Closing the Performance Gap in Palliative Care by Reducing Clinical Variation

The Dartmouth Medical Atlas gives us a compelling portrait of the variations in practice in late-life care. It also offers insights into the palliative performance improvement opportunities in communities.


How wide are the variations? Let’s take a look at Charlottesville, Virginia, an area of about 100,000 residents, with an academic medical center and a community hospital, a large not-for –profit hospice, and plenty of smaller hospices. According to the DAI Palliative Performance Profile (drawn from the Dartmouth Medical Atlas), Charlottesville earned a B grade for its late-life care practices. Respectable, for sure, but short of exemplary. What’s the difference between respectable performance and that of the top 10% performers? Consider the following: in Charlottesville, 32% of Medicare decedents died in a hospital. That’s better than the state average, yet 25% higher than residents of a community in the top 10%. In other words, a Charlottesville resident is 25% more likely than a resident of a high-performing community to die in a hospital than at home. That same Charlottesville resident is 40% more likely to have spent 7 days or more in a hospital during the last six months of life than someone in a top-performing community. Considerable room for improvement, I think you'd agree, and yet Charlottesville's performance is better than most communities across the nation.

Tightly integrated delivery systems have proven to be the most effective in reducing clinical variation. Because of their structure, these delivery systems are adept at disseminating evidence-based practices. It is time that hospice and palliative care leaders accelerate collaborative efforts to create networks with greater potential to reduce clinical variation in late-life care. What better opportunity for HPM specialists to take the lead?






　

Is Palliative Care A Disruptive Innovation in Health Care?

It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care?  In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed  during the intervening decade? And, it set me to wondering, is  palliative care  considered a disruptive innovation?

James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below",  start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens  for palliative care as a disruptive innovation.

So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth  the palliative care sector. That is likely to change soon, as  the formation of Accountable Care Organizations (ACOs),  encouraged by the health reform bill,  reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be  successful models for improving delivery of chronic and late-life care because their characteristics encourage processes of care that are:

Timely - delivered to the right patient at the right time (early identification of patients)


Patient-centered - based on the goals and preferences of the patient and family, articulated in goals of care conversations


Beneficial and effective - demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)


Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

I invite our readers to weigh in.  Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?

What Might A "Sought-After" Hospice and Palliative Medicine (HPM) Practice Look Like?

At a recent forum addressing the subject of HPM physician performance, one of the panelists asked the above question. During our study of bellwether practices, we've asked ourselves a similar question - how does a HPM practice create value? While our research has been far from exhaustive, our findings offer some insight into this question. A post last year on this blog offered an early take on this question.

Let's revisit this question, this time from a post-reform legislation view.

Unarguably, HPM practices are not, and will not be, sought after because of their revenue-generating capacities, either from direct patient care services (home visits, hospital consults, inpatient hospice management) or ordering tests, performing procedures, or utilizing a hospital's facilities. To be sure, hospital palliative consults have proven to be effective cost avoidance services for hospitals. This effectiveness, however, is subject to the law of diminishing returns, in that the "savings" are front-loaded in the first few years following introduction of the palliative care service. Once the "new" standard of care is firmly in place, savings become more difficult to squeeze out of the palliative care service. Some counter that eliminating the palliative care service would return costs to the hospital. While that may be the case to some extent, I don't know of many health care CEOs and CFOs who would "recount" savings that had already been accounted for.

The Dartmouth Medical Atlas has shown that there is enormous variation in late-life care, AMONG and WITHIN communities. In fact, it is not unusual to find wide variation in practice from one IDT to another within a hospice provider. Reducing clinical variation, simply put, is not a quality improvement priority for most hospices and palliative care organizations. In future posts, we'll take a closer look at the clinical variation question.

Tightly integrated delivery systems have proven to be effective in reducing clinical variation. These delivery systems may soon serve as models for the development of Accountable Care Organizations (ACOs). A recent article highlighted Dartmouth-Medical Clinic, a 900-physician group practice in New Hampshire, which has earned $13 million so far in the Medicare Physician Group Practice Demonstration, the model for accountable care organizations. The Clinic focused on reaching out to patients with chronic illness, improving coordination of care for patients transitioning between care settings, and more aggressively monitoring patient between physician visits.

For these activities, surely HPM physicians, palliative care nurse practitioners, and hospices play a vital role. A network of physicians and palliative care clinicians will be extremely valuable to these ACOs. Why? Because these networks will already be in place to provide timely, patient/family centered, and evidence-based care to those with advanced illnesses. Such care will likely cost less, as fewer days are spent in ICUs and hospitals, and more at home, under hospice and palliative care.

You may be thinking, ACOs aren't called for in the health reform legislation until January 2012.
Keep in mind, building an effective delivery network is a years-long process, so yesterday was the best time to start. There are at least three steps, each of them formidable, to building a tightly integrated network to deliver advanced-illness care. These are:

- applying clinical protocols proven to reduce clinical variation,
- electronic capture and transfer of clinical information across settings,
-"internal transfer" of reimbursement.

Future posts will look closely at each of these steps, as well as the value that a high-performing hospice medcial staff brings to the formation of a HPM network, and how HPM practices may best position themselves to become the "go-to provider" for late-life care.

September Edition of Palliative Care Grand Rounds

Read here for this month's edition of Palliative Care Grand Rounds, hosted by Christian Sinclair. You'll find a wide-ranging mash-up of the best from the blogosphere around palliative care, including discussions and commentary about Atul Gawande’s article in the New Yorker titled ‘Letting Go.‘ and research published in the NEJM demonstrating early palliative care improves quality of life.

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 Medicinenet.com). 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 :
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"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."
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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.

Palliative Care Grand Rounds - July MMX

Read here for this month's PCGR, hosted at the GeriPal blog. You'll find an interesting, enlightening, and well-rounded mash-up of the best from the blogosphere.