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Palliative Carein the Continuum

of Oncologic Management

Michael W. Rabow, MDDirector, Symptom Management ServiceHelen Diller Family Comprehensive Cancer CenterHelen Diller Family Chair in Palliative CareProfessor of Clinical Medicine and UrologyUCSF

May 25 & June 22, 2017

PC in the Routine Continuum of Cancer Care

“…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

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How knowledgeable are you about Palliative Care?

1. Not at all knowledgeable2. Somewhat knowledgeable3. Knowledgeable4. Very knowledgeable5. Don’t know

Public (Mis)Understanding

Once they know…

• 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

The Current Definition

• Palliative care is specializedmedical 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.

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The Core Elements of Palliative Care

• Symptom management• Excellent communication• Comprehensive care• Bio-­psycho-­social-­sexual-­spiritual• Family• Continuity

• Team-­based care

Palliative Care is Not…

• For old people only• End-­‐of-­‐life care• Hospice

Palliative Care

End-­‐Of-­‐Life Care

Hospice

Conceptual Shift for Palliative Care: NEED, not Prognosis

Hospice

Main Points

• Definition• Benefits• Availability• Challenges/Opportunities

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Proven Benefits

1. Improved patient and family satisfaction2. Reduction in symptom burden3. Prolonged life (hospice, outpatient)4. Improved efficiency/Reduced costs

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, 2007. 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, 2013.

1. Improved Satisfaction§ Patients§ Family§ Clinicians

Rabow, JPM, 2014

2. Improved Symptoms• 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, 2011Follwell, J Clin Onc, 2008 Kim, JPM, 2012Rabow, Arch Intern Med, 2004Zimmermann, The Lancet, 2014

3. Prolonged Survival in Hospice (Connor, J Pain Sx Mgmt, 2007)

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What was the mortality impact of concurrent palliative care in the

Temel study?

1. It shortened survival2. It had no effect3. It prolonged survival by about 3 weeks4. It prolonged survival by about 3 months5. I don’t know about the Temel study

Prolonged Survival: The Post-­Temel Universe

151 patients with NSCLC at Mass GeneralImmediate 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 UtilizationInpatient PC Triggers = Improved Utilization

• Decreased 30-­‐day readmissions (35% to 18%)• Increased hospice referrals• Decreased chemotherapy after discharge

Adelson, JOP, 2017

Early-­‐PC = Better Utilization & Quality

*NQF measures Scibetta, Kerr, McGuire, Rabow, 2015

Early-­‐PC associated with better performance on EOL quality measures

0%

10%

20%

30%

40%

50%

60%

70%

>1 ED visit final 30 days of life*

ICU stay in the final 30-­‐days of life*

Death w/i 3 days hospital DC

Inpatient death 30-­‐day mortality case

Early-­‐PC

Late-­‐PC

5% 7%

15%

33%

14%

20% 20%

34%

66%

P<0.001

P<0.001

P=0.001P=0.001

P=0.044

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Average health system direct cost per patient for medical care in final 6 months of life

Early PC: $5000/patient Lower Total Costs

13,040

19,067

32,107

11,549

25,754

37,303

$-­‐

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

Direct Outpatient Costs Direct Inpatient Costs Total Direct Costs

Early PCLate PC

p=0.006

p<0.001

p=0.86

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. 2016 Jan;19(1):69-­‐75.

*Early PC = first contact with specialty service >90 days prior to death

Main Points

• Definition• Benefits• Availability• Challenges/Opportunities

142 cancer centers (Hui et al. JAMA. 2010)

PC in Cancer Centers

NCI site Non-NCI site

Palliative care program

98% 78%

Inpatient palliative care consult team

92% 56%

Outpatient palliative care

59% 22%

• 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, 2016

PC in NCCN Cancer Centers

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Main Points

• Definition• Benefits• Availability• Challenges/Opportunities

What percent of people who die from cancer get palliative care?

1. 0%2. 25%3. 45%4. 65%5. 100%

• 45% of patients who died at a comprehensive cancer center got palliative care.

Hui, Oncologist, 2012

• 52% of Vets with cancer who died got palliative care.

Gidwani, JPM, 2016

NotMeeting Our Goals Challenges/Opportunities

1. Specialty PC Workforce Shortage2. Primary Palliative Care in Oncology3. Integration4. The Historic Alignment: Managing Populations

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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, 2010

2. Primary Palliative CareOncology 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, 2013Hui, Oncologist, 2016Bickel, JOP, 2016

3. Models of 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, 2015Schenker, JPM, 2015

Barriers to Integration

1. Cultural change2. Systems approach3. Agreed-­‐upon metrics for quality4. Financial support

Davis, Supp Care Cancer, 2015Ramachandran, Cancer Control, 2015

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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