Palliative Care in the Continuum of Oncologic Management

Transcription

1 Palliative Care in the Continuum of Oncologic Management PC in the Routine Continuum of Cancer Care Michael W. Rabow, MD Director, Symptom Management Service Helen Diller Family Comprehensive Cancer Center Helen Diller Family Chair in Palliative Care Professor of Clinical Medicine and Urology UCSF May 25 & June 22, 2017 combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Main Points Definition Benefits Availability Challenges/Opportunities 1

2 How knowledgeable are you about Palliative Care? Public (Mis)Understanding 1. Not at all knowledgeable 2. Somewhat knowledgeable 3. Knowledgeable 4. Very knowledgeable 5. Don t know Once they know The Current Definition Extremely positive about it and want access >92% say: It is important Patients with serious illness and their families should be educated Likely to consider PC for a loved one Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. 2

3 The Core Elements of Palliative Care Palliative Care is Not Symptom management Excellent communication Comprehensive care Bio-psycho-social-sexual-spiritual Family Continuity Team-based care For old people only End- of- life care Hospice Palliative Care End- Of- Life Care Hospice Conceptual Shift for Palliative Care: NEED, not Prognosis Main Points Definition Benefits Availability Challenges/Opportunities Hospice 3

4 Proven Benefits 1. Improved patient and family satisfaction 2. Reduction in symptom burden 3. Prolonged life (hospice, outpatient) 4. Improved efficiency/reduced costs 1. Improved Satisfaction Patients Family Clinicians Morrison, Annals Intern Med, 2008;; Teno et al, JAMA, 2004;; Christakis & Iwashyna, Soc Sci Med, 2003;; Miller et al, JPSM, 2003;; Connor et al, JPSM, Jordhay et al Lancet 2000;; Higginson et al, JPSM, 2003;; Finlay et al, Ann Oncol 2002;; Higginson et al, JPSM 2002, Zimmerrman, JAMA 2008;; Follwell, J Clin Onc, 2008;; Rabow, Arch Intern Med, 2004;; Temel, NEJM, 2010;; Rabow J Palliative Med, Rabow, JPM, Improved Symptoms 3. Prolonged Survival in Hospice (Connor, J Pain Sx Mgmt, 2007) Improved outcomes pre/post Data mostly cancer (also CHF, COPD, MS Pain, Fatigue, Nausea, Depression, Anxiety, Drowsiness, Appetite, Dyspnea, Insomnia, Constipation, and Satisfaction Improved outcomes in controlled trials Pain, Dyspnea, Anxiety, Sleep, QOL, Spiritual Well-being Yennurajalingam, JPSM, 2011 Follwell, J Clin Onc, 2008 Kim, JPM, 2012 Rabow, Arch Intern Med, 2004 Zimmermann, The Lancet,

5 What was the mortality impact of concurrent palliative care in the Temel study? 1. It shortened survival 2. It had no effect 3. It prolonged survival by about 3 weeks 4. It prolonged survival by about 3 months 5. I don t know about the Temel study Prolonged Survival: The Post-Temel Universe 151 patients with NSCLC at Mass General Immediate vs. delayed PC along with usual oncologic care Early pc patients with Improved QOL Less depression Less chemo in last 2 weeks Fewer hospitalizations in last month Nearly 3 months longer survival (11.6 mos. vs. 8.9 mos, p<0.02) 4. Improved Utilization Inpatient PC Triggers = Improved Utilization Early- PC = Better Utilization & Quality 70% P< % 60% Decreased 30- day readmissions (35% to 18%) Increased hospice referrals Decreased chemotherapy after discharge 50% 40% 30% 20% P=0.044 P=0.001 P= % 20% P< % 33% Early- PC Late- PC 10% 14% 15% Adelson, JOP, % 5% >1 ED visit final 30 ICU stay in the final 30- days of life* days of life* 7% Death w/i 3 days hospital DC Inpatient death 30- day mortality case Early- PC associated with better performance on EOL quality measures *NQF measures Scibetta, Kerr, McGuire, Rabow,

6 Early PC: $5000/patient Lower Total Costs Average health system direct cost per patient for medical care in final 6 months of life $45,000 $40,000 Early PC p=0.006 $35,000 Late PC 37,303 $30,000 p< ,107 $25,000 25,754 $20,000 $15,000 p= ,067 $10,000 13,040 11,549 $5,000 $- Direct Outpatient Costs Direct Inpatient Costs Total Direct Costs Main Points Definition Benefits Availability Challenges/Opportunities *Early PC = first contact with specialty service >90 days prior to death Scibetta C, Kerr K, Mcguire J, Rabow MW. The Costs of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center. J Palliat Med Jan;19(1): cancer centers (Hui et al. JAMA. 2010) Palliative care program Inpatient palliative care consult team Outpatient palliative care PC in Cancer Centers NCI site 98% 78% 92% 56% 59% 22% Non-NCI site PC in NCCN Cancer Centers 22/26 response(85%) 100% inpatient PC consult service 91% clinic- based PC (3/4 in the last 10 years) 469 consults/year (GI, Breast, Thoracic) 3.3 FTEs 17- day wait time Solid tumors > hematologic malignancies 80% w/ insufficient PC capacity Calton, JNCCN,

7 Main Points What percent of people who die from cancer get palliative care? Definition Benefits Availability Challenges/Opportunities 1. 0% 2. 25% 3. 45% 4. 65% % Not Meeting Our Goals 45% of patients who died at a comprehensive cancer center got palliative care. Hui, Oncologist, % of Vets with cancer who died got palliative care. Challenges/Opportunities 1. Specialty PC Workforce Shortage 2. Primary Palliative Care in Oncology 3. Integration 4. The Historic Alignment: Managing Populations Gidwani, JPM,

8 1. The Gap: Specialty Workforce Shortage 1 oncologist for every 145 new patients with cancer 1 PC doc for every 300 deaths 1 PC doc for every 1,300 patients with serious illness = 6,000-18,000 projected gap in pc physicians Just for hospitals and hospices Similar/worse gaps for Nursing, Chaplains, Social Work Lupu, J Pain Sx Mgmt, Primary Palliative Care Oncology Team as Primary PC Clinician Increased with increased comfort with end- of- life care ASCO/AAHPM Joint Statement on focus areas: EOLC, Communication, ACP Not spiritual, cultural, psychosocial Quill & Abernethy, NEJM, 2013 Hui, Oncologist, 2016 Bickel, JOP, Models of Integration Barriers to Integration Interdisciplinary PC teams (eg training onc RNs) Simultaneous care approach (eg embedded clinics) Routine symptom screening PC guidelines Care pathways Combined tumor boards Hui, Ann Pall Med, 2015 Schenker, JPM, Cultural change 2. Systems approach 3. Agreed- upon metrics for quality 4. Financial support Davis, Supp Care Cancer, 2015 Ramachandran, Cancer Control,

9 4. Finances: Historic Alignment If you provide outpatient clinic with long appointment times and IDT care you will lose money unless you have revenue in addition to CPT Billing Billing = <50% of expenses (Rabow, Arch Intern Med, 2010) BUT other benefits (value) sufficient to justify funding Clinical (paying for quality) Financial (decreased global costs) The Historic Alignment: Managing Populations Palliative Care is serving a key role in health care reform: caring for seriously ill patients The 10% cost 63% (Kaiser Family Foundation, 2011) Systems of Shared Cost/Risk need PC Triple Aim & Historic alignment Aligned incentives for providers, patients, payers Everyone now wants the same thing Quality, Quantity, and Cost Savings Medicare s Oncology Care Model Take Home Points PC as a routine part of cancer care Involves generalist and specialist PC There is now an unprecedented historic alignment / opportunity 9