Quill eol policy

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


Financial Disclosure Statement

Dr. Quill has no relevant financial

relationships to disclose


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


As Illness Progresses…An Increasing Emphasis on Palliation


Age Distribution of US population Age Distribution of US population

10,000 people/day

http://www:metlife.comhttp://www:metlife.com





Where more can be less


Fisher,E. NEJM 2-26-09

5%

4%

3%

2.4%

Regional Variation in Health Care costs


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.


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



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



Two Recent Palliative Care Studies Relevant to Cost, Quality, and Mortality


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


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


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


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)


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


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


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


Palliative Care and Cost Outcomes

* p<.05; + p<.01; ++ p<.001; N/A Not Applicable


Cost/Day For Patients Discharged Alive


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.


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


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


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.

Health & Medicine

Quill eol policy