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

Discussion

This study examining the effect of the IHPC revealed several positive findings. The IHPC intervention improved patient satisfaction at 30 and 90 days after enrollment, improved the likelihood of dying at home, and significantly reduced the cost of care overall and by average cost per day. First, providing an interdisciplinary palliative care team within the home of terminally ill homebound patients earlier in the disease trajectory has a positive effect on patient satisfaction with medical care in addition to influencing costs of care at the end of life. Recent studies have found that, although costs of care vary from state to state and from hospital to hospital, they remain high in the last 2 years of life.[25] In addition, previous studies focusing on costs of care in the last year of life found that average per-member costs have remained constant over the past decade, representing approximately 25% of all Medicare expenditures.[26] Moreover, a recent study examining costs of care in the last 2 years of life estimated average costs to be approximately $58,000.[25] This finding suggests that end-of-life care programs should not be limited to the last 6 months of survival, because costs associated with end-of-life care are likely to accrue over the last 2 years of life. This study supports findings from a previous study of this model[17] that found significantly lower costs for palliative care than for standard care.

There was a strong trend toward shorter survival for those in the palliative care group (196 days vs 242 days) after study enrollment. The differential in survival period after study enrollment may be attributed to several factors. First, although the Palliative Performance Scale was used to measure severity of illness, the two groups may have had several differences in disease severity and range of medical conditions that were not collected as part of this study. In addition, the data do not take into account personal preferences for care at the time of study enrollment and changes in these preferences throughout the course of the study. Moreover, the palliative care intervention contains strong components, such as patient education, ongoing conversations about care preferences, and care plans, that are developed to ensure adherence to patient preferences and directives, all of which may influence patient survival time. Several studies have found that older patients would choose pain and symptom relief and comfort care over aggressive treatment to extend life.[27,28] Thus, the intervention components that focused on delineating and following patient care preferences also may have affected survival time. This notion was supported in a chart review of a sample of 90 study participants that found that IHPC patients had fewer 911 calls and fewer life-sustaining interventions conducted in the emergency department or intensive care unit.

Although enrollment in hospice was not a stated goal of this program, a retrospective examination of enrollment rates in participants of one study site was conducted that found no significant difference in the rate of hospice enrollment between groups. This may be attributed to the fact that the focus was on implementing the in-home palliative care program rather than facilitating transfer to hospice and to the structure of the in-home palliative care program. Enrollment in hospice would entail changing care providers from those employed at the managed care organization to a care team in a free-standing outside (non-managed care) organization.

Satisfaction with care improved significantly for those enrolled in the intervention arm of this study at 30 days and remained high, with more than 90% reporting being very satisfied with their medical care. At 30 and 90 days, individuals in the palliative study group were three times as likely to report high levels of satisfaction. This may be attributable to several factors. As suggested above, the palliative care model itself may be more conducive to the needs and preferences of the patients. One study[29] found that the most important elements in end-of-life care identified by seriously ill patients and their families related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care, and life completion, all of which are core components of the IHPC program. Another positive finding from the current study was the ability to enroll diverse participants and retain them in the intervention arm. Satisfaction appeared to be high in this diverse population.

This study was limited in several respects. The adequate sample of individual minority groups limited further analysis of ethnic variation. This area merits additional investigation and attention given the IHPC program's apparent success in enrolling a wide range of ethnic groups. This study was conducted within closed-system managed care settings; as a result, it may be less generalizable to all healthcare settings, and the relative cost savings may not be realized across other settings. Additionally, the use of proxy costs of care calculated from aggregated patient records further limits the ability to generalize findings across settings. It also did not extend to an examination of the effect of the individual model components (such as 24-hour call center and physician home visits) on patient outcomes; this element is a critical next step in determining what aspects of the model are associated with key outcomes. Relying on death at home as a measurement of patient preferences for site of death also presented a limitation. Although a better measurement would have been death in the patient's preferred locale, these data were not collected as part of this study. Finally, this study was limited in the lack of accurate hospice data available at one of the sites.

This is one of the first rigorous studies to examine the effectiveness of an in-home, community-based, palliative care program for terminally ill individuals. It provides strong clinical and financial evidence supporting the provision of palliative care in the home of terminally ill patients with cancer, COPD, and CHF with a life expectancy of approximately 1 year. It also suggests major policy implications for reforming end-of-life care. Evidence provided here and in a previous study[17] supports the need for fundamental changes in the design of our healthcare system by adjusting our current hospice benefit to better meet the needs of patients or developing a new, "pre-hospice" palliative care benefit that provides a bridge between standard medical care and hospice care.


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