Brian Cassel

Nonclinical outcomes of hospital-based palliative care.

EXECUTIVE SUMMARY Evidence‐based outcomes are commonly used in making decisions about clinical care. For healthcare executives, evidence‐based outcomes also can be useful in making decisions about hospital services. Finkler and Ward (2003) suggest a model whereby cost measurement, cost control, and value assessment can be used as nonclinical, evidence‐based outcome measures to provide decision support and to guide management decisions. The Finkler and Ward framework is used to understand the financial implications of establishing an inpatient palliative care unit (PCU). A longitudinal study was conducted to examine the nonclinical outcomes associated with opening and operating an inpatient PCU at a large academic medical center during the first four years of the units operation. First, the cost of providing inpatient palliative care was measured. Results indicated that the cost per day to care for patients hospitalized in the last 20 days leading up to their death was significantly less on the PCU than on intensive care units and non‐PCUs. Average daily total charges exceeded reimbursement on the ICU and non‐PCUs, but the cost on the PCU for the same population was equal to or below the average daily total charges. Second, ways to control costs when operating an inpatient PCU were identified and measured. Evidence from one organization suggests that costs can effectively be controlled by admitting patients directly to the PCU and by appropriate use of hospital resources, including staff, ancillary services, and pharmaceuticals. Third, the study assessed the value to the institution of operating an inpatient PCU. Results indicated that the inpatient PCU yielded a cost savings of nearly

Palliative care in the USA and England: a critical analysis of meaning and implementation towards a public health approach

1 million by the third year of operations. This study highlights the nonclinical outcomes of one institutions inpatient PCU and provides guidelines for healthcare executives and managers to use in making decisions about adopting such programs.

Embedding palliative care into bone marrow transplantation clinic.

Abstract Delivering optimal and equitable palliative care is an international challenge. There are few cross-national comparisons examining challenges in expanding palliative care along public health lines. This paper presents a critical review of palliative care in the USA and England, which share similar challenges but have different contexts of healthcare. Beyond some obvious differences in the organisation of palliative care, a set of underlying common issues can be identified. A key tension in both is balancing attention ‘downstream’ in the dying phase, as well as ‘upstream’ earlier in the course of serious illness. In both, the dominant models of palliative care provision have resulted in excellent care towards the end of life for some patients, but there remain major deficiencies in care for the majority. England has a National Strategy for End-of-life care; the US has no equivalent, although a number of influential agencies have published statements. Achieving a public health approach in palliative care requires international consensus on the meaning and target population of palliative care, replacement of prognosis based understandings of entitlement to palliative care with a needs-based approach and development of an evidence base for cost-effective partnerships between providers across the specialist–generalist divide.

APRN Palliative Care Externship: Potential impact on oncology nursing palliative care delivery.

157 Background: Stem cell/bone marrow transplantation (SC/BMT) is intensive therapy that creates the potential for a number of physical and emotional symptoms. Despite the symptom burden and support needs of these patients there are no publications describing palliative care involvement in the course of treatment. METHODS Retrospective chart review was performed on 37 patients followed over a 6-month period by a palliative care service embedded within the SC/BMT clinic. RESULTS 37 patients were referred by SC/BMT clinic physicians or nurses to a palliative care team embedded within the clinic (including a physician, physical therapist, and psychologist). Almost all patients were referred for symptom management rather than goals of care; only three (9%) died during the review period and for none of them was the reason for consultation goals of care/hospice referral. Patients were seen between once and eight times during the six month period by various members of the team. Most (77%) were allogenic transplant patients and most were seen within 6 months of their transplantation. The most common reasons for referral were fatigue (57%), anorexia (27%), pain (38%) and depression and/or anxiety (35%). At initial assessment the highest-rated symptoms were lack of appetite (mean 4.78, SD 3.08), fatigue (4.51 [2.59]), and diminished feeling of well-being (4.16, [2.51]). At initial assessment, 73% of patients had 3 or more different symptoms that they rated at 4+; this dropped to 39.1% at follow-up (n = 23). Of the 9 symptoms assessed at both initial and follow-up visits, 7 decreased significantly (all but fatigue and dyspnea) and none increased. For example appetite improved from 5.52 (2.98) to 3.13 (2.96); pain improved from 3.52 (2.92) to 1.78 (1.88) (n = 23, p < .01). SC/BMT providers requested an expansion of the service after three months of experience. CONCLUSIONS Patients who have undergone SC/BMT experience many physical and emotional symptoms. Palliative care embedded within the bone marrow transplant clinic can provide benefit by lessening the symptomatic burden of patients.

Promoting Primary Palliative Care: A Novel Advanced Practice Palliative Nursing Clinical Externship (TH323)

149 Background: Understanding primary palliative care is essential for advanced practice nurses, no matter where they practice. Limitations resulting from the variability of APRN state practice acts, financial considerations, and expenses, challenge post-graduate education for APRNs. With the shortage of health care providers, it is necessary to consider innovative programs to offer this education. Although there are many palliative educational opportunities, there are few abilities to translate the education into practice. Few are focused on the APRN, particularly for community and rural practice where many oncology patients are located and receive care. METHODS The APRN Externship selected 48 externs who completed the week long course. Topics includes pain and symptom assessment and management; fostering communication skills; building understanding of community resources such as hospice, palliative care, and home care; incorporating palliative care into an oncology practice, introducing concepts of business and finance in palliative care; and developing of safe practice with policy, procedure, and guideline development with a focus on rural providers. Externs complete pre course and post course testing along with completing goals to improve patient care. RESULTS Through an IRB approved process, utilizing both quantitative and qualitative evaluation, we followed the effect of the externship on externs. Externs performed both pre-course as well as 1 month and 6 month post-course testing. They also completed a report on achievement of clinical goals to improve patient care delivery. CONCLUSIONS APRN Palliative Externs reported positive effects from the externship experience to clinical practice. The qualitative and quantitative data has demonstrated sustained effect towards improving palliative care within advanced practice nursing. The APRN palliative externship model could serve as a model to promote better palliative care education for oncology APRNs thereby improving palliative care delivery within oncology nursing.

Influence of palliative care consult on radiation therapy utilization for metastatic cancer patients within the last six months.

Background: Workforce issues necessitate a focus on midcareer advanced practice nurses to promote primary palliative care. Although there are many palliative educational opportunities, there are few which can help practitioners translate education into practice. This is particularly true for APRNs (both CNSs and NPs), especially in rural areas. Outside of APRN fellowships and observerships, there are few clinical experiences. Moreover, there are limitations of patient care exposure due to licensure, time, and expense. We developed the Palliative Care APRN Externship – an innovative partnership between an academic medical center, a palliative care service, and a school of nursing to incorporate palliative principles into practice.

Retrospective assessment of quality of cancer care in last 6 months of life.

149 Background: Palliative care encounters (PCE) have been demonstrated to reduce resource utilization and costs within an inpatient setting. Little is known about influence PCE on delivery of radiation therapy (RT). We hypothesize that terminally ill cancer patients completing PCE would have increased utilization of palliative RT (PRT) with decreased fractions and overall costs. METHODS Retrospective review of 3,128 cancer patients that had at least one hospital contact within 6 months prior to death. Data from single academic institution decedent database, hospital billing claims, and radiation oncology electronic medical record (RO EMR) was combined into one database that could be queried. RESULTS From January 2009 to June 2011, 417 patients with soft tissue/bone/not other specified (NOS) excluding brain metastatic disease and at least one palliative contact within 6 months prior to death were identified. Palliative contact: PRT or palliative care consult or admission (PCE). 232 patients completed 321 RT courses (87% palliative, 8% curative, and 5% unknown). 18% of PRT was delivered in 1 fraction, 30% in 2-5, 4% in 6-9, 36% in 10, and 12% > 10 fractions. PRT and PCE were both completed in 48% (33% before, 13% during and 54% after delivery of RT). PCE prior to PRT vs. PCE none/during/after PRT were more likely to result in 5 or fewer PRT treatments (62% vs. 40%, p=0.0309) and there was a trend for increased delivery of single fraction PRT (18 vs. 15%). Based on timing of PCE, no increase in PRT courses per patient and no overall cost reduction was observed beyond direct cost reduction by reducing PRT fractions. Other non-significant factors included sex, race, and payer type. Majority of PCE were within 30 days prior to death 52% vs. only 44% of PRT. CONCLUSIONS Relationship between PCE and PRT is complex and are likely compounded by factors not accounted for in this study. Despite these limitations, PCE prior to delivery of PRT correlates to reduced treatment numbers. This report highlights that overall referrals for palliative services could be integrated into comprehensive cancer much earlier and in a more multi-disciplinary way.

A High-Volume Specialist Palliative Care Unit and Team May Reduce In-Hospital End-of-Life Care Costs

234 Background: National organizations such as the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) have developed metrics that assess the quality of cancer care. These metrics include consensus standards by the NQF for management of symptoms and end-of-life-care. Cancer centers need feasible methods for self-evaluating their performance on such metrics. METHODS Claims for our cancer patients were matched to Social Security Death Index data to determine date of death.3,128 adult cancer patients died between January 2009 and July 2011 and had at least 1 contact with our center in their last six month of life. All inpatient and outpatient claims data generated in the last six months of life at our hospital were analyzed. RESULTS 32% of patients had an admission in their last 30 days of life, with 15% dying in the hospital. 19% had at least one 30-day readmission in their last six months of life. 6.7% had chemotherapy in the 2 weeks prior to death, and 11.4% in the last month. 27.5% had some contact with the specialist palliative care (SPC) team. Solid tumor patients with SPC earlier than 1 month until death had fewer in-hospital deaths (15.6%) versus those with later or no SPC (19.5%), p=.041. There was no SPC difference for 30-day mortality, or 14- or 30-day chemotherapy metrics. CONCLUSIONS Hospitals can self-evaluate their own performance on NQF endorsed measures, and CMS outcome measures. These data provide additional impetus for earlier integration of specialist palliative care teams. SPC in the last 1-3 weeks of life did not improve most utilization metrics.[Table: see text].