The Institute of Medicine recently released a report, Dying in America, focused on improving the quality and availability of end-of-life care for patients in the United States.
A committee of experts on the topic found that the nation suffers from a shortage of palliative care specialists and that other clinicians lack appropriate knowledge to treat patients dealing with end-of-life issues.
The group analyzed this treatment and provided recommendations in areas including care delivery, communication, planning, professional education, patient engagement and provider reimbursement. They found holes in the system in many areas and offered solutions that include patients, providers and payers.
"It was an exciting piece of work," said June Simmons, CEO of the Partners in Care Foundation and a member of the committee that worked on the project. "This is a time of change and there has been a lot of progress on the part of hospitals in that a lot of them have brought greater emphasis to end-of-life care."
Cost savings and increased quality
For hospitals, appropriate palliative care treatment should be an important issue because it may improve quality of care and reduce costs.
A study released in February in the Lancet looked at more than 450 patients with various kinds of advanced cancers, including breast, lung and gynecologic, who had a prognosis of more than six months to live. All of the patients were provided the same amount of clinical care, but about half were part of an early intervention group that took part in monthly, comprehensive consultations with a palliative care team and received regular follow-ups by phone.
Patients in the intervention group actually had worse health status at the beginning of the analysis, but had better improvements in quality of life than the control group after three months and better clinical improvements than the control group after four months. Patient satisfaction with care also improved greatly in the intervention group, but worsened in the group that did not receive palliative care. Symptom management and medical interactions were better in the intervention group after four months.
A 2008 study in the Archives of Internal Medicine looked at whether or not implementing palliative care could reduce costs. The study compared more than 5,000 patients who received palliative care services with nearly 20,000 that did not receive this treatment.
Palliative care patients who lived and were discharged saved the system $1,696 in direct costs per admission and $279 in direct costs each day. Patients who received palliative care but died saved the system $4,908 per admission and $374 per day. The reductions were seen in costs related to pharmacy, laboratory and time in the intensive care unit.
Gaps in the system
One of the recommendations in the IOM report addresses a chief issue that can hamper palliative care. The group said that a "major reorientation" of payment systems and incentives will be needed to create incentives for the use of social services, care coordination and advanced care planning—instead of the current focus on acute-care treatment.
A second issue is a dearth of skilled palliative care providers. The number of palliative care specialists is small, even with the growth in the industry.
A November 2013 article in Becker's Hospital Review found that in 2000, fewer than 20% of larger hospitals offered palliative care; in 2013, about 70% had implemented a program. But, the article also noted a shortage of providers to work in these programs. This is largely in part because of a cap on the number of Medicare-funded graduate medical education slots for palliative care.
When these patients aren't getting treatment from palliative care specialists, they receive it from other providers who are often lacking education in end-of-life services. According to Simmons, there is no excuse for hospitals not having trained professionals. With the availability of telehealth technology, providers can get training via webinars or video conferencing.
The report also recommends care be provided in an integrated, highly-accessible manner at the end of life. The best way to provide this care is to foster it early with as much communication as possible between families, patients and caregivers.
Hospitals shouldn't have to be alone in these efforts, according to Simmons: Part of the job for providers is being aware of what resources are available and directing patients appropriately. Health systems can also play a role in creating and encouraging development of new resources in the community.