View
213
Download
0
Category
Tags:
Preview:
Citation preview
Improving oncology care with more integration of palliative care
Thomas J. Smith, MD FACP Harry J. Duffey Family Professor of Palliative Medicine
Director of Palliative MedicineJohns Hopkins Medical Institutions
Professor of OncologySidney Kimmel Comprehensive Cancer Center
tsmit136@jhmi.edi
Objectives1. Reasons why.2. Smaller fixes within reach.
a) More use of palliative care consultation services.b) More “primary palliative care” in oncology practicesc) More and earlier use of hospice (live better and longer)
3. Big fixes.a) Insurance: Aetna’s Compassionate Care Programb) Sutter Health Advanced Illness Model
Medical care costs 2-fold more in the US than any other country
OECD Health Data 2011
Australi
a
Austria
Belgium
Canad
a
Denmark
Finlan
d
France
German
y
Icelan
d
Irelan
dIsr
ael
ItalyJap
an
Netherla
nds
New Zeala
nd
Norway
Sweden
Switz
erland
United Kingd
om
United St
ates
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$4500
$8100
Cancer care costs are rising exponentially- $173 billion at 2% growth rate
1990 1995 2000 2005 2010 2015 20200
20406080
100120140160180
Cancer Care Costs (Billions)
Year
Mariotto AB, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28.
Claxton G, et al. Health Aff (Millwood). 2010 Oct;29(10):1942-50.
Care patterns for cancer patients who died at a major medical center, Summer 2011 (see Dy S et al, JPM 2011; *Dow and Smith, JCO 2010)
Process measure N (%) Targets
Seriously ill 61
Use of ventilator 16 (26) 10%
Deceased 35 (57)
Any goals of care discussion 26 (43) 95%
Advance directives on file 4 (7) 90%
Oncologist brought up Ads* 2/75 (1%) 100%
Death in hospital 21 (34) 10%
Discharged with hospice 14 (23) 60%
Chemo with 2 weeks of death, solid tumor patients
28-35% <10%
Quality of care is not optimal
We are still hospital oriented and not hospice oriented near the very predictable end of life.
Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics, Morden, Health Affairs 2011
Measure AllNCCN cancer centers
Academic hospitals
Community hospitals
Death in hospital (%) 30.2 32.6 33.8 29.7Hospice use, last month of life (%) 53.8 53.4 50.3 54.2
Days in hospice, last month of life (per decedent)
8.4 8.6 7.6 8.5
Hospitalized, last month of life (%) 64.9 60.2 64.4 65.1
ICU use, last month of life (%) 24.7 23.3 26 24.6
QOL concerns are not raised or discussed in cancer clinical settings.
2010 ACS CAN National Poll on Facing Cancer in the Health Care System (www.acscan.org)
Q: After diagnosis and before starting treatment, did anyone on care team ask what is important to you/family in terms of QOL?
3/4s of patients with lung and colon cancer think they could be cured with chemo (Weeks J, et al. NEJM 2012)• Half of all lung cancer patients have had NO discussion with any of their
doctors about hospice 2 months before they die. Huskamp HA, et al. Arch Intern Med. 2009
• Only 37% of patients have any conversation about dying. (Wright AA, JAMA 2008)
• 60% of us prefer not to have “hard conversations” (DNR, AMDs, hospice) until “there are no more treatment options left”. Keating NL, et al. Cancer. 2010
• Telling some one they are “incurable” is not enough – people want information about prognosis, what will happen to them, and their options.
Definition of palliative care“Palliative care is specialized medical care for people with
serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.
Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”
– Diane Meier, MD, Director, Center to Advance Palliative Care, July 1, 2011
Palliative care in addition to usual oncology care allowed lung cancer patients to live almost 3 months longer than those who got usual oncology care. Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011
Longer and better survival Better understanding of
prognosis Less IV chemo in last 60 days Less aggressive end of life
care More and longer use of
hospice $2000 per person savings to
insurers and society
The American Society of Clinical Oncology now recommends “…combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”
- Now 5 randomized trials showing the same results.- No trials showing harm or increased costs.
Hospice in the United States• Hospice is defined as a Medical Benefit• Truly managed care:
– $150 a day outpatient, $500 a day inpatient– Everything must be paid from that
• Must have a 50/50 chance of death in the next 6 months if the disease runs its natural course
• Hospice eligibility: Hospice in a Minute
How do we better integrate palliative care into our care?
• Primary PC: every oncologist should be able to do.– Communication (ask, tell, ask)– Symptom Assessment and management (ESAS, MSAS)– Spiritual assessment (FICA, SNAP, AMEN)– Hospice referrals
• Secondary PC: referral, just like referral to cardiologist.• Tertiary PC: specialized inpatient and research programs.
• Need more PC people– Fellowships– Advanced training (EPEC-O, ELNEC, OncoTalk)
How to do palliative care in the office.Cheng J, King L, Alesi ER, Smith TJ. J Oncol Practice, 2013
Table 1: Components of Office-based Primary Oncology Palliative Care 1. Ask, Tell, Ask.
Always ask people how much they want to know, and what they do know.Then tell them, in understandable words.Ask “What is your understanding of your situation?”
2. At each transition point (when changing treatments or prognosis) ask, tell, ask. “What are you hoping for?” and “What is your understanding of your situation?”
3. Always do a symptom assessment. 4. At least some of the time, do a spiritual assessment. 5. Make a “hospice information referral” when the patient still has 3-6 months left to live.
6. Audit hospice referrals, like QOPI does. 7. Set up “best practices” for seriously ill patients who have less than a year to live. 8. Take advantage of decision aids to help those patients who want to know their prognosis. Use www.Eprognosis.org
9. Use some “palliative care pearls” in your practice, such as olanzapine for nausea, ginger for nausea, ginseng or dexamethasone for fatigue and better quality of life.
10. Use chart prompts in your EMR.Advance Directive __Yes __ No __ Not discussedCode status __Full ___DNR Other _______________DPMA ___________________________________
There are opportunities to improve our practice on hospice referrals
Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics, Morden N, Health Affairs 2011
Measure AllNCCN cancer centers
Academic hospitals
Community hospitals
Death in hospital (%) 30.2 32.6 33.8 29.7
Hospice use, last month of life (%) 53.8 53.4 50.3 54.2
Days in hospice, last month of life (per decedent)
8.4 8.6 7.6 8.5
Hospitalized, last month of life (%) 64.9 60.2 64.4 65.1
How do we better integrate hospice into our care?
• Have a “hospice information visit” when we think the person has 3-12 months to live.
• Can’t hurt. OK to predict wrongly.• Can dramatically help
– Makes us address difficult issues like “code status”– Informs family that the situation is serious and their loved
one is dying– MOLST– Will, Living Will, DPMA, Life Review, Dignity therapy
Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct 25;367(17):1651-2. doi: 10.1056/NEJMe1211160.
Hospice eligibility is straightforward
• The SURPRISE QUESTION: “Would you be surprised if this person were to die in the next 6 months?”
• Failure to thrive: BMI < 22, involuntary weight loss
• CHF NYHA Class IV, EF < 20%• COPD: hypoxemia at rest, FEV1 < 30%• Dementia < 6 words• Liver disease: INR > 1.5, albumin < 2.5• Cancer – much easier. Salpeter et al. J
Palliat Med. 2012 Feb;15(2):175-85– Hypercalcemia, any malignant effusion, spinal
cord compression, ECOG PS 2 or higher
The benefits are straightforward…better care, and people who use hospice for even one day live longer.
Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.
We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more.
U of Iowa Hospitals. • 688 in-hospital deaths • 209 decedents had preceding admission • 60% of decedents were eligible for hospice on the
penultimate admission, based on NHPCO, National Hospice and Palliative Care Organization worksheets.
-Only 14% had any discussion of hospice, despite being eligible; 14 of 17 enrolled, all from ONE service
- Hopkins among the lowest of UHC Hospitals for hospice discharges from Cardiology, some other services
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.
We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more.
Table: Comparison of Cost and Length of Stay Between Patients Enrolled and Not Enrolled in Hospice During a Terminal Hospital Admission
Enrolled in hospice before last admission n = 7/14
Not enrolled in hospice, all diagnoses, n = 202/209
Cost Mean $4963 $52 219 Median $3690 $23 322 Standard deviation
$3250 $85 101
Standard deviation
4.47 25.05
Palliative Care Consultation YES, $41,859 NO, $58,386P<0.04
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.Weckmann MT, et al. Am J Hosp Palliat Care. 2012 Sep 5.
People who use hospice are re-admitted less often, use less medical resources, and get better care.
Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9.
Table 2. Readmission Rate by Post-discharge Medical Service Use Post-discharge medical services Ratio of readmissions Percent Hospice 11/240 4.6 Home-based palliative care 5/60 8.3 Home health 2/15 13.3 Nursing facility 14/58 24.1 Home no care 9/35 25.7
Hospice saves Medicare $2309 per decedent, and the longer the hospiceLength of stay, the bigger the savings. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27.
Better care, consistent with what people would choose. Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-of-life care. J Palliat Med. 1998 Fall;1(3):221-30.
Identifying hospice eligible patients makes a difference
Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul0
5
10
15
20
25
30
Fig 1. Increase in GH Referrals Since JH PC Program Started Oct 2011
PC program
Change our standards of care to incorporate national guidelines and best practices about palliative care.
7. Set guidelines like the U S Oncology pathways that preserve survival, reduce cost by 35% in lung and colon cancer
For NSCLC and colon cancer, equal results, less toxicity, less cost.Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8. Hoverman JR, et al. J Oncol Pract. 2011 May;7(3 Suppl):52s-9s
Equal survivalWith no 3, 4, 5th
Line chemo
GenericsLimit to 3 “lines”Of chemo
Less chemoLess hospital
More hospice2x↑ LOS, use
Someone in the office- AMDs- DPMA- Hospice info visit
Advanced Care:
How choice, comfort and dignitycan drive cost reduction
in a shared risk/shared savings world
Brad Stuart MDstuartb@sutterhealth.org
“Bending the Cost Curve for Seriously Ill Patients” Annual Assembly of AAHPM & HPNA
March 8, 2012
Moving Care Out of the Hospital
HOSPITALS• Emergency Dept.• Hospitalists• Inpatient palliative care• Case managers• Discharge planners
MEDICAL OFFICES• Physicians• Office staff
HOME-BASED SERVICES• Home health• Hospice
• Telesupport Center
New Advanced Care staff & services
EHR• Patient Registry
911
• Care Liaisons
• Care managers• Telesupport
• Transitions Team
CRITICAL EVENTS• Acute exacerbation• Pain crisis• Family anxiety
CRITICAL EVENTS• Acute exacerbation• Pain crisis• Family anxiety
Tracking the Process of Personal Choice
HOSPITALS
PHYSICIANOFFICES
HOME-BASED SERVICES
TELESUPPORTEHR
Shared decisionsmade over timeat the patient’s
own pace
Start the conversation• Inpatient PC• Hospitalist• PCP
Handoff
Trained teamlinked acrossall settings
Continuityat high or lowacuity
Advanced Illness Management (AIM) 90 Days Pre/Post Enrollment
– Hospital• 54% reduction in admissions• 80% reduction in ICU days• 26% reduction in inpatient LOS (2
days/case)– Physicians
– Home• 52% reduction in MD visits
• 60% increase in hospice enrollment• 49% increase in home health enrollment
Net System, Payer SavingsPayer Mix = 71% Medicare
• Per Beneficiary Per Month:
312 million x 10% = $ 14.2 billionPotential Medicare Savings:
– System savings $1125– AIM rollout expense ($ 912)– Net system gain $ 213 PBPM
Total payer savings $ 760 PBPM
x 5% x $760/mo.
x 12 mo/yr.
Lessons Learned in Advanced Care
• Re-engineer, re-brand, integrate– Add services people, clinicians want &
need– Integrate MDs, AC, PC & Hospice
• Personal goals drive cost savings– Person-centered trumps “patient-
centered”– Seriously ill people don’t want to be
patients
• Turn the business model upside down– Get the heads out of the beds– Invest in home and community
1. Palliative care alongside usual care is now the accepted best practice.
2. All the evidence suggests equal or better quality of life, fewer symptoms, equal or better survival, and less cost, with no harms.
3. There is still a LOT of research to be done to improve “trigger points”, symptoms, integration of PC into usual care, identification of patients and families who can benefit, and communication.
4. Advanced Illness Management Models improve care and save money but require an integrated health system.
Conclusions
Recommended