Lower ICU use and inpatient costs due to palliative care

Palliative care was compared to usual care

An increasing body of studies are demonstrating the financial benefits, as well as quality improvement benefits of including palliative care in a hospital system.

One of the latest studies looked at the use of palliative care in the Veterans Administration system.

"There are many studies that have demonstrated that palliative care programs have been associated with improved clinical outcomes when compared to conventional care, particularly with extremely ill patients," says R. Sean Morrison, MD, director of the National Palliative Care Research and Training Center and a Hermann Merkin professor of palliative care and professor of geriatrics and medicine at Brookdale Department of Geriatrics and Adult Development of Mount Sinai School of Medicine in New York, NY. Morrison also is the vice-chair for research.

"The big question is 'How do we pay for this improved care?' and that's predicated on an assumption that because it's better, it must cost more money," Morrison says. "So what our group has started to do, and this is the first of a series of studies that will be coming out, is find out what are the financial implications to hospitals of palliative care programs."

The study found that palliative care was associated with lower intensive care unit use and lower inpatient costs, when compared with usual care.1

Investigators began with the belief that palliative care programs provide quality care, and they do so in a fiscally responsible manner, he says.

"At worst, they are as expensive as usual care," Morrison says. "But in the best-run programs, they result in cost savings at the same time they improve care."

The reasons why palliative care programs might be cost effective are three-fold, Morrison says. Here's why:

  • Palliative care programs start with the premise that palliative care is patient-centered care, so they start by identifying the goals of medical care for patients and their families, he says.
  • Then they help patients and families select treatments that meet those goals.
  • And third, they help patients either discontinue or not start treatments that may be available, but which don't meet those goals, Morrison says.

"Ideally, when you do that, patients get what they want and need — the right care at the right time, but they don't get other treatments or expensive treatments that they don't want or that don't meet their goals," he explains.

"That was our hypothesis," Morrison adds.

To test the hypothesis, investigators looked at two urban VA hospitals and compared patients who received consultation by the palliative care program in each of those hospitals with patients who looked exactly like those perceived patients, but who don't receive palliative care, he says.

They selected VA hospitals because these are contained health systems in which the billing and financial records are very well documented and because veterans tend to stay within the VA hospitals.

"So it's a much tighter health care system to begin to look at this, and VAs are extremely concerned about costs because VA health care is 100 percent supported by tax dollars," Morrison says. "So it's very important for us to show high quality care for our veterans and, also, that we're doing it in a fiscally responsible manner."

Another reason they selected VA hospitals for the study is because if these studies demonstrated that palliative care was cost effective, then it would be extremely easy to roll out the programs across the country in other VAs, he adds.

"We felt if our hypothesis was borne out we could rapidly influence care to both a very deserving and large population of veterans," Morrison says.

In the VA hospitals studied, there were active palliative care programs that were dependent on physician referrals, so many patients in the hospitals might have benefited from palliative care, but they did not receive it, he notes.

"We knew which ones received palliative care from an administrative database, and we used a matching methodology where we identified patients of the same age, same diagnosis, and same number of serious medical conditions," Morrison says. "For every palliative care patient, we found a usual care patient who looked just like the palliative care patient on all of those parameters."

Then investigators looked to see what the cost differences were, and they found that the palliative care patients had an average daily cost of $239 less than the usual care patients, and there were almost $100 less in costs of lab tests,X-rays, MRIs, and imaging systems, Morrison says.

"At the same time, and it was not in this paper, but it's been in other work we've done, we found that families with palliative care patients were more satisfied than families where patients received the usual care, and the palliative care patients had better symptom management," Morrison says. "Most importantly, there has been no difference in survival between the two groups."

This is the second study that has demonstrated that a palliative care program can be implemented without increasing the budget, Morrison says.

"Our next study, for which we're doing a similar analysis with seven hospitals outside the VA system, doesn't have preliminary data yet," Morrison says. "We'll look at hospital costs and also at what happens to reimbursement to the hospitals."

The VA system already has a mandate requiring each hospital to have a palliative care program, and it's a little too early to say what the impact will be from the cost-effectiveness study, Morrison says.

"This research adds a lot of support for VA hospitals that are worried about keeping costs down," Morrison says. "It's a win-win for everybody."

Reference:

1. Penrod JD, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Pall Med. 2006;9:855-860.

Need More Information?

  • R. Sean Morrison, MD, Director, National Palliative Care Research and Training Center; Hermann Merkin Professor of Palliative Care, Professor of Geriatrics and Medicine, Vice-Chair for Research, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, Box 1070, One Gustave L. Levy Place, New York, NY 10029. Telephone: (212) 241-1466.