Sunday, August 22, 2010

Spreading the Message and Science of Palliative Care

A recent study published in the New England Journal of Medicine identified the merits of early palliative care intervention, for patients with a lung cancer diagnosis. Among the benefits from such interventions were improved quality of life and longer survival. This study has received wide coverage in the mainstream press -New York Times (read here) , Wall Street Journal Health Blog (read here) , Boston Globe ( read here) , USA Today (read here) , and Associated Press (read here) and medical blogs, such as this blog post by the Deputy Medical Officer of the American Cancer Society).

While an important study, to be sure, it is hardly the first to tout the benefits of palliative care.
A study published in an August 19, 2009 issue of JAMA (read here) found that patients with advanced cancer who received a palliative care intervention focused on addressing physical and psychosocial issues and care coordination provided AT THE SAME TIME as cancer treatment had improved quality of life and mood. Interestingly enough, these patients did not experience a significant change in the number of days in the hospital or the severity of their symptoms compared to patients who received usual care.
In an earlier article, published in the June 2007 issue of Critical Care Medicine, (read here)
researchers at the University of Rochester Medical Center found that early palliative care interventions reduced the length of stay for seriously ill patients in the medical intensive care unit (MICU) by more than seven days without having an impact on mortality rates.

And, in early 2008, a Kaiser Permanente study (read here) was the first multi-center randomized trial to show that hospital-based palliative care results in improved quality of care, including higher patient satisfaction, improved communication, and fewer ICU admissions.

So is this most recent study a “game-changer”? Could be. Just like previous similar studies have been/could have been.

Evidence that palliative care intervention (regardless of timing) improves quality-of-life has been available for some time. Whether as a result of such evidence, or other factors, unquestionably there has been growth in the availability AND use of palliative care services. Most would also agree that the “spread of science” around palliative care has been slow, that is to say, programs whose results could replicate the benefits of these studies have been slow to produce similar results. Why?

It certainly hasn’t been for lack of effort. So then, one might ask, what are the obstacles? Simply put, two of the most formidable barriers are organizational and financial. Let’s take a closer look at this most recent study.

It was performed at a single, tertiary care site with a specialized group of thoracic oncology
providers and palliative care clinicians, thereby limiting generalization of the results to other
care settings or patients with other types of cancer. And I suspect that reimbursement for these palliative care services was not an issue.

Such care requires organizational models tightly integrated in order to produce similar results. As has been discussed in previous posts on this blog, such organizational models exist only in a few areas across the country. In most communities, palliative care has been viewed as an alternative to curative care, not as concurrent care. Moreover, current delivery models within today’s health care system (more on this in future posts) do not encourage nor facilitate the close coordination and collaboration among providers (individual and organizational) necessary to replicate this study’s findings. Nor do they encourage the adoption of evidence-based best practices. And, of course, the current reimbursement system, which rewards more procedures and aggressive care, surely does not encourage coordination. In future posts, we’ll explore the make-up of those communities (and its health care providers) that encourage tightly coordinated and bundled care.

A final thought on the study. Of course, more studies are needed to identify the value of palliative care. The efforts to promote study results should focus on VALUE (most significantly, quality), rather than longer survival (“Cancer Patients Live Longer With Palliative Care” screamed the headline from the consumer website As Drew Rosielle, MD reminds us, “surveying the 'average' advanced cancer patient will reveal that most of them rate QOL (Quality of Life) as more important than survival" and we “should not spend too much time basking in the survival benefit”. And as Lyle Fettig, MD posts in Pallimed blog, “the PRIMARY (emphasis added) outcomes of the study stand on their own as important--it's yet more evidence that palliative care interventions improve quality of life and reduce psychological morbidity.”

David Weissman, MD puts it bluntly and best :

"While three cheers are certainly in order, I would be very cautious about saying that palliative care improves survival. Although randomized, the study was small and from a single institution. I love the results, but think we all need to be careful about over-interpreting single study results. When the next study shows no change in survival, which I fully expect, the fall for the field could be hard."

Tim Kirk , assistant professor of philosophy at the City University of New York where he specializes in philosophy of nursing and healthcare ethics with an emphasis on hospice and palliative care, writes “ All of these organizations have been focusing on the fact that patients in the study who received palliative care lived a bit (2.7 months) longer than patients who did not. While I understand that the hospice and palliative care communities have long suffered from the stigmatized perception that they welcome (or, even, hasten) death, and that this study seems to provide a rebuttal to such a perception, I believe the way the study is being embraced and promoted is misleading. He continues, "The emphasis on time to death perpetuates exactly the belief that hospice and palliative care have been working to change for decades: that what is important is how long you live rather than how well you live. If we begin promoting hospice and palliative care under the premise that such care extends life, we tacitly accept that extension of life is the primary goal of healthcare. And, we tacitly send that message to our colleagues, patients, and the public at large.”

More aggressive care is not necessarily associated with longer survival. That’s an important message in the efforts to lower cultural barriers to palliative care access. But as important, perhaps even more so, in achieving the “spread of science” in palliative care, will be how effectively we reconfigure organizational and reimbursement models that will improve access to, and delivery of, palliative care.

Certainly, there is a need to replicate this study in other settings. And since this intervention is probably very dependent on the skill of the palliative medicine providers, we need to better understand how various models of palliative care delivery improve outcomes.

Finally, I do not consider as insignificant the matter of prolonging life. Nonetheless, it is an issue with more relevance to other populations for whom palliative care intervention can be important. Alex Smith, MD describes it this way in the blog GeriPal,
“I would hazard a guess that those who would have the greatest survival benefit are geriatric patients with multiple co-morbid illnesses and no dominant terminal condition. Nothing like tailoring of medication, attention to physical, psychological, social, and spiritual concerns for frail elders. I think that's why so many patients with "general debility" and "failure to thrive" are discharged from hospice alive, only to fall apart again after discharge.”

As always, I invite your feedback.