Can a palliative care program improve patient outcomes at end of life while also reducing service use?

Kaiser Permanente designed an innovative palliative care program for patients with life-threatening chronic illnesses who don't yet qualify for hospice and wish to maintain their options for receiving curative care while gradually obtaining more supportive care at home as their condition worsens. This program allowed more participants to receive services and die at home rather than in an institution—an outcome most people say they desire—with increased satisfaction and at lower cost.

Why is this important?

The leading causes of death among persons ages 65 and older include congestive heart failure, cancer, stroke, and chronic obstructive pulmonary disease (CDC 1999). The health care system has failed to provide an adequate continuum of care for these individuals, who often cycle between bouts of acute hospital care followed by home health care (IOM 1997).

Many patients find that acute care at the end of life causes pain, discomfort, and distress to themselves and their families (Baker et al. 2000). Moreover, although most people say they would prefer to die at home, one-half of Americans die in the hospital and almost one-quarter die in nursing homes (BMS 2004). Many patients who desire and would benefit from palliative care may not be admitted to hospice if they desire to continue receiving some ongoing complex services (Lorenz et al. 2004).

Interventions

The Kaiser Permanente Palliative Care Project is an interdisciplinary home-based system of health care designed to provide patients suffering from life-threatening chronic conditions with the option of continuing to receive curative care while gradually transitioning to receive more palliative care at the end of life.

Palliative care enhances comfort and improves patients' quality of life through the provision of symptom control and pain relief, emotional and spiritual support, and patient education. The central care team consists of the patient and family plus a physician, nurse, and social worker (Brumley et al. 2003a; Brumley et al. 2003b).

Findings

Patients enrolled in the palliative care program with congestive heart failure, chronic obstructive pulmonary disease, or cancer were more satisfied with the care they received (measured 60 days after enrollment) and more likely to die at home compared with those who received usual Medicare home health care before dying.

Those receiving palliative care received 2.6 times more home health care visits and reported half as many visits to the physician, 75 percent fewer hospital days, and 80 percent fewer nursing home days as those in usual care.

The average cost of personal health care services (not including facility charges) in the intervention group was $6,580 (45%) lower per patient than for the usual care group (Brumley et al. 2003a; Brumley et al. 2003b; personal communication with Susan Enguidanos 2005).

Implications

The authors suggest that by introducing palliative care to chronically ill patients before the onset of dramatic functional declines, patients nearing the end of life can better manage their care to their own satisfaction in their homes—an outcome most people say they desire (Curtis et al. 2002; Pritchard et al. 1998).

Improvement Ideas and Resources

An online resource manual provides more information for replicating this model. The Robert Wood Johnson Foundation's Promoting Excellence in End-of-Life Care program at the University of Montana worked with several organizations to create similar flexible, innovative palliative care options in diverse care settings. The nonprofit Center to Advance Palliative Care offers tools, training, and technical assistance to help hospitals and other health care institutions create palliative care programs.

Measure:

This comparison study was conducted at the Kaiser Permanente (KP) TriCentral Service Area located in southern California. A subgroup analysis of 300 patients who died during the study from congestive heart failure, chronic obstructive pulmonary disease, or cancer was performed; 161 patients were enrolled in the KP Palliative Care Project intervention. The comparison group included 139 patients who received usual Medicare home care. All patients had a life expectancy of less than 24 months. Palliative care patients could maintain their primary care physician while being treated at home by the palliative care physician. Pain was assessed at each home visit, and 24-hour telephone support was provided to palliative care patients.

Data on resource use were obtained from the KP service utilization database. Research assistants blinded to the group assignments conducted telephone interviews with patients seven days after their enrollment in the study and every 60 days thereafter to obtain information regarding demographics, the severity of illness, and satisfaction with services. Satisfaction was measured using the Reid-Gundlach Satisfaction with Services instrument. Scores at 60 days post-enrollment were 43.55 and 40.97 for the intervention and usual care groups, respectively, as compared with 41.13 and 40.19 at baseline. The mean satisfaction score was significantly higher at 60 days post-enrollment only for the intervention group. For purposes of the chart, satisfaction scores were converted into a percentage by dividing them by the total possible score of 48. Costs of care (not shown) were calculated based on 1999 staff salary rates; medication, facility, and administrative costs were not included. Rates of service use were adjusted to control for days enrolled, congestive heart failure diagnosis, and severity of illness. All between group differences in service use shown in the chart were statistically significant (Brumley et al. 2003a; personal communication with Susan Enguidanos 2005).

Limitations:

The study might not be generalizable to other practice settings; a randomized trial is needed to confirm results. Although many people say they would prefer to die at home (an outcome measured in this study), it would be helpful to assess whether patients' preferences were met for preferred place of death as well as the family's perception of care provided at the end of life (Curtis et al. 2002).

Source:

Evaluation of the Kaiser Permanente Palliative Care Project was based on utilization data and patient survey and was conducted by physicians and researchers at Southern California Permanente Medical Group, Pasadena; the Partners in Care Foundation, Burbank; and California State University, Bakersfield (Brumley et al. 2003a; Brumley et al. 2003b).

References:

* Indicates source of data used in the chart(s).Baker, R., A. W. Wu, J. M. Teno et al. 2000. Family Satisfaction with End-of-Life Care in Seriously Ill Hospitalized Adults. Journal of the American Geriatrics Society 48 (5 Suppl): S61–9.

BMS (Brown Medical School). 2004. Brown Atlas of Dying. Providence, R.I.: Brown University, Center for Gerontology and Health Care Research.

Brumley, R. D., S. Enguidanos, and D. A. Cherin. 2003a. Effectiveness of a Home-Based Palliative Care Program for End-of-Life. Journal of Palliative Medicine 6 (5): 715–24.

* Brumley, R. D., S. Enguidanos, and K. Hillary. 2003b. The Palliative Care Program. Permanente Journal 7 (2): 7–12.

CDC (Centers for Disease Control and Prevention). 1999. Reasons Reported by Medicare Beneficiaries for Not Receiving Influenza and Pneumococcal Vaccinations—United States, 1996. Morbidity and Mortality Weekly Report 48(39): 886–90.

IOM (Institute of Medicine). 1997. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press.

Curtis, J. R., D. L. Patrick, R. A. Engelberg et al. 2002. A Measure of the Quality of Dying and Death. Initial Validation Using After-Death Interviews with Family Members. Journal of Pain and Symptom Management 24 (1): 17–31.

Lorenz, K. A., S. M. Asch, K. E. Rosenfeld et al. 2004. Hospice Admission Practices: Where Does Hospice Fit in the Continuum of Care? Journal of the American Geriatrics Society 52 (5): 725–30.

Pritchard, R. S., E. S. Fisher, J. M. Teno et al. 1998. Influence of Patient Preferences and Local Health System Characteristics on the Place of Death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment. Journal of the American Geriatrics Society 46 (10): 1242–50.