Palliative Care Tied to Cost Savings for Seriously Ill Hospitalized Adults

NEW YORK (Reuters Health) - Palliative-care consultations are associated with reduced direct hospital costs for adults with serious illness, according to a meta-analysis.

"Previous studies have often found that patterns of treatment for the sickest people, and especially those at end of life, are immutable," Dr. Peter May from Trinity College Dublin, in Ireland, told Reuters Health by email. "But our findings instead suggest that interdisciplinary decision-making may be more effective for that group - in effect, complex patients are best served by complex interventions."

Palliative care takes an interdisciplinary approach to improve quality of life for seriously ill patients and their families through symptom management, communication and patient autonomy. A previous literature review found that palliative-care consultation (PCC) teams are associated with reduced hospital costs.

Dr. May and colleagues estimated the association of PCC with total direct cost of hospital care for adults with serious illness and investigated whether the association varies by primary diagnosis and number of comorbidities in their meta-analysis of six studies including more than 133,000 patients.

Overall, 3.6% of patients received a PPC, 40.8% had a primary diagnosis of cancer and 93.2% were discharged alive, the team reports in JAMA Internal Medicine, online April 30.

In the pooled analysis, PCC was associated with a significant $3,237 reduction in costs within three days of hospital admission, with significant reductions of $4,251 for cancer patients and $2,105 for non-cancer patients.

The cost savings were greater for patients with higher numbers of comorbidities, irrespective of their primary diagnosis. In post hoc analyses, the differences were significant for comparisons of groups with four or more comorbidities versus those with two or fewer comorbidities and for comparisons of those with three versus one or no comorbidities.

"Our findings contribute to a growing evidence base that palliative care both improves outcomes and reduces unnecessary treatments for people with serious and complex medical illness," Dr. May said.

"Integrating this evidence base into care of this population is a major systemic issue: in the U.S., a majority of physicians still report not having had training to discuss end-of-life care; and large numbers of people over 65 have neither documented their end-of-life care preferences nor discussed these with a physician," he explained. "This study has to be part of a larger conversation among physicians, policymakers, and the public to increase provision of care that is appropriate and responsive to the needs of seriously ill people."

"There is a potentially important economic aspect to these findings also," Dr. May said. "Those with multimorbidity account disproportionately for Medicare expenditures, including hospital admissions, and are growing in absolute and proportional terms among program beneficiaries. Increasing palliative care capacity and teams' involvement in the treatment of this population could not only improve patient experience but also improve long-term fiscal sustainability of health care for the aged."

Dr. Clare Gardiner from The University of Sheffield School of Nursing and Midwifery, in the U.K., recently examined the cost of palliative care there. She told Reuters Health by email, "The difference in cost savings between cancer and non-cancer is interesting, but should not be interpreted as evidence that palliative care is any less effective or worthwhile in non-cancer conditions. A more considered conclusion would be that further work is required to develop non-cancer palliative care approaches that have the capacity to influence hospital costs to the same extent as cancer palliative care consultations."

"It would be interesting to know whether the reduction in hospital costs was mediated by a reduction in length of hospital stay, as this has important implications for the potential shifting of costs from hospital into the community and onto patients and family caregivers," said Dr. Gardiner, who was not involved in the study. "If a reduction in hospital costs is accompanied by an increase in financial burden for patients and carers, then this should be acknowledged in any cost-benefit analysis."

"Hospital cost savings are important and politically appealing," Dr. Gardiner said, "but the improved patient and family outcomes that are also associated with palliative care should be paramount."

Dr. Nathan R. Handley from the University of Pennsylvania, in Philadelphia, who recently described strategies to reduce unplanned acute care for patients with cancer, told Reuters Health by email, "While not surprising, it's helpful to see the data that the patients who most benefit from palliative care consultation are the patients who need the services most - those with serious and complex medical illnesses, who account for a disproportionate amount of utilization that doesn't necessarily generate value of the same magnitude as the input."

"Cost reductions are most dramatic for patients with malignancy and patients with multiple comorbidities," he said. "These are patients that we're not always good at helping, but who need us most."

"While we cannot draw the conclusion that long-term costs are lower for patients receiving palliative care consultation based on this analysis specifically, lower costs for a single admission still strengthen the argument of moving away from fee-for-service (in which case, total reimbursement to a health system could be lower for a particular patient) to a value-based care (a system which would correctly incentivize the use of care across the continuum)," Dr. Handley said. "Such a recognition is important as we actively move into the world of the merit-based incentive payment system (MIPS) and advanced alternative payment models (aAPMs)."

"It's important to recognize that palliative care consultation is not a panacea, nor is it feasible for all hospitalized patients to receive specialized palliative-care consultation (the number of palliative-care-trained providers is simply insufficient for this)," said Dr. Handley, who also was not involved in the study. "As this report very clearly notes, prioritizing staff to high-need patients is of the utmost importance."


JAMA Intern Med 2018.



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