The Cost of Waiting: Implications of the Timing of Palliative Care Consultation among a Cohort of Decedents at a Comprehensive Cancer Center PCQN Group Discussion, March 12, 2015 Colin Scibetta, MD Clinical Fellow Hospice and Palliative Medicine March 12, 2015
Disclosures • No relevant financial relationships or conflicts of interest to disclose
Objectives 1. Introduce metrics used to assess quality of medical care provided at the end of life 2. Discuss how quality outcomes differ between patients who received early vs. late palliative care consultation 3. Consider financial implications of early PC consultation at UCSF
Background 1. ASCO recommends that palliative care (PC) be offered alongside standard oncologic care for pts with metastatic CA and/or high symptom burden 2. Multiple studies have demonstrated improved quality, cost savings, improved patient satisfaction with PC 3. Limited data on how timing and setting of PC is associated with quality, intensity and cost of medical care at EOL in pts with advanced CA
Research Question • Among a population of patients who received regular care at an academic cancer center and who died of cancer, we sought to understand: o The overall rate of referral to specialty Palliative Care o Associations of Early (>90 days prior to death) versus Late (<90 days prior to death) provision of PC with overall quality of care as well as direct cost of medical care o The setting (inpatient vs outpatient) in which both Early and Late PC were delivered
Study Design: Retrospective Cohort • Patients who received regular cancer care at UCSF o Died within 29 month study period o Cancer as known cause of death o At least 2 visits with UCSF oncology • Looked at patients who had contact with specialty palliative care (PC) o Groups divided into Early (>90 days) and Late PC (>90 days) • Evaluated clinical outcomes and overall cost in the 6 months preceding death 6
Too little, too late • 922 patients identified • Only 32% of patients had any contact with IP and /or OP PC services • 10% received Early-PC (initial PC contact more than 90 days prior to death) • 21% received Late-PC (initial PC contact 90 or fewer days prior to death) 7
Early-PC = Better Quality P<0.001 70% 66% 60% 50% 40% P<0.001 Early-PC Late-PC 34% 33% 30% P=0.001 P=0.001 20% P=0.044 20% 20% 15% 14% 10% 7% 5% 5% 0% >1 ED visit final 30 ICU stay in the final Death w/i 3 days Inpatient death 30-day mortality days of life* 30-days of life* hospital DC case Early-PC associated with better performance on EOL quality measures 8 *NQF measures
Early PC = Less Spending on Futile Care Average direct cost per patient for medical care in final 6 months of life $40,000 p=0.006 37303 $35,000 32,107 $30,000 P<0.001 $25,000 25,754 $20,000 19,067 p=0.86 Early PC $15,000 13,040 Late PC $10,000 11,549 $5,000 $- Direct Outpatient Direct Inpatient Total Direct Costs Costs Costs 9
Early-PC = less escalation in utilization Average direct cost per inpatient admission by month, final 6 months of life $14,000 $12,000 $10,000 Direct costs per $8,000 Early PC $6,000 admission Late PC $4,000 $2,000 $0 6 5 4 3 2 1 Month preceding death 10
Early Palliative Care = Outpatient PC 91% of patients that only saw • Median Days 1st PC to inpatient PC team received Late- Death PC 140 25% Late PC patients had any OP • PC 120 84% of patients with OP PC • 100 received Early-PC 75% of patients where 1st PC • 80 contact was in OP setting received Early-PC 60 Early PC allows for multiple • 40 contacts with palliative care over time 20 78% of Early-PC patients had multiple • contacts with PC services, compared 0 to only 18% of Late-PC cases Inpatient PC Outpatient PC 11
Opportunities for earlier referral to PC 35 67% (137/204) of Late-PC patients 30 had at least 2 office visits in months 6-4 preceding death 25 Late-PC = late referral, not late # Cases 20 presentation to the cancer center 15 10 5 0 2 3 4 5 6 7 8 9 12 # Office Visits in months 6-4 preceding death 12
Big picture findings • Specialty Palliative Care is underutilized in advanced cancer patients at UCSF • Early PC is associated with better clinical outcomes when compared to late PC • Early PC associated with significant inpatient and overall cost savings • Early PC is best delivered in the outpatient setting
Acknowledgements Mike Rabow Kathleen Kerr Joseph Mcguire UCSF Cancer Center Registry UCSF Cancer Committee UCSF Palliative Medicine fellowship Palliative Care Quality Network
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