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Palliative Care – A Luxury you cannot afford?

Palliative Care – A Luxury you cannot afford?. James Hallenbeck, MD Assistant Professor of Medicine Director, Palliative Care Services VA Palo Alto HCS. Agenda. Review data regarding where veterans die, associated costs and correlations

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Palliative Care – A Luxury you cannot afford?

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  1. Palliative Care – A Luxury you cannot afford? James Hallenbeck, MD Assistant Professor of Medicine Director, Palliative Care Services VA Palo Alto HCS

  2. Agenda • Review data regarding where veterans die, associated costs and correlations • Encourage you to think about barriers to the expansion of palliative care in VA • Challenge the assumption that palliative care is a luxury we cannot afford

  3. Palliative Care in the VA Important to study because… • VA is the largest unified healthcare system in the country • 28% of Americans dying each year are veterans (more than die from all cancers annually) • VA is a potential model for universal healthcare of an aged, chronically ill population • Unified database for analysis

  4. Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

  5. Questions for VA and for You • Should VA invest in palliative care? • Is such care “cost-effective”? • Could adequate dollars be cost-shifted or avoided to justify such an investment? • Why is there such variance across VA regions and facilities? Is palliative care is luxury the VA cannot afford, or can the VA not afford not to have palliative care?

  6. Good News  • Establishment of hospice treating specialty 2002 • Interprofessional Palliative Care Fellowship 2002 • Mandated palliative care consult teams 2003 • Accelerated Administrative and Clinical Training (AACT) initiative 2002- • Establishment of Hospice-Veteran Partnerships (HVPs) 2002-

  7. Examples of Palliative Care Interventions • Palliative care consultation teams • Palliative care clinics • Nursing home hospice programs • Active management of home hospice programs • Palliative care training programs for students, residents, palliative care fellowships

  8. Challenges • Assumption: Something “nice” like palliative care must be a luxury we cannot afford • Zero-Sum Game and Life-Boat Triage • To spend more on palliative care in the short run means to spend less on something else • Competing missions • Institutional Inertia

  9. Management Argument: “We cannot afford palliative care” • Assumptions- • We have no choice as to where veterans die or how much it costs • Palliative care services would just be an additional expense without true cost savings Even if it would be “nice” to have…

  10. The skeptical manager says… SHOW ME DATA!

  11. Initial Questions: • What do people want toward the end-of-life? • What constitutes good care? What do they get • Where do people die? • What do they die from? • How much does it cost? • How much variability exists in the above parameters • And what accounts for this variability?

  12. WHAT DO PEOPLE WANT? What would be most important to you?

  13. Steinhauser K et. al. , Factors considered important at the end of life by patients, family, physicians, and other care providers JAMA, 2000; 284(19):.2476-2482

  14. Where do people die?

  15. Major Site: Acute Care Hospital Traditionally, people died in their homes. Only a few decades ago, the hospital was considered the “place where people went to die,” and was avoided by many, including the dying, for that very reason. Now, perhaps ironically, that the hospital is seen as being for short-term care, people enter more readily – and die there more often. Richard A. Kalish

  16. Honoring Veterans’ Preferences at the End-of-Life

  17. Patient Preferences for Site of DeathHome vs. Hospital or Nursing Home “Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics.” Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment." J Am Geriatr Soc 46(10): 1242-50.

  18. Palliative and End-of-Life Care in the VA Early Findings

  19. Patient Demographics VA Inpatient Deaths FY00 • 47% over age 75 • 45% married • Median annual income < $10,000 • 25% no reported income • 35% Service Connected Many veterans dying as inpatients have poor social support structures

  20. Average Cost per Day for Terminal Admissions FY00

  21. Non-Hospice Percent Total Costs Acute Care VA Palo Alto FY00 0% Mental Health 21% Medical Procedures

  22. Palo Alto Hospice Costs FY00 13% Mental Health 2% Medical Procedures NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR PIE

  23. MOST CAUSES OF DEATH IN ACUTE CARE PREDICTABLE AND NOT SIGNIFICANTLY DIFFERENT FROM HOSPICE

  24. Responses from Managers… • “Doesn’t prove anything” – differences may have arisen from: • Referral and selection biases: (hospice patients more end-stage, preferred less aggressive/expense care) • “You don’t know our patients - they want more aggressive care based on… different illnesses, age, ethnicity etc.”

  25. Background Message: • ‘Immutable patient variables predominantly determine where patients die and how much it costs’ • Implication: Changing the system will make little difference And thus status-quo is maintained

  26. Patient variables Age Gender Race Income Diseases (DRG) Proximity/distance to care venues Preferences for care System variables Total hospital beds ICU beds Nursing Home beds Availability of Palliative Care Consult Team Dedicated PC beds Geographic locations of hospitals and PC units Patient vs. System Variables

  27. Demographics and Associated Costs of Dying for Enrolled VeteransPreliminary Findings James Hallenbeck, MD James Breckenridge, PhD Co-Principal Investigators VA Palo Alto HCS Susan Ettner, PhD, UCLA, Karl Lorenz, MD, UCLA David Draper, PhD. U.C. Santa Cruz Co-investigators Funded by the Robert Wood Johnson Foundation

  28. Study Purposes • Archeological – A “dig” in VA databases • Where veterans die • Demographic and system correlates with terminal venue • Patterns of care across venues • Economic – Examining relationship between care patterns and cost of care • Costs of care in different venues • Instrumental variable analysis: comparing costs of deaths in dedicated palliative care beds to deaths elsewhere

  29. Methodology • Population: All veterans during FY 00-02 with at least one institutional stay: 849,489 individuals • Veterans who died during this time period:172,086 (20%) • Last institutional venue: • ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed • Analyze associated demographics and costs

  30. In Hospital Deaths Dartmouth Atlas: www.dartmouthatlas.org/

  31. n = 79,389 41% of Acute Care Deaths in ICU 39% of acute care deaths for Pts 65+

  32. Controlling for Charlson Co-morbidity Index, HCUP/CCS Diagnosis-based Risk adjustment, Age, Sex, Race and Distance Nearest VA

  33. p = .002, r = -.64

  34. Plots facility nursing home deaths per 1000 patients in the study population against ICU deaths as a percentage of all institutional deaths and deaths within 30 days of discharge r= -.52, p=000

  35. What do people die from in ICUs?

  36. ICU Terminal Stay ICD9 Codes Diagnosis Freq % Diagnosis Freq %

  37. How much does it cost?

  38. Cost per Day Terminal Stays n = 79,389

  39. Direct Costs of Care for Last Six Months and Last Year of Life > 10% VA clinical budget spent for <1.5% VA enrolled population in the last year of life…

  40. Costs of Terminal Stays Annual direct DSS costs of terminal admits: $387,367,000 67% of costs in acute care

  41. How can we put this all together?

  42. National Trends Affecting Terminal Venues • Decreasing acute care workload • 55% decrease in # of acute beds 1994-98* • (ADC down 23% FY02 vs. FY97) • A proportional increase in ICU workload, as percentage of acute workload • VA nursing homes: Mandate to keep high ADC * Ashton: N Engl J Med, Volume 349(17).October 23, 2003.1637-1646

  43. ICU Beds as Percentage Acute Care Beds

  44. Need to decompress beds Need to maintain high ADC

  45. Acute Care Triage: Up, Down or Out • Non-ICU acute care less a venue for treatment than for triage • Patients triaged “up” to ICU or “down” (to nursing homes) or “out” discharged to home/non-VA care • Imperative to “decompress” acute care beds using nursing home beds in conflict with mandate to maintain high ADC. Like squeezing the middle of a tube of toothpaste…

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