Transcript Improving oncology care with more integration of palliative care Thomas J. Smith, MD FACP Harry J.

Improving oncology care with more
integration of palliative care
Thomas J. Smith, MD FACP
Harry J. Duffey Family Professor of Palliative Medicine
Director of Palliative Medicine
Johns Hopkins Medical Institutions
Professor of Oncology
Sidney Kimmel Comprehensive Cancer Center
[email protected]
Objectives
1. Reasons why.
2. Smaller fixes within reach.
a)
b)
c)
More use of palliative care consultation services.
More “primary palliative care” in oncology practices
More and earlier use of hospice (live better and longer)
3. Big fixes.
a) Insurance: Aetna’s Compassionate Care Program
b) Sutter Health Advanced Illness Model
OECD Health Data 2011
United States
United Kingdom
$8,000
Switzerland
Sweden
Norway
New Zealand
Netherlands
Japan
Italy
Israel
Ireland
Iceland
Germany
France
Finland
Denmark
Canada
$5,000
Belgium
Austria
Australia
Medical care costs 2-fold more in the US than any
other country
$9,000
$8100
$7,000
$6,000
$4500
$4,000
$3,000
$2,000
$1,000
$0
Cancer care costs are rising exponentially
- $173 billion at 2% growth rate
200
150
Cancer
Care 100
Costs
(Billions)
50
0
1990 1995 2000 2005 2010 2015 2020
Year
Mariotto AB, et al. Projections of the cost
of cancer care in the United States: 20102020. J Natl Cancer Inst. 2011 Jan
19;103(2):117-28.
Claxton G, et al. Health Aff
(Millwood). 2010 Oct;29(10):1942-50.
Quality of care is not optimal
Care patterns for cancer patients who died at a major medical center,
Summer 2011 (see Dy S et al, JPM 2011; *Dow and Smith, JCO 2010)
Process measure
Seriously ill
N (%)
Targets
61
Use of ventilator
16 (26)
Deceased
35 (57)
Any goals of care discussion
26 (43)
95%
4 (7)
90%
2/75 (1%)
100%
Death in hospital
21 (34)
10%
Discharged with hospice
14 (23)
60%
Chemo with 2 weeks of death, solid tumor
patients
28-35%
<10%
Advance directives on file
Oncologist brought up Ads*
10%
We are still hospital oriented and not hospice oriented
near the very predictable end of life.
Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics,
Morden, Health Affairs 2011
Measure
Death in hospital (%)
Hospice use, last month
of life (%)
Days in hospice, last
month of life (per
decedent)
Hospitalized, last month
of life (%)
ICU use, last month of life
(%)
All
NCCN
cancer
centers
Academic
hospitals
Community
hospitals
30.2
32.6
33.8
29.7
53.8
53.4
50.3
54.2
8.4
8.6
7.6
8.5
64.9
60.2
64.4
65.1
24.7
23.3
26
24.6
QOL concerns are not raised or discussed in cancer
clinical settings.
Q: After diagnosis and
before starting treatment,
did anyone on care team
ask what is important to
you/family in terms of
QOL?
2010 ACS CAN National Poll on Facing Cancer in the
Health Care System (www.acscan.org)
3/4s of patients with lung and colon cancer think they could be cured with
chemo (Weeks J, et al. NEJM 2012)
• Half of all lung cancer patients have had NO discussion with any of their
doctors about hospice 2 months before they die. Huskamp HA, et al. Arch
Intern Med. 2009
• Only 37% of patients have any conversation about dying. (Wright AA, JAMA
2008)
• 60% of us prefer not to have “hard conversations” (DNR, AMDs, hospice)
until “there are no more treatment options left”. Keating NL, et al. Cancer.
2010
• Telling some one they are “incurable” is not enough – people want
information about prognosis, what will happen to them, and their options.
Definition of palliative care
“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.”
– Diane Meier, MD, Director, Center to Advance Palliative Care, July 1, 2011
Palliative care in addition to usual oncology care allowed
lung cancer patients to live almost 3 months longer than
those who got usual oncology care.
Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011
Longer and better survival
 Better understanding of
prognosis
 Less IV chemo in last 60 days
 Less aggressive end of life
care
 More and longer use of
hospice
 $2000 per person savings to
insurers and society
The American Society of Clinical Oncology now
recommends “…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.”
- Now 5 randomized trials showing the same results.
- No trials showing harm or increased costs.
Hospice in the United States
• Hospice is defined as a Medical Benefit
• Truly managed care:
– $150 a day outpatient, $500 a day inpatient
– Everything must be paid from that
• Must have a 50/50 chance of death in the next 6 months if
the disease runs its natural course
• Hospice eligibility: Hospice in a Minute
How do we better integrate palliative care
into our care?
• Primary PC: every oncologist should be able to do.
– Communication (ask, tell, ask)
– Symptom Assessment and management (ESAS, MSAS)
– Spiritual assessment (FICA, SNAP, AMEN)
– Hospice referrals
• Secondary PC: referral, just like referral to cardiologist.
• Tertiary PC: specialized inpatient and research programs.
• Need more PC people
– Fellowships
– Advanced training (EPEC-O, ELNEC, OncoTalk)
How to do palliative care in the office.
Cheng J, King L, Alesi ER, Smith TJ. J Oncol Practice, 2013
Table 1: Components of Office-based Primary Oncology Palliative Care
1. Ask, Tell, Ask.
Always ask people how much they want to know, and what they do know.
Then tell them, in understandable words.
Ask “What is your understanding of your situation?”
2. At each transition point (when changing treatments or prognosis) ask, tell,
ask. “What are you hoping for?” and “What is your understanding of your
situation?”
3. Always do a symptom assessment.
4. At least some of the time, do a spiritual assessment.
5. Make a “hospice information referral” when the patient still has 3-6 months
left to live.
6. Audit hospice referrals, like QOPI does.
7. Set up “best practices” for seriously ill patients who have less than a year to live.
8. Take advantage of decision aids to help those patients who want to know their
prognosis. Use www.Eprognosis.org
9. Use some “palliative care pearls” in your practice, such as olanzapine for nausea,
ginger for nausea, ginseng or dexamethasone for fatigue and better quality of life.
10. Use chart prompts in your EMR.
Advance Directive __Yes __ No __ Not discussed
Code status __Full
___DNR Other _______________
DPMA ___________________________________
There are opportunities to improve our practice on
hospice referrals
Medicare Patients, Unadjusted Cancer Care Measures, By Hospital
Characteristics, Morden N, Health Affairs 2011
All
NCCN
cancer
centers
Academic
hospitals
Community
hospitals
Death in hospital (%)
30.2
32.6
33.8
29.7
Hospice use, last month
of life (%)
53.8
53.4
50.3
54.2
Days in hospice, last
month of life (per
decedent)
8.4
8.6
7.6
8.5
Hospitalized, last month of
life (%)
64.9
60.2
64.4
65.1
Measure
How do we better integrate hospice into
our care?
• Have a “hospice information visit” when we think the person
has 3-12 months to live.
• Can’t hurt. OK to predict wrongly.
• Can dramatically help
– Makes us address difficult issues like “code status”
– Informs family that the situation is serious and their loved
one is dying
– MOLST
– Will, Living Will, DPMA, Life Review, Dignity therapy
Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct
25;367(17):1651-2. doi: 10.1056/NEJMe1211160.
Hospice eligibility is straightforward
• The SURPRISE QUESTION: “Would you be
surprised if this person were to die in the
next 6 months?”
• Failure to thrive: BMI < 22, involuntary
weight loss
• CHF NYHA Class IV, EF < 20%
• COPD: hypoxemia at rest, FEV1 < 30%
• Dementia < 6 words
• Liver disease: INR > 1.5, albumin < 2.5
• Cancer – much easier. Salpeter et al. J
Palliat Med. 2012 Feb;15(2):175-85
– Hypercalcemia, any malignant effusion, spinal
cord compression, ECOG PS 2 or higher
The benefits are straightforward…better care, and
people who use hospice for even one day live longer.
Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.
We miss opportunities to recognize hospice-eligible
patients, they are readmitted, and cost more.
U of Iowa Hospitals.
• 688 in-hospital deaths
• 209 decedents had preceding admission
• 60% of decedents were eligible for hospice on the
penultimate admission, based on NHPCO, National
Hospice and Palliative Care Organization worksheets.
-Only 14% had any discussion of hospice, despite being
eligible; 14 of 17 enrolled, all from ONE service
- Hopkins among the lowest of UHC Hospitals for hospice
discharges from Cardiology, some other services
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.
We miss opportunities to recognize hospice-eligible
patients, they are readmitted, and cost more.
Table: Comparison of Cost and Length of Stay Between Patients Enrolled and
Not Enrolled in Hospice During a Terminal Hospital Admission
Enrolled in hospice before last
Not enrolled in hospice, all diagnoses,
admission n = 7/14
n = 202/209
Cost
Mean
Median
Standard
deviation
Standard
deviation
$4963
$3690
$3250
$52 219
$23 322
$85 101
4.47
25.05
Palliative Care Consultation
YES, $41,859 NO, $58,386
P<0.04
Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.
Weckmann MT, et al. Am J Hosp Palliat Care. 2012 Sep 5.
People who use hospice are re-admitted less often,
use less medical resources, and get better care.
Table 2. Readmission Rate by Post-discharge Medical Service Use
Post-discharge medical services Ratio of readmissions
Percent
Hospice
Home-based palliative care
Home health
Nursing facility
Home no care
11/240
4.6
5/60
2/15
14/58
9/35
8.3
13.3
24.1
25.7
Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat
Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9.
Hospice saves Medicare $2309 per decedent, and the longer the hospice
Length of stay, the bigger the savings.
Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice
use maximizes reduction in medical expenditures near death in the US Medicare program?
Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27.
Better care, consistent with what people would choose.
Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-oflife care. J Palliat Med. 1998 Fall;1(3):221-30.
Identifying hospice eligible patients makes a difference
Fig 1. Increase in GH Referrals Since JH PC Program
Started Oct 2011
35
30
PC program
25
20
15
10
5
0
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Change our standards of care to incorporate national guidelines and
best practices about palliative care.
7. Set guidelines like the U S Oncology pathways that preserve
survival, reduce cost by 35% in lung and colon cancer
Someone in the office
- AMDs
- DPMA
- Hospice info visit
Generics
Limit to 3 “lines”
Of chemo
Less chemo
Less hospital
More hospice
2x↑ LOS, use
Equal survival
With no 3, 4, 5th
Line chemo
For NSCLC and colon cancer, equal results, less toxicity, less cost.
Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8.
Hoverman JR, et al. J Oncol Pract. 2011 May;7(3 Suppl):52s-9s
“Bending the Cost Curve for Seriously Ill Patients”
Annual Assembly of AAHPM & HPNA
March 8, 2012
Advanced Care:
How choice, comfort and dignity
can drive cost reduction
in a shared risk/shared savings world
Brad Stuart MD
[email protected]
Moving Care Out of the Hospital
EHR
• Patient Registry
HOSPITALS
• Emergency Dept.
• Hospitalists
• Inpatient palliative care
• Case managers
• Discharge planners
• Telesupport
Center
911
• Care Liaisons
HOME-BASED SERVICES
• Home health
• Hospice
MEDICAL OFFICES
• Physicians
• Office staff
• Care managers
• Telesupport
• Transitions Team
CRITICAL EVENTS
• Acute exacerbation
• Pain crisis
• Family anxiety
New Advanced Care staff & services
Tracking the Process of Personal Choice
EHR
Continuity
at high or low
acuity
HOSPITALS
Start the conversation
• Inpatient PC
• Hospitalist
• PCP
PHYSICIAN
OFFICES
Handoff
TELESUPPORT
HOME-BASED
SERVICES
Trained team
linked across
all settings
Shared decisions
made over time
at the patient’s
own pace
Advanced Illness Management
(AIM)
90 Days Pre/Post Enrollment
– Hospital
• 54% reduction in admissions
• 80% reduction in ICU days
• 26% reduction in inpatient LOS (2 days/case)
– Physicians
• 52% reduction in MD visits
– Home
• 60% increase in hospice enrollment
• 49% increase in home health enrollment
Net System, Payer Savings
Payer Mix = 71% Medicare
• Per Beneficiary Per Month:
– System savings
– AIM rollout expense
– Net system gain

Total payer savings
$1125
($ 912)
$ 213 PBPM
$ 760 PBPM
Potential Medicare Savings:
312 million x 5% x $760/mo. x 12 mo/yr. x 10% = $ 14.2 billion
Lessons Learned in Advanced Care
• Re-engineer, re-brand, integrate
– Add services people, clinicians want & need
– Integrate MDs, AC, PC & Hospice
• Personal goals drive cost savings
– Person-centered trumps “patient-centered”
– Seriously ill people don’t want to be patients
• Turn the business model upside down
– Get the heads out of the beds
– Invest in home and community
Conclusions
1. Palliative care alongside usual care is now the accepted best
practice.
2. All the evidence suggests equal or better quality of life, fewer
symptoms, equal or better survival, and less cost, with no
harms.
3. There is still a LOT of research to be done to improve “trigger
points”, symptoms, integration of PC into usual care,
identification of patients and families who can benefit, and
communication.
4. Advanced Illness Management Models improve care and save
money but require an integrated health system.