Palliative Care in the Outpatient Setting

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Nigel Cobb
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1 Palliative Care in the Outpatient Setting Dan Ollendorf, PhD Chief Scientific Officer September 21, 2016 Contact:

2 Disclosures ICER s reports are supported by unrestricted grants from the Laura & John Arnold Foundation, BlueShield of California Foundation, and California HealthCare Foundation Reports for New England Comparative Effectiveness Public Advisory Council are also supported by a grant from NESCSO* Research Team Members: Anne Loos, MA Shanshan Liu, MS, MPH *New England States Consortium Systems Organization

3 About ICER Independent non-profit organization with academic history (MGH/Harvard) Staff of 20 clinicians, epidemiologists, health economists, and policy researchers 70% of funding from private foundations Supports ALL of ICER s project work Project process includes multiple opportunities for public engagement and comment All of ICER s reports, presentations, and other documents freely and publicly available

4 Topic in Context Palliative care is a multi-disciplinary management approach with the goal of improving QoL for both patients and their families Experts in the field have identified the outpatient setting as the new frontier in palliative medicine* Two dominant types of palliative care:** Generalist: led by providers who have some clinical experience and basic training in palliative care concepts but whose primary specialty is not palliative care Specialist: led by providers with higher specialty education and advanced training in palliative care who are able to treat more complex aspects of disease management *Rabow MW, et al. Cancer Control. 2015;22(4): **Quill TE, et al. NEJM. 2013;368(13):

5 Project Scope Populations Adults 18 years or older Interventions Palliative care interventions that included both physical and psychosocial elements Comparators Usual/standard care Outcomes QoL, symptom burden, mood, satisfaction, survival, caregiver outcomes, resource utilization, costs Setting All outpatient settings (skilled nursing facilities excluded)

6 Strength of Evidence

7 Patient-Centered Outcomes The majority of studies showed that palliative care interventions improved QoL, mood, (anxiety or depression), and patient satisfaction compared to usual care Most studies showed no impact on overall symptom burden Benefits observed limited to discrete and diseasespecific symptoms (e.g., shortness of breath in COPD)

8 Resource Utilization 7 of 10 studies showed palliative care had benefits on at least one resource utilization outcome Most robust data (4 out of 6 studies) for reductions in hospitalization and ED use for mixed cohorts of patients (i.e., cancer and other serious conditions)

9 Survival 2 of 5 studies showed palliative care had improved median survival (3-6 months) and rate of survival at one year for advanced cancer patients Better than many cancer therapeutics An additional study in evaluating early vs. delayed palliative care also showed improved 1- yr survival Remaining 2 studies showed no differences in survival

10 Costs & Cost-Effectiveness Multiple studies have shown outpatient palliative care to be cost-neutral or cost-saving, but Cost to develop and implement programs typically not included in these analyses Direct medical care services and costs averted may instead be transferred to unpaid, informal caregivers

11 Potential Budget Impact: % of Eligible Patients Enrolling in Last Year of Life

12 Evidence Gaps / Research Needs Identification of components of palliative care that lead to success Additional clarity on outcomes from specialist vs. generalist palliative care with possible adjustments to certification process Psychosocial and economic outcomes for families and caregivers Confirm potential survival benefit for patients receiving palliative care

Palliative Care in the Community

Palliative Care in the Community Carol Babcock, MFT Director Palliative Care, Navicent Health American College of Surgeons Commission on Cancer (CoC) Standard 2.4 Palliative care services are available