Palliative Care – A Palliative Care – A Luxury you cannot Luxury you cannot

afford?afford?

James Hallenbeck, MDJames Hallenbeck, MDAssistant Professor of MedicineAssistant Professor of Medicine

Director, Palliative Care Director, Palliative Care ServicesServices

VA Palo Alto HCSVA Palo Alto HCS

AgendaAgenda

Review data regarding where veterans Review data regarding where veterans die, associated costs and correlationsdie, associated costs and correlations

Encourage you to think about barriers to Encourage you to think about barriers to the expansion of palliative care in VAthe expansion of palliative care in VA

Challenge the assumption that palliative Challenge the assumption that palliative care is a luxury we cannot affordcare is a luxury we cannot afford

Palliative Care in the VAPalliative Care in the VA

VA is the largest unified healthcare system VA is the largest unified healthcare system in the countryin the country

28% of Americans dying each year are 28% of Americans dying each year are veterans (more than die from all cancers veterans (more than die from all cancers annually)annually)

VA is a potential model for universal VA is a potential model for universal healthcare of an aged, chronically ill healthcare of an aged, chronically ill populationpopulation

Unified database for analysisUnified database for analysis

Important to study Important to study because…because…

Annual Veteran Annual Veteran DeathsDeaths

A small percentage of veterans die as inpatients in VA facilities

Questions for VA and for YouQuestions for VA and for You

Should VA invest in palliative care?Should VA invest in palliative care? Is such care “cost-effective”?Is such care “cost-effective”? Could adequate dollars be cost-shifted or Could adequate dollars be cost-shifted or

avoided to justify such an investment? avoided to justify such an investment? Why is there such variance across VA Why is there such variance across VA

regions and facilities? regions and facilities?

Is palliative care is luxury the VA cannot afford, or can the VA not

afford not to have palliative care?

Good News Good News Establishment of hospice treating Establishment of hospice treating

specialty 2002specialty 2002 Interprofessional Palliative Care Interprofessional Palliative Care

Fellowship 2002Fellowship 2002 Mandated palliative care consult teams Mandated palliative care consult teams

20032003 Accelerated Administrative and Clinical Accelerated Administrative and Clinical

Training (AACT) initiative 2002-Training (AACT) initiative 2002- Establishment of Hospice-Veteran Establishment of Hospice-Veteran

Partnerships (HVPs) 2002-Partnerships (HVPs) 2002-

Examples of Palliative Care Examples of Palliative Care InterventionsInterventions

Palliative care consultation teams Palliative care consultation teams Palliative care clinicsPalliative care clinics Nursing home hospice programsNursing home hospice programs Active management of home hospice Active management of home hospice

programsprograms Palliative care training programs for Palliative care training programs for

students, residents, palliative care students, residents, palliative care fellowshipsfellowships

ChallengesChallenges

Assumption: Assumption: Something “nice” like Something “nice” like palliative care must be a luxury we palliative care must be a luxury we cannot affordcannot afford

Zero-Sum Game and Life-Boat TriageZero-Sum Game and Life-Boat Triage To spend more on palliative care in the To spend more on palliative care in the

short run means to spend less on short run means to spend less on something else something else

Competing missions Competing missions Institutional Inertia Institutional Inertia

Management Argument: Management Argument: “We cannot afford palliative “We cannot afford palliative

care”care”

Assumptions-Assumptions- We have no choice as to where veterans We have no choice as to where veterans

die or how much it costsdie or how much it costs Palliative care services would just be an Palliative care services would just be an

additional expense without true cost additional expense without true cost savingssavings Even if it would be “nice” to have…Even if it would be “nice” to have…

SHOW ME DATA!SHOW ME DATA!

The skeptical The skeptical manager says…manager says…

Initial Questions:Initial Questions: What do people What do people wantwant toward the end-of- toward the end-of-

life?life? What constitutes good care? What do they What constitutes good care? What do they getget

Where do people die?Where do people die? What do they die from?What do they die from? How much does it cost?How much does it cost? How much variability exists in the above How much variability exists in the above

parameters parameters And what accounts for this variability?And what accounts for this variability?

WHAT DO PEOPLE WHAT DO PEOPLE WANT?WANT?

What would be most What would be most important to you?important to you?

Steinhauser K et. al. , Factors considered important at the end Steinhauser K et. al. , Factors considered important at the end of life by patients, family, physicians, and other care providers of life by patients, family, physicians, and other care providers

JAMA, 2000; 284(19):.2476-2482JAMA, 2000; 284(19):.2476-2482

Where do people Where do people die?die?

Major Site: Acute Care Major Site: Acute Care HospitalHospital

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

Richard A. KalishRichard A. Kalish

Honoring Veterans’ Honoring Veterans’ Preferences at the Preferences at the

End-of-LifeEnd-of-Life

Patient Preferences for Site of DeathPatient Preferences for Site of DeathHome vs. Hospital or Nursing HomeHome vs. Hospital or Nursing Home

Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient preferences and local health system characteristics on the place preferences and local health system characteristics on the place

of death. SUPPORT Investigators. Study to Understand of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Prognoses and Preferences for Risks and Outcomes of

Treatment." Treatment." J Am Geriatr SocJ Am Geriatr Soc 46 46(10): 1242-50.(10): 1242-50.

“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.”

Palliative and End-Palliative and End-of-Life Care in the of-Life Care in the

VAVAEarly FindingsEarly Findings

Patient Demographics VA Patient Demographics VA Inpatient Deaths FY00Inpatient Deaths FY00

47% over age 7547% over age 75

45% married45% married

Median annual income < $10,000Median annual income < $10,000 25% no reported income25% no reported income

35% Service Connected 35% Service Connected

Many veterans dying as inpatients have poor social support structures

Average Cost per Day for Average Cost per Day for Terminal Admissions FY00Terminal Admissions FY00

$0$100$200$300$400$500$600$700$800$900

$1,000

Palo Alto AcuteCare

Other Facility 1 Other Facility 2 Palo AltoHospice Care

Center

Non-Hospice Percent Total Costs Non-Hospice Percent Total Costs Acute Care VA Palo Alto FY00Acute Care VA Palo Alto FY00

Non-Hospice Percent Total Costs

Pharmacy8%

MedProc21%

Nursing55%

MH0%

Other16%

0% 0% MentMental al HealtHealthh

21% 21% Medical Medical ProceduProceduresres

Palo Alto Hospice Costs FY00 Palo Alto Hospice Costs FY00

Hospice Percent of Total Costs

Pharmacy7% MedProc

2%

Nursing75%

MH13%

Other3%

13% 13% Mental Mental HealthHealth

2% 2% Medical Medical ProcedurProcedureses

NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR PIEPIE

Palo Alto VA: Acute/ICU Deaths: 30 pts Discharge Diagnoses FY00

41%

10%7%3%

3%

21%

3%

3%

3%

3%

3%

Met cancer

Cirrhosis

End-stage renal

Hip fx

Stroke

Heart dx

COPD

Aneurism

Pericarditis

Sepsis

Head injury

MOST CAUSES OF DEATH IN ACUTE CARE PREDICTABLE AND NOT SIGNIFICANTLY DIFFERENT

FROM HOSPICE

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

National Palo Alto Lebanon Dayton

National vs three stations with palliative care units

FY 2000 Inpatient Deaths by Location

ICU (all)

General Medicine

Intermediate Medicine

Nursing Home

Responses from Managers…Responses from Managers…

““Doesn’t prove anything”Doesn’t prove anything” – differences – differences may have arisen from:may have arisen from: Referral and selection biases: (hospice Referral and selection biases: (hospice

patients more end-stage, preferred less patients more end-stage, preferred less aggressive/expense care)aggressive/expense care)

““You don’t know our patients - they want You don’t know our patients - they want more aggressive care based on… different more aggressive care based on… different illnesses, age, ethnicity etc.”illnesses, age, ethnicity etc.”

Background Message:Background Message:

‘‘Immutable patient variables Immutable patient variables predominantly determine where predominantly determine where patients die and how much it costs’patients die and how much it costs’

Implication: Changing the system will make Implication: Changing the system will make little differencelittle difference

And thus status-quo is And thus status-quo is maintainedmaintained

Patient vs. System VariablesPatient vs. System Variables

Patient variablesPatient variables AgeAge GenderGender RaceRace IncomeIncome Diseases (DRG)Diseases (DRG) Proximity/Proximity/

distance to care distance to care venuesvenues

Preferences for Preferences for carecare

System variablesSystem variables Total hospital bedsTotal hospital beds ICU bedsICU beds Nursing Home bedsNursing Home beds Availability of Availability of

Palliative Care Palliative Care Consult TeamConsult Team

Dedicated PC bedsDedicated PC beds Geographic Geographic

locations of locations of hospitals and PC hospitals and PC unitsunits

Demographics and Associated Demographics and Associated Costs of Dying for Enrolled Costs of Dying for Enrolled

VeteransVeteransPreliminary FindingsPreliminary Findings

James Hallenbeck, MDJames Hallenbeck, MD

James Breckenridge, PhDJames Breckenridge, PhD

Co-Principal InvestigatorsCo-Principal Investigators

VA Palo Alto HCSVA Palo Alto HCS

Susan Ettner, PhD, UCLA, Susan Ettner, PhD, UCLA,

Karl Lorenz, MD, UCLAKarl Lorenz, MD, UCLA

David Draper, PhD. U.C. Santa Cruz David Draper, PhD. U.C. Santa Cruz

Co-investigators Co-investigators Funded by the Robert Wood Johnson Funded by the Robert Wood Johnson

FoundationFoundation

Study PurposesStudy Purposes

Archeological – A “dig” in VA databasesArcheological – A “dig” in VA databases Where veterans dieWhere veterans die Demographic and system correlates with terminal venueDemographic and system correlates with terminal venue Patterns of care across venuesPatterns of care across venues

Economic – Examining relationship between care Economic – Examining relationship between care patterns and cost of carepatterns and cost of care Costs of care in different venuesCosts of care in different venues Instrumental variable analysis: comparing costs of Instrumental variable analysis: comparing costs of

deaths in dedicated palliative care beds to deaths deaths in dedicated palliative care beds to deaths elsewhereelsewhere

MethodologyMethodology Population: Population: All veterans during FY 00-02 All veterans during FY 00-02

with at least one institutional staywith at least one institutional stay: 849,489 : 849,489 individualsindividuals

Veterans who died Veterans who died during this time periodduring this time period:: 172,086 172,086 (20%)(20%)

Last institutional venue:Last institutional venue: ICU, Acute Care (non-ICU), Nursing Home, ICU, Acute Care (non-ICU), Nursing Home,

Other, Dedicated Palliative Care Bed Other, Dedicated Palliative Care Bed Analyze associated demographics and Analyze associated demographics and

costscosts

In Hospital DeathsIn Hospital Deaths

Dartmouth Atlas: Dartmouth Atlas: www.dartmouthatlas.org/ www.dartmouthatlas.org/

VA Institutional Deaths by VISN

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

VISN

Pe

rce

nt

by

ve

nu

e

OTHER/PSCH

NHC/INT

Acute

ICU

41% of Acute Care Deaths in 41% of Acute Care Deaths in ICUICU

39% of acute care deaths for 39% of acute care deaths for Pts 65+ Pts 65+

n = n = 79,38979,389

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

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

Plots facility nursing home deaths per 1000 patients in the Plots facility nursing home deaths per 1000 patients in the study population against ICU deaths as a percentage of all study population against ICU deaths as a percentage of all institutional deaths and deaths within 30 days of dischargeinstitutional deaths and deaths within 30 days of discharge

r= -.52, r= -.52, p=000p=000

What do people die What do people die from in ICUs?from in ICUs?

ICU Terminal Stay ICD9 ICU Terminal Stay ICD9 CodesCodes

Diagnosis Freq Diagnosis Freq % %

Diagnosis Freq Diagnosis Freq % %SUBENDO INFARCT, INITIAL 467 2.19

AMI NOS, INITIAL 459 2.15FOOD/VOMIT PNEUMONITIS 424 1.98CRNRY ATHRSCL NATVE VSSL 407 1.9CARDIAC ARREST 368 1.72ACUTE RENAL FAILURE NOS 339 1.59ALCOHOL CIRRHOSIS LIVER 331 1.55GASTROINTEST HEMORR NOS 246 1.15MAL NEO UPPER LOBE LUNG 229 1.07MAL NEO BRONCH/LUNG NOS 206 0.96INTRACEREBRAL HEMORRHAGE 184 0.86URIN TRACT INFECTION NOS 181 0.85ATRIAL FIBRILLATION 174 0.81HYPOVOLEMIA 171 0.8OTHER PULMONARY INSUFF 170 0.8STAPH AUREUS PNEUMONIA 168 0.79SHOCK W/O TRAUMA NEC 164 0.77CRBL ART OCL NOS W INFRC 162 0.76ACUTE PANCREATITIS 158 0.74STAPH AUREUS SEPTICEMIA 155 0.73AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58

AMI ANTERIOR WALL, INIT 146 0.68AC VASC INSUFF INTESTINE 141 0.66ABDOM AORTIC ANEURYSM 138 0.65AMI INFERIOR WALL, INIT 137 0.64HUMAN IMMUNO VIRUS DIS 135 0.63HEPATIC COMA 123 0.58CVA 121 0.57PNEUMOCOCCAL PNEUMONIA 117 0.55CHR AIRWAY OBSTRUCT NEC 115 0.54PULM EMBOL/INFARCT NEC 103 0.48CIRRHOSIS OF LIVER NOS 102 0.48AORTIC VALVE DISORDER 98 0.46MAL NEO LOWER LOBE LUNG 97 0.45PLEURAL EFFUSION NOS 94 0.44PSEUDOMONAL PNEUMONIA 93 0.44INTESTINAL OBSTRUCT NOS 92 0.43ACT MYL LEUK W/O RMSION 91 0.43RUPT ABD AORTIC ANEURYSM 91 0.43HEMATEMESIS 87 0.41POSTINFLAM PULM FIBROSIS 78 0.36HYPOTENSION NOS 77 0.36ANOXIC BRAIN DAMAGE 76 0.36ATH EXT NTV ART GNGRENE 76 0.36CHRONIC RENAL FAILURE 76 0.36SEPTICEMIA NEC 73 0.34AMI ANTEROLATERAL, INIT 72 0.34

How much does it How much does it cost?cost?

Cost per Day Terminal StaysCost per Day Terminal Stays

AverageAverage MedianMedian Average Average LOSLOS

ICUICU $1624$1624 $1406$1406 10.710.7

AcuteAcute $641$641 $536$536 10.310.3

NHCNHC $253$253 $230$230 **

Palliative Palliative

CareCare

$278$278 $262$262 2424

n = 79,389n = 79,389

Direct Costs of Care for Last Six Direct Costs of Care for Last Six Months and Last Year of LifeMonths and Last Year of Life

Institutional Institutional CostsCosts

Outpatient & Outpatient & Fee CostsFee Costs

TotalTotal

Direct CostsDirect Costs

Six Six MonthsMonths

$743,162,000$743,162,000 $159,604,000$159,604,000 $902,766,000$902,766,000

One One

YearYear

$966,439,000$966,439,000 $204,832,000$204,832,000 $1,172,237,000$1,172,237,000

> 10% VA clinical budget spent for > 10% VA clinical budget spent for <1.5% VA enrolled population in the <1.5% VA enrolled population in the

last year of life…last year of life…

Costs of Terminal StaysCosts of Terminal Stays

Percentage total cost by venue

38%

29%

18%

4%

11%ICU Deaths

Acute Care Deaths

NHC Deaths

Ded. Palliative CareDeaths

Other Setting

Annual direct DSS costs of terminal admits:Annual direct DSS costs of terminal admits: $387,367,000 $387,367,000

67% of costs in acute care67% of costs in acute care

Total Inpatient Costs in Last Six Months for All Deaths and the Percentage of Deaths in Intensive Care by VA Facility

y = 14504e2.3383x

R2 = 0.3286

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

0% 10% 20% 30% 40% 50% 60% 70%

Percentage Dying in Intensive Care

Six

Mon

th T

otal

Cos

ts

How can we put this How can we put this all together?all together?

National Trends Affecting National Trends Affecting Terminal VenuesTerminal Venues

Decreasing acute care workloadDecreasing acute care workload 55% decrease in # of acute beds 1994-98*55% decrease in # of acute beds 1994-98* (ADC down 23% FY02 vs. FY97)(ADC down 23% FY02 vs. FY97)

A proportional A proportional increase increase in ICU in ICU workload, as percentage of acute workload, as percentage of acute workloadworkload

VA nursing homes: Mandate to keep VA nursing homes: Mandate to keep high ADChigh ADC

* Ashton: N Engl J Med, Volume 349(17).October 23, 2003.1637-1646

ICU Beds as Percentage Acute ICU Beds as Percentage Acute Care BedsCare Beds

1972 1972 All All

HospHosp

1990 VA 1990 VA Med/SurgMed/Surg

1992 1992 All All

Hosp Hosp

2001 VA 2001 VA Med/SurgMed/Surg

20012001

JapanJapan

% % Acute Acute CareCare

2.5%2.5% <6%<6% 8.6%8.6% 21%21% 1%1%

Acute Care Triage: Up, Down or Acute Care Triage: Up, Down or OutOut

Non-ICU acute care less a Non-ICU acute care less a venue for venue for treatmenttreatment than than for for triagetriage Patients triaged “up” to ICU Patients triaged “up” to ICU

or “down” (to nursing or “down” (to nursing homes) or “out” discharged homes) or “out” discharged to home/non-VA careto home/non-VA care

Imperative to Imperative to “decompress” acute care “decompress” acute care beds using nursing home beds using nursing home beds in conflict with beds in conflict with mandate to maintain high mandate to maintain high ADC.ADC.

Like squeezing Like squeezing the middle of a the middle of a

tube of tube of toothpaste…toothpaste…

An Impacted SystemAn Impacted System

Dying veterans tend to follow other sick Dying veterans tend to follow other sick veterans veterans A greater proportion go to ICU and get A greater proportion go to ICU and get

“stuck” there, even if dying is eventually “stuck” there, even if dying is eventually recognized, perhaps because of a lack of recognized, perhaps because of a lack of reasonable, alternative venues reasonable, alternative venues

Dying veterans at risk for discharge Dying veterans at risk for discharge without appropriate or adequate without appropriate or adequate services such as home hospiceservices such as home hospice

Perhaps…Perhaps…

A Field of Dreams…

SUMMARYSUMMARY

System variables are major factors in determining System variables are major factors in determining where and how veterans diewhere and how veterans die

Significant cost-savings/cost-avoidance can be Significant cost-savings/cost-avoidance can be realized by incorporating palliative care into VA realized by incorporating palliative care into VA healthcare systemshealthcare systems

Palliative care is not a luxury, but should be a Palliative care is not a luxury, but should be a standard of care that should be incorporated standard of care that should be incorporated into all venues in which seriously-ill patients into all venues in which seriously-ill patients are treated within VAare treated within VA

Evidence Evidence SuggestsSuggests::