Comprehensive Assessment with Rapid Evaluation and Treatment: Integrating palliative care into the care of patients with advanced cancer Leslie J

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1 Comprehensive Assessment with Rapid Evaluation and Treatment: Integrating palliative care into the care of patients with advanced cancer Leslie J Blackhall MD MTS Section Head, Palliative Care University of Virginia School of Medicine

2 Making MyCourse Better This work is supported by Funding Opportunity Number CMS-1C from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

3 In the last year of life patients have worsening symptoms, increasing number of hospitalizations, declining functional status and deteriorating quality of life.

4 Functional status Illness trajectory of advanced cancer Advanced cancer Months prior to death

5 Symptom prevalence Pain: 42-99% Fatigue 13-91% Depression 31-57% Nausea:8-71% Anorexia: 8-85%

6 Costs in dollars Hospitalization for cancer care at the end of life Chastek et al Health Care Costs for Patients With Cancer at the End of Life J Oncol Pract S 75s-80s 25,000 20, ,000 Acute inpatient costs 10,000 Hospice costs , , months 5 months 4 months 3 months 2 months 1 month Months prior to death

7 Does hospitalization at the end of life improve care? Aggressive care at end of life is not associated with improved morbidity or mortality. Deaths in hospital are associated with a worse quality of life for patients and family members. Tracking the care of patients with severe chronic illness: The Dartmouth Atlas of Health Care (2008) Zhang B, Wright AA Huskamp HA et al Health care costs in the last week of life. JAMA Internal Medicine 2009; 169 (5):

8 How do we improve care for these patients? Reduce: Hospitalizations, ICU admissions at the end of life, deaths in hospital Improve: Quality of life, satisfaction, access to care

9 Concurrent care: a collaborative model for the care of those with life-limiting illnesses Oncology Highest quality care with evidence- based interventions and clinical trials to prolong life and improve quality of life. Palliative and supportive care Intensive, evidence-based treatment of troubling symptoms to improve quality of life and functional status.

10 Concurrent care: a best practice model Addition of palliative care early in the course of incurable lung cancer: Improved quality of life Decreased hospitalizations and deaths in hospital Increased hospice utilization and LOS In addition patients lived almost 4 months longer Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med Aug 19;363(8):

11 Where do we go from here? Can such an intense intervention become a model for all cancer management? On the one hand, the trial suggests a standard of care to which health-care providers should aspire

12 Where do we go from here? On the other, health systems are unlikely to be able to provide such intense specialist care uniformly because of the scarcity of trained palliative care clinicians.necessarily, the scope of specialist palliative care must become more focused. Susan D Block, J Andrew Billings Zimmermann C, Swami N, Krzyanowksa M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014; published online Feb 19.

13 Making My Course Better: Proactive Palliative Care and Palliative Radiation in Patients with Advanced Cancer CMS 2012 Innovation Challenge Award Paul W. Read, M.D., Ph.D., Leslie Blackhall, M.D. MTS, James Harrison, M.D., PhD. George Stukenborg, Ph.D. Program 1: MyCourse: an informatics infrastructure for palliative care that will be for project monitoring and clinical decision-making by the other Programs in this proposal. Program 2: Comprehensive Assessment with Rapid Evaluation and Treatment: CARE Track : expansion of palliative and supportive care services, with increased access, early identification of needs, tracking response to interventions and improved integration of care over time. Program 3: STAT Rad: new workflows for the palliative treatment of patients bone metastases which will transform the current workflow from a 2-3 week treatment course to a single day noninvasive procedure. Program 4: Outcomes

14 Functional status Illness trajectory Advanced cancer Months prior to death

15 CARE Track

16 MyCourse Symptom Assessment Tool Patient Reported Outcomes System NIH PROMIS Cancer short form for: Functional status Pain (interference) Fatigue Mood (Anxiety and depression) Other: Dyspnea Nausea, vomiting, anorexia, constipation Neuropathy Quality of life Patient Reported ECOG functional status

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20 Tracking symptoms over time

21 Triggers for action Abnormal results create an alert to primary providers and the CARE Track Team.

22 Supportive Care Tumor Board

23 Who is presented? All CARE Track patients who have been admitted to the hospital in the past week. Patients with poorly controlled symptoms, especially pain, or declining functional status. Patients with psychosocial problems or who are at an important transition.

24 Attendees Number of clinicians attending increased from an average of 7.2 to an average of 15. Disciplines represented include: Social work, psychology Chaplaincy Nursing (including oncology, palliative care, other) Physicians and NPs (radiation oncology, anesthesia pain, medical-oncology, surgical- oncology, palliative care, primary care) Dietary Pharmacy

25 Supportive Care Tumor Board: symptom management Care coordination and communication: sharing information, discussing concerns and plans. Discussion regarding symptom management: multiple disciplines can weigh in on complex symptom management. Shorten timeline for interventions, and look at impact on symptoms.

26 Ms. T. 68 yo woman with a history of endometrial cancer, admitted to the hospital with worsening pain and found to have metastatic disease. She is an immigrant and lives alone, and has almost no social support.

27 Discussion about her further management includes social work, palliative care, gyn-onc and rad-onc. Social worker expresses concern about her mood and her safety at home, and discussion of APS referral. Pain is felt to be most urgent problem.

28 Triggers for action Abnormal results create an alert to primary providers and the CARE Track Team.

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30 Ms.T. Decision is made to do focused radiation to abdominal wall lesions in 4 treatments, simulation done on the day of SCTB. Because she is receiving treatment, she agreed to a SNF admission for rehabilitation.

31 Results of interventions

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33 End of life care Patients seen in CARE Track Year 1 an average of 70 days (median) prior to death 207 patients seen in Year 1 Compared to UVA controls with similar diagnoses

34 CARE Track, Year 1 data Hospitalization last month of life and deaths in hospital 60.0% 58.5% 50.0% 42.9% 40.0% 30.0% 28.6% CARE Track Year 1 UVA Control 20.0% 10.1% 10.0% All p < % Deaths on the hospital Hospital in last month of life

35 Deaths in hospital: types of control Deaths in hospital 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 10.1% CARE Track, Year % UVA control total 31.0% Controls never seen 55.9% Controls seen in hospital only Deaths in hospital

36 Hospitalization, last month of life Types of control Chart Title 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 80.6% 58.5% 44.4% 28.6% Hospital in last month of life CARE Track Year 1 UVA Control controls never seen controls seen in hospital

37 CARE Track, Year 1 data ICU in last month of life and death in ICU 30.0% 25.2% 25.0% 19.6% 20.0% 15.0% CARE Track UVA Control 10.0% 7.9% 5.0% 3.7% 0.0% ICU last month of life Death in ICU

38 CARE Track Pilot, Year 1 data Hospice care at end of life 70.0% 68.5% % 49.4% % 40.0% 30.0% 20.0% CARE Track UVA Control CARE Track UVA Control 10.0% 0.0% Hospice utilization 0 Hospice LOS (median, days)

39 Take home points Highly statistically significant even after controlling for differences between control and intervention. Controls included two groups: those never seen by palliative care, and those only seen in hospital. Those only seen in hospital did not do better than those never seen by palliative care.

40 Take home points Data similar to Temel, but did not need to see from time of diagnosis. Patient reported outcomes data may help us identify those who really need us most, and to determine if we are making a difference