Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care

Richard Brumley, MD; Susan Enguidanos, PhD, MPH; Paula Jamison, BA; Rae Seitz, MD; Nora Morgenstern, MD; Sherry Saito, MD; Jan McIlwane, MSW; Kristine Hillary, RNP; Jorge Gonzalez, BA

Disclosures

J Am Geriatr Soc. 2007;55(7):993-1000. 

In This Article

Methods

This was a randomized, controlled trial conducted at two separate managed care sites to test the replicability and the effectiveness of an In-home Palliative Care (IHPC) program. Specific hypotheses tested for this study were that

 

  • Late-stage patients with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or cancer enrolled in the IHPC program will experience higher satisfaction with care than patients receiving usual and customary care (usual care).

  • Medical costs will be lower for end-of-life patients enrolled in the IHPC program than for end-of-life patients receiving usual care.

The settings for this trial were two group-model, closed-panel, non-profit health maintenance organizations (HMOs) providing integrated healthcare services in Hawaii and Colorado. The Colorado site has more than 500 physicians representing all medical specialties and subspecialties in 16 separate ambulatory medical offices spread across a greater metropolitan area. The HMO contracts with outside providers for emergency department, hospital, home health, and hospice care to serve its 477,000-person membership, which spans the six-county Denver metropolitan area.

The Hawaii site is located on Oahu and serves approximately 224,000 members, with 12 medical offices in Oahu, three in Maui, and three on the Big Island. Three hundred seventeen medical group physicians provide care. In contrast to Colorado, the HMO provides all outpatient and most inpatient care. The Hawaii site operates a 217-bed medical center and also has an internal home health agency, accepting referrals from hospital- and clinic-based medical group physicians. Referrals are processed via a referral center staffed by home care nurses. The Hawaii site does not have an internalized hospice agency and refers patients to outside providers for hospice care only.

Principal investigators in Southern California, where data collection and analysis were conducted, coordinated the study. The institutional review boards of the HMO in Hawaii, Colorado, and the external evaluator approved this study. Participants were enrolled and followed from September 2002 to August 2004. Patients eligible to participate in the study must have had a primary diagnosis of CHF, COPD, or cancer and a life expectancy of 12 months or less, have visited the emergency department or hospital at least once within the previous year; and scored 70% or less on the Palliative Performance Scale.[12,13] The Palliative Performance Scale is a modified Karnofsky scale that ranks the patient's health condition from 0 (death) to 100 (normal). This scale was used to assess the patients' severity of illness. To determine life expectancy, the primary care physician was asked, "Would you be surprised if this patient died in the next year?" This indicator has been used widely to ascertain appropriateness for end-of-life care.[14,15] Patients with physician responses indicating no surprise if the patient died within the next year were included in the study.

Discharge planners, primary care physicians, and other specialty physicians referred potentially eligible terminally ill patients to the study. All patients referred were assessed for study eligibility. For those meeting the initial criteria, the intake clerk contacted the primary care physician to determine the prognosis. Once eligibility was determined, the intake clerk gained informed consent from the patient to participate in the study. The intake clerk then contacted evaluators, who randomly assigned patients to the palliative care intervention or usual care. Group assignment was determined by blocked randomization using a computer-generated random number chart, stratified according to study site. Based on methods established previously,[16] it was determined that, using a significance criterion of .05, a sample size of 300 would be necessary for a statistical power of 0.80, using nondirectional (two-tailed) tests to detect whether the intervention had a significant effect on medical care costs.

Intervention

Each patient enrolled in the intervention arm received customary and usual standard care within individual health benefit limits in addition to the IHPC program. The IHPC program is an interdisciplinary home-based healthcare program designed to provide treatment with the primary intent of enhancing comfort, managing symptoms, and improving the quality of a patient's life. Modeled after hospice programs in that it offers pain management and other comfort care in the patient's home, the IHPC program features three important modifications, all of them intended to increase access and timely referrals to the program.

 

  • Physicians are not required to give a 6-month prognosis. Recognizing that it is often difficult to estimate life expectancy, referral guidelines were expanded to target patients earlier in their disease process, with an estimated 12-month life expectancy.

  • Although the IHPC program emphasizes much-improved pain control and other symptom management, patients do not have to forgo curative care, as they do in hospice programs.

  • Patients are assigned a palliative care physician who coordinates care from a variety of healthcare providers, including specialists and the patients' primary care physician, thus preventing the service fragmentation that often occurs in healthcare systems. The structure of the IHPC program allows patients to maintain their primary care provider while also receiving home visits from the palliative care physician.

The IHPC program uses an interdisciplinary team approach, with the core care team consisting of the patient and family plus a physician, nurse, and social worker with expertise in symptom management and biopsychosocial intervention. The core team is responsible for coordinating and managing care across all settings and providing assessment, evaluation, planning, care delivery, follow-up, monitoring, and continuous reassessment of care. Comprehensive education and discussions focus on identifying goals of care and the expected course of the disease and expected outcomes, as well as the likelihood of success of various treatments and interventions.

Upon admission, the team assesses the physical, medical, psychological, social, and spiritual needs of the patient and family. All patients received initial assessments from physicians, nurses, and social workers. Additional team members, including spiritual counselor or chaplain, bereavement coordinator, home health aide, pharmacist, dietitian, volunteer, physical therapist, occupational therapist, and speech therapist, join the core care team in service provision as needed. The team convenes to develop a care plan in accordance with the wishes of the patient and the family. Frequency of subsequent medical visits is based on the individual needs of the patient. Physicians conduct home visits and are available along with nursing services on a 24-hour on-call basis. In addition, advanced care planning is provided that involves patients and their families in making informed decisions and choices about care goals and end-of-life care.

The team provides education, support, and medical care to the patients and their families. Additionally, patients and families are trained in the use of medications, self-management skills, and crisis intervention in the home with the goal of stabilizing the patient and minimizing excessive emergency department visits and acute care admissions. Participants enrolled in the IHPC arm received palliative care until death or transfer to a hospice program. (For more information on this model, see[17,18]).

Usual Care

Usual care consisted of standard care to meet the needs of the patients and followed Medicare guidelines for home healthcare criteria. These services included various amounts and levels of home health services, acute care services, primary care services, and hospice care. Patients were treated for conditions and symptoms when they presented them to attending physicians. Additionally, they received ongoing home care when they met the Medicare-certified criteria for an acute condition.

Data Collection

Data were collected from patient interviews and from the HMO service utilization databases at each site. Interviews were conducted via telephone within 48 hours of study enrollment and every 30, 60, 90, and 120 days to gather demographic information and satisfaction with services. Undergraduate- and graduate-level research assistants, blinded to group assignments, were recruited and trained to conduct telephone interviews with the patient or, if the patient was unable to participate, the primary caregiver. Interviews were approximately 20 minutes long. Site of death was obtained from HMO records, death certificates, and family report.

Utilization Data. Service utilization data for each subject were collected retrospectively from the HMO mainframe database. Medical service use data were collected from the time the patient enrolled in the study until the time of death or the end of the study period. Medical service use data included costs for all standard medical care as well as the costs associated with the palliative care program. Service data included number of emergency department visits, physician office visits, hospital days, skilled nursing facility days, home health and palliative visits, palliative physician home visits, and days on hospice. Service costs were calculated using actual costs for contracted medical services (services provided by non-HMO contracted facilities in Colorado) and proxy cost estimates for all services provided within the HMO. Because services provided within the HMO are not billed separately, it was necessary to use proxy costs. Costs were based on figures from 2002. Hospitalization and emergency department cost estimates were calculated using aggregated data from more than 500,000 HMO patient records and include ancillary services such as laboratory and radiology. Costs of physician office visits included nurse and clerk expenses. Home health and palliative care visits were calculated using average time spent on each visit and multiplying that by the cost for each discipline's reimbursement rate. Proxy costs generated for hospital days and emergency department visits were significantly lower than the actual costs received from contracted providers. A total cost variable was constructed by aggregating costs for physician visits, emergency department visits, hospital days, skilled nursing facility days, and home health or palliative days accumulated from the point of study enrollment until the end of the study period or death.

Enrollment in hospice was gathered retrospectively and was only available from one study site because of difficulty obtaining data from community hospice providers at the second site.

Satisfaction Instrument. The Reid-Gundlach Satisfaction with Services instrument[19] was used to measure study group member satisfaction, rating overall satisfaction with services, perception of service providers, and likelihood of positive recommendations of services to others. This instrument has been employed in previous studies examining satisfaction with end-of-life care programs.[17,20,21] Satisfaction with care was calculated by adding the score of 12 of the 13 items (one item was a qualitative measure) on the instrument for a total possible score of 48. This method has been employed in previous studies using this instrument.

Severity of Illness. The Palliative Performance Scale,[12,13] described earlier in this manuscript, was used to measure severity of illness.

Statistical Analysis

Differences between study group sample characteristics were analyzed using two-tailed t tests for continuous variables where the distribution was normal. Chi-square tests were used to determine significant differences between discrete variables. Satisfaction with services was analyzed in two ways. First, to determine the clinical meaningfulness of the change in satisfaction according to study group, satisfaction scores were dichotomized as recommended previously[22] and used in other studies,[23] with those with a total score of 37 or above categorized as very satisfied. Next, logistic regression models were developed for dichotomous satisfaction variables using baseline and 30-, 60-, and 90-day follow-up measures. Linear regression was employed to determine the effect of study group on the number of hospital inpatient days and emergency department days while controlling for length of time enrolled in the study (survival) and demographic variables. Logistical regression was used to determine study group likelihood of dying at home. Kaplan-Meier survival analysis, using the log rank statistic, tested for study group differences in survival time. All study participants were included in the analysis, with those who survived to the end of the study period censored on the last day of the study.

Medical cost data are generally skewed, requiring transformation of the dependent variable for better data fit. As expected, analysis of total medical costs indicated that they were extremely right-skewed; hence, a log transformation of medical costs and Duan's smearing estimate followed linear regression to determine whether transformation of data resulted in a better fit. A comparison of models revealed that, although the log transformation resulted in a normal distribution, the ordinary least squares regression explained a larger amount of the variance (higher coefficient of determination; R2) and had lower error. Further comparison of the residual distributions (the difference between the actual value of the dependent variable and its value as estimated by the equation) revealed a linear relationship between the nontransformed costs. Based on these findings, ordinary least squares regression was used in the final analysis, a decision supported by other studies.[24] Owing to the differences in survival time between study groups, analysis of service use and medical care costs were adjusted for length of time on the program before death or the end of the study period. Analyses were conducted using SPSS 10.1 statistical software package (SPSS Inc., Chicago, IL) and LIMDEP, version 8.0 (Econometric Software, Inc., Plainview, NY).

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