Dale Lupu

Estimate of Current Hospice and Palliative Medicine Physician Workforce Shortage

CONTEXT In the context of the establishment of a new medical specialty, rapid growth in hospices and palliative care programs, and many anecdotal reports about long delays in filling open positions for hospice and palliative medicine (HPM) physicians, the American Academy of Hospice and Palliative Medicine (AAHPM) appointed a Workforce Task Force in 2008 to assess whether a physician shortage existed and to develop an estimate of the optimal number of HPM physicians needed. OBJECTIVES Develop estimates of the current supply and current need for HPM physicians. Determine whether a shortage exists and estimate size of shortage in full-time equivalents (FTEs) and individual physicians needed. METHODS The Task Force projected national demand for physicians in hospice- and in hospital-based palliative care by modeling hypothetical national demand on the observed pattern of physician use at selected exemplar institutions. The model was based on assumptions that all hospices and hospitals would provide an appropriate medical staffing level, which may not currently be the case. RESULTS Approximately 4400 physicians are currently HPM physicians, as defined by board certification or membership in the AAHPM. Most practice HPM part time, leading to an estimated physician workforce level from 1700 FTEs to 3300 FTEs. An estimated 4487 hospice and 10,810 palliative care physician FTEs are needed to staff the current number of hospice- and hospital-based palliative care programs at appropriate levels. The estimated gap between the current supply and the hypothetical demand to reach mature physician staffing levels is thus 2787 FTEs to 7510 FTEs, which is equivalent to 6000-18,000 individual physicians, depending on what proportion of time each physician devotes to HPM practice. CONCLUSION An acute shortage of HPM physicians exists. The current capacity of fellowship programs is insufficient to fill the shortage. Changes in graduate medical education funding and structures are needed to foster the capacity to train sufficient numbers of HPM physicians.

Measuring What Matters: Top-Ranked Quality Indicators for Hospice and Palliative Care From the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association

CONTEXT Measuring quality of hospice and palliative care is critical for evaluating and improving care, but no standard U.S. quality indicator set exists. OBJECTIVES The Measuring What Matters (MWM) project aimed to recommend a concise portfolio of valid, clinically relevant, cross-cutting indicators for internal measurement of hospice and palliative care. METHODS The MWM process was a sequential consensus project of the American Academy of Hospice and Palliative Medicine (AAHPM) and Hospice and Palliative Nurses Association (HPNA). We identified candidate indicators mapped to National Consensus Project (NCP) Palliative Care Guidelines domains. We narrowed the list through a modified Delphi rating process by a Technical Advisory Panel and Clinical User Panel and ratings from AAHPM and HPNA membership and key organizations. RESULTS We narrowed the initial 75 indicators to a final list of 10. These include one in the NCP domain Structure and Process (Comprehensive Assessment), three in Physical Aspects (Screening for Physical Symptoms, Pain Treatment, and Dyspnea Screening and Management), one in Psychological and Psychiatric Aspects (Discussion of Emotional or Psychological Needs), one in Spiritual and Existential Aspects (Discussion of Spiritual/Religious Concerns), and three in Ethical and Legal Aspects (Documentation of Surrogate, Treatment Preferences, and Care Consistency with Documented Care Preferences). The list also recommends a global indicator of patient/family perceptions of care, but does not endorse a specific survey instrument. CONCLUSION This consensus set of hospice and palliative care quality indicators is a foundation for standard, valid internal quality measurement for U.S. SETTINGS Further development will assemble implementation tools for quality measurement and benchmarking.

Development of a Medical Subspecialty in Palliative Medicine: Progress Report

There is significant interest in seeking professional recognition of expertise in caring for people with serious life-threatening illness and their families through creation of a specialty in palliative medicine. Certification of physicians and accreditation of training programs are key elements for formal recognition. The American Board of Hospice and Palliative Medicine was established to achieve these goals. The next step in the maturation of the subspecialty of palliative medicine is to have both the certification and the accreditation recognized by the professional self-governing bodies in organized medicine. This paper answers common questions about obtaining recognition by the Accreditation Council of Graduate Medical Education, the American Board of Medical Specialties and its member boards. Formal recognition of the subspecialty of palliative medicine is sought in order to extend the knowledge and skills inherent in the domains of palliative medicine. Such recognition will also encourage more physicians to enter the field and assure standards of care for those patients and their families who need it.

Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement

PURPOSE Integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to specialist palliative medicine. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. METHODS An expert steering committee outlined 966 palliative care service items, in nine domains, each describing a candidate element of primary palliative care delivery for patients with advanced cancer or high symptom burden. Using modified Delphi methodology, 31 multidisciplinary panelists rated each service item on three constructs: importance, feasibility, and scope within medical oncology practice. RESULTS Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision Making (79%); and Advance Care Planning (78%). The lowest proportions were in Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea, and pain. Within the Appropriate Palliative Care and Hospice Referral domain, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients appropriately. CONCLUSION This statement describes the elements comprising high-quality primary palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find this information useful to inform operational changes and quality improvement efforts.

Initial Voluntary Program Standards for Fellowship Training in Palliative Medicine

Initial voluntary standards for fellowship programs in palliative medicine were developed through a collaborative process involving the directors of fellowship training programs, the American Academy of Hospice and Palliative Medicine (AAHPM), and the American Board of Hospice and Palliative Medicine (ABHPM). These groups worked with a consultant and representatives from the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) to create a training structure for the programs that will maximize the likelihood for recognition and accreditation of the subspecialty. An accreditation group modeled after an ACGME residency review committee will be formed to review and adopt the standards, then accredit programs voluntarily.

AAHPM Position Paper: Requirements for the Successful Development of Academic Palliative Care Programs

In this position paper, we outline the essential features for an academic palliative care program. Our goal was to assist both academic palliative care faculty and their stakeholders (department chairmen, deans, and others) in building sustainable high-quality academic palliative care programs. We also provide the background that justifies such an effort. Palliative medicine provides coordinated, interdisciplinary care for a growing population of patients and their families with complex care needs as they face a life-threatening or serious condition. These programs have recently matured in the United States and have become

The Influence of the Newly Formed Hospice and Palliative Medicine Subspecialty on Radiation Oncology and End-of-Life Care

p s t t o i p a t he American Board of Medical pecialties has announced the foration of hospice and palliative edicine as a new subspecialty. he American Board of Radiology as enthusiastically agreed to serve s 1 of the 10 cosponsoring boards Table 1) for the examination, hich will be administered for the rst time in 2008. The American oard of Hospice and Palliative edicine first established a certifiation program in 1996 to help efine the standard of specialty ractice deemed appropriate for hysicians in hospice and palliative edicine. Nearly 3,000 physicians et the requirements for practical xperience and written examina-

Progress towards systems of quality measurement that capture the essence of good palliative care

Like Lewis Carroll’s snark-hunters, palliative care researchers are pursuing a creature that we know exists, but are not quite sure what it is or how to find it. We recognize good palliative care when we experience it. We know that reducing suffering and improving quality of life and health care, including communication and coordination, for patients with serious illness are worthy and achievable goals, desired by patients, families and providers.1 But how, exactly, to measure and promote ‘good’ in palliative care remains an elusive goal. Measuring the quality of hospice and palliative care is necessary to decide where to focus efforts in improving quality and for measuring the effectiveness of quality improvement initiatives. Quality measurement in palliative care usually involves health care utilization indicators, such as number of hospitalizations at the end of life; medical record review for issues such as pain management; or survey data, such as after-death surveys for families of hospice patients.2 However, although many tools have recently been developed, quality measurement in this area is limited by challenges of assessment in vulnerable populations and lack of consistent documentation of many key aspects (such as pain management or end-of-life decisionmaking) in medical records. Many palliative care indicators have not been well evaluated; in particular, there is little good evidence for correlation between indicators (particularly for utilization) and patient outcomes. In addition, most indicators only address processes of care that are a small part of the complex and varied issues necessary for high-quality end-of-life care, and none collect data directly from patients. Four articles in this issue of Palliative Medicine provide some insights into how to continue developing this field. Some of the studies evaluate in greater depth how these indicators reflect actual quality of care; others describe innovative approaches, expanding boundaries of measuring quality and implementing indicators to improve patient care. Two articles address how information on quality can be collected and used to impact care and policy both regionally and nationally. Sussman and colleagues3 used population-level utilization quality indicators (such as emergency department use at the end of life) to compare regional health systems in Ontario, Canada, and develop a framework to identify potentially modifiable health system organization factors associated with quality of care. Specifically, the framework identified six key structural features of regional health systems, such as 24/7 palliative care team access, that were associated with higher palliative care indicator performance. This study advances how indicators have previously been used by examining how differences in performance are associated with differences in key characteristics of regional health systems. These types of methods may be useful for comparisons and prioritization of program features in systems that have the capability to compare indicator performance and structural issues across health care providers. On a larger scale, Lundström and colleagues4 described a multi-year effort to establish a national quality registry for end-of-life care in Sweden. The registry began with data on 5% of Swedish deaths and within a few years advanced to 34% of deaths – nearly 60% of all cancer deaths. The registry collects standardized data on various structural, process and clinical outcomes to measure quality. The data has helped identify areas for improvement, such as end-of-life care in residential care facilities. The power of the registry is clearly in its national scope, but also that Sweden can modify the indicators collected as the field of quality measurement advances. Unlike most quality measurement projects, where reports are generated long after care occurs, internet-entered data allows real-time, actionable reporting for providers and policymakers. This project also demonstrates that providers and managers are willing to enter relatively straightforward data, solving the ubiquitous problems of not having meaningful data sources or research staff to enter data. In contrast to the broad regional and national scale of these two articles, the other two articles in this issue are more focused and examine a single quality dimension – place of 444796 PMJ26410.1177/0269216312444796Dy et al.Palliative Medicine 2012

Defining high-quality palliative care in oncology practice: An ASCO/AAHPM Guidance Statement.

108 Background: When integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to subspecialty palliative medicine for referral. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. METHODS An expert steering committee developed a list of 966 palliative care service items, divided into nine domains, each describing an aspect of palliative care delivery for patients with advanced cancer. Using a modified Delphi methodology, 31 multi-disciplinary panelists ranked each service item according to importance, feasibility and scope. RESULTS Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision-Making (79%); and Care Planning (78%). Lowest proportions were in: Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea and pain. Under the domain of Appropriate Palliative Care and Hospice Referral, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients with an expected survival of under 3 months or poor performance status (Zubrod 3-4) to hospice. CONCLUSIONS This statement describes high-quality palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find the guidance useful to inform operational changes and quality improvement efforts.

Hospice Innovation Impediments: Can Halfway Efforts Tame the Terrible Choice?

Dear Editor: We greeted the March 2014 announcement of the Medicare Care Choices Model (MCCM) demonstration project with enthusiasm and hope. Here was an opportunity, under the auspices of the Innovation Center of the Center for Medicare and Medicaid Services, to experiment with expanding access to hospice services for patients still pursuing curative treatments. Unfortunately, as the terms of the demonstration became clearer, we realized that the rules are unlikely to lead to the innovative changes needed to improve access to hospice. In this article we explain the specific problems with the MCCM, calculate the financial risk that would be imposed on participating hospices, and make recommendations for improving the MCCM so that true innovation in hospice care can be tested. Medicare rules require patients to give up regular Medicare benefits in order to receive hospice care. This is widely perceived as a ‘‘terrible choice’’ between curative and comfort care, leading to suboptimal access to hospice. Although almost half of Medicare decedents use hospice, half of those enroll two to three weeks before death, and a quarter die within a week of enrolling in hospice. This ‘‘brink of death’’ hospice care results in lost opportunities both to improve patients’ and families’ quality of life and to decrease health care costs. The hypothesis behind the MCCM demonstration is that education, gentle encouragement, and relationship building between the hospice and the patient/family will reduce patient/family concerns about ‘‘giving up’’ regular Medicare benefits and increase their willingness to forgo costly and ineffectual treatment. Other payers including Aetna, Kaiser, Sutter, and the Veterans Administration have tried this with success. They have used more flexible admission criteria combined with case management to promote both earlier enrollment and cost savings. The MCCM demonstration seeks to replicate these successes. The MCCM directs hospices to provide care planning and case management services to eligible Medicare beneficiaries (those with an expected life prognosis of six months or less) who have had at least two hospitalizations within the past year but have not yet elected hospice. The demonstration pays the hospice a monthly fee of