Cost of Advanced Cancer Reduced by Earlier Palliative Care

Pam Harrison

March 02, 2016

The cost of caring for patients with advanced cancer in an academic medical center is significant and increases substantially as disease progresses, suggesting that academic medical centers are using more aggressive treatment during end-of-life care than necessary, a new cost analysis suggests.

Importantly, offering patients palliative care in a palliative care unit significantly attenuates the usual cost of hospital care, another cost analysis shows.

Both studies were presented at the American Society of Clinical Oncology's Quality Care Symposium (QCS) 2016, in Phoenix, Arizona.

"I think it would be surprising for most people to understand how little institutions actually know about the costs of care spent on their patients," lead author Kerin Adelson, MD, Yale University School of Medicine, New haven, Connecticut, told Medscape Medical News.

"Furthermore, we don't know how much care is received outside of our healthcare system, so while we may be the primary hospital treating a patient's cancer, if they are hospitalized at their community hospital for toxicity issues, we would never know what that cost might be," she added.

"And we saw that care at the end of life is really a major cost driver in academic medical centers, so there is a clear opportunity to improve end-of-life planning and reduce futile care," she said.

For their study, Dr Adelson and colleagues used the 5% Medicare Limited Dataset from 2012 to 2013 to map the cost of care in 6-month episodes for all Medicare patients receiving chemotherapy. Dr Adelson pointed out that Medicare artificially designates episodes of care as being the first episode of care during the first through the sixth month of treatment; the second episode as being from months 6 to 12; and the third episode as being from months 12 to 18.

"When a patient is on chemotherapy for multiple episodes, this may reflect the fact that he or she has advanced disease requiring continuous treatment," Dr Adelson said.

"We saw that at academic medical centers, costs escalated substantially in successive episodes and were highest if a patient died during an episode," she said.

On average, a first episode of care at her academic medical center, the Smilow Cancer Hospital, in New Haven, costs $26,500; the second, $38,000;and the third, $45,600.

In-hospital cancer care costs for patients who had one or fewer visits to the emergency department during an episode of treatment averaged at $21,000, compared with $49,000 for patients who averaged two or more visits to the emergency department. Dr Adelson explained that in her institution, an emergency department visit is a surrogate for hospital admission, because 75% to 80% of cancer patients who go to the emergency department are admitted to hospital.

Important Patterns

"We looked at markers as to why costs increased more at academic hospitals during the second and the third episode of treatment than the state average, and a few important patterns emerged," Dr Adelson explained.

First, when cancer patients experience disease progression, they are often referred to an academic center for additional care. Academic medical centers also serve as research centers, and the care they offer may be more intensive than that offered by community hospitals, even though such interventions are not known to improve outcomes, Dr Adelson observed.

"Too often, patients aren't prepared for what's to come," Dr Adelson said.

"They have worsening symptoms, they get admitted to hospital, and after successive, really futile interventions, they are finally told that they really should consider hospice care," she added.

As an oncologist, I feel like it's a failure every time I admit someone to hospital with advanced disease. Dr Kerin Adelson

"We should be having these conversations in the outpatient setting earlier in the course of disease. As an oncologist, I feel like it's a failure every time I admit someone to hospital with advanced disease. It's my responsibility to counsel patients earlier and transition them to hospice before they get so sick that they need to come to the hospital," Dr Adelson commented.

Financial Impact of PCU

In a separate cost analysis, Sarina Isenberg, a doctoral candidate at the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues studied the financial impact of introducing a six-bed palliative care unit on Johns Hopkins Medicine's bottom line between March 2013 and March 2014.

The team calculated the variable cost per day for patient care prior to their transfer into the unit and then after patients were in palliative care. Fees were multiplied by the number of patients transferred to the palliative care unit and the average length of stay.

During its first year, the palliative care unit operated at 54% capacity, Isenberg noted. Symptoms were well managed, and the cost of care, which was $1610 for patients prior to their transfer to the unit, was reduced to $759 following their transfer.

"A total of 153 patients were transferred into the palliative care unit from other units in the hospital, while 56 patients were directly transferred into the palliative care unit upon admission," Isenberg told Medscape Medical News. More than half of these patients (57%) came from the intensive care unit, freeing beds there, she added.

The average length of stay in the palliative care unit was only 5.1 days.

Isenberg explained that the philosophy of palliative care that Johns Hopkins has adopted emphasizes symptom management, so palliation is not restricted to end-of-life care.

"The majority of our patients are discharged to home care or to home hospice care or to subacute institutional care, like a nursing home, and only 25% of patients died in the unit," she explained.

"So we are seeing patients at a point where we can still intervene and help patients cope with whatever their needs are at the moment. We go from what patients tell us they want, and then we try to provide it with a multidisciplinary team."

During that year, the palliative care unit saved Johns Hopkins Medicine $367,751 in direct costs.

When the team added cost savings for palliative care consultations conducted by the multidisciplinary team on other units in the hospital, the estimated savings to the hospital was $2.7 million.

The palliative care unit will soon be expanded to 11 beds. On the basis of projections for the next 5 years, Isenberg and colleagues estimate that with that expansion of the palliative care unit, the hospital could save a substantial amount of money as well as increase quality of life and patients' satisfaction with their care.

Study coauthor Rab Razzak, MD, director of outpatient palliative care at Johns Hopkins Medicine, reaffirmed that in an email: "Our goal is to provide the best care for patients, understand their goals by explicitly asking them what they want, and help patients through the trajectory of their illness, whether early on in disease course, when they have acute symptoms, to the end of life.

Palliative care is better care at a cost we can afford, Dr Rab Razzak

"So a conversation has to happen around palliative care, because we know that palliative care improves quality of life for both patients and caregivers, and now we've shown that it also saves money. Palliative care is better care at a cost we can afford," Dr Razzak said.

Dr Adelson has a consulting or advisory role with Wellpoint, and an immediate family member of hers currently or in the past 2 years was employed with Lyra Health. Neither Sarina Isenberg nor Dr Razzak have disclosed any relevant financial relationships.

Quality Care Symposium (QCS) 2016: Abstracts 2 and 3. Presented February 27, 2016.


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