Affecting Terminal VenuesTerminal Venues
Decreasing acute care workloadDecreasing acute care workload 55% decrease in # of acute beds 1994-98*55% decrease in # of acute beds 1994-98* (ADC down 23% FY02 vs. FY97)(ADC down 23% FY02 vs. FY97)
A proportional A proportional increase increase in ICU in ICU workload, as percentage of acute workload, as percentage of acute workloadworkload
VA nursing homes: Mandate to keep VA nursing homes: Mandate to keep high ADChigh ADC
* Ashton: N Engl J Med, Volume 349(17).October 23, 2003.1637-1646
ICU Beds as Percentage Acute ICU Beds as Percentage Acute Care BedsCare Beds
1972 1972 All All
HospHosp
1990 VA 1990 VA Med/SurgMed/Surg
1992 1992 All All
Hosp Hosp
2001 VA 2001 VA Med/SurgMed/Surg
20012001
JapanJapan
% % Acute Acute CareCare
2.5%2.5% <6%<6% 8.6%8.6% 21%21% 1%1%
Acute Care Triage: Up, Down or Acute Care Triage: Up, Down or OutOut
Non-ICU acute care less a Non-ICU acute care less a venue for venue for treatmenttreatment than than for for triagetriage Patients triaged “up” to ICU Patients triaged “up” to ICU
or “down” (to nursing or “down” (to nursing homes) or “out” discharged homes) or “out” discharged to home/non-VA careto home/non-VA care
Imperative to Imperative to “decompress” acute care “decompress” acute care beds using nursing home beds using nursing home beds in conflict with beds in conflict with mandate to maintain high mandate to maintain high ADC.ADC.
Like squeezing Like squeezing the middle of a the middle of a
tube of tube of toothpaste…toothpaste…
An Impacted SystemAn Impacted System
Dying veterans tend to follow other sick Dying veterans tend to follow other sick veterans veterans A greater proportion go to ICU and get A greater proportion go to ICU and get
“stuck” there, even if dying is eventually “stuck” there, even if dying is eventually recognized, perhaps because of a lack of recognized, perhaps because of a lack of reasonable, alternative venues reasonable, alternative venues
Dying veterans at risk for discharge Dying veterans at risk for discharge without appropriate or adequate without appropriate or adequate services such as home hospiceservices such as home hospice
Perhaps…Perhaps…
A Field of Dreams…
SUMMARYSUMMARY
System variables are major factors in determining System variables are major factors in determining where and how veterans diewhere and how veterans die
Significant cost-savings/cost-avoidance can be Significant cost-savings/cost-avoidance can be realized by incorporating palliative care into VA realized by incorporating palliative care into VA healthcare systemshealthcare systems
Palliative care is not a luxury, but should be a Palliative care is not a luxury, but should be a standard of care that should be incorporated standard of care that should be incorporated into all venues in which seriously-ill patients into all venues in which seriously-ill patients are treated within VAare treated within VA
Evidence Evidence SuggestsSuggests::