Early Palliative Care Curbs Costs, Especially for Cancer

Roxanne Nelson, BSN, RN

May 10, 2018

A palliative care consultation (PCC) within 3 days of hospital admission can reduce the cost of care. The reduction in cost burden was particularly evident for cancer patients and those with multiple comorbidities, according to a new meta-analysis.

The study was published online April 30 in JAMA Internal Medicine.

The findings showed that there was a significant cost savings of $3237 for all patients who received an early PCC. The savings in cost were even greater when the analysis was narrowed to cancer patients — there was a significant reduction in cost of $4251 for cancer patients as compared to a reduction of $2105 for those without cancer.

For patients without cancer, initiating early PCC had a greater effect on cost among those with four or more comorbidities as compared with patients who had two or less comorbidities.

"The evidence now appears very strong that hospital palliative care changes patterns of care if provided early after admission — and the earlier it is provided, the greater is the effect," said lead author Peter May, PhD, from the Center for Health Policy and Management, Trinity College, Dublin, Ireland. "Multiple other studies have also shown that palliative care early in the disease trajectory improves outcomes for patients and their families, although that is not featured in our study."

May told Medscape Medical News that hospital costs are the biggest single component of healthcare utilization for people with complex illness and those at the end of life. "Our finding that hospital palliative care reduces costs suggests substantial cost savings to the system as a whole," May said, "and this effect is greatest for the clinically complex patients with highest illness burden and highest costs."

Significant Reduction in Costs

A growing body of evidence points to the benefits of palliative care, not only for the patient but the caregiver as well. The American Society of Clinical Oncology updated its guidelines to emphasize the importance of early palliative care, which should be offered soon as the cancer becomes advanced.

Previous studies have shown that early implementation of palliative care can improve quality of life, mood, coping, and the frequency of end-of-life discussions for patients, although some data suggest that the effect of palliative care interventions differ by cancer type. Palliative care has also been identified as a key driver in reducing healthcare costs for patients with advanced cancer when initiated early.

For the current study, May and colleagues hypothesized that PCC would reduce hospital costs, and that the estimated reduction would be greater for patients with a primary diagnosis of cancer as well as those with multiple comorbidities.

Their meta-analysis included six cohort studies that involved 133,118 patients. The studies evaluated the economic implications of PCC for hospitalized adults with at least one of seven illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions). PCC in the hospital inpatient setting was compared to usual-care only, controlling for a minimum list of confounders.

Of the study population, 93.2% were discharged alive, 40.8% had a primary diagnosis of cancer, and only 3.6% had received PCC.

In the meta-analysis, the results suggested a statistically significant reduction in costs (-$3237; 95% confidence interval (CI), &minus$3581 to −$2893; P < .001). In the stratified analyses, there was a significant cost reduction for both cancer (&minus$4251; 95% CI, &minus$4664 to −$3837; P < .001) and noncancer (&minus$2105; 95% CI, &minus$2698 to −$1511; P < .001) subsets.

For all patients, regardless of their primary diagnosis, the magnitude of the estimated treatment effect was higher for those with multiple comorbidities. When the authors conducted post hoc analyses, they found that the differences were significant when comparing patients with four or more comorbidities to those with two or fewer comorbidities, as well as in comparisons of those with three comorbidities and those with none or 1 comorbidity.

The results were the same on equivalent analyses for cancer patients — the magnitude of estimated treatment effect was greater for those with four or more comorbidities vs two or fewer.

Improvements in Access Needed

"Palliative care has been recognized as a specialty for nearly 30 years in the UK and over a decade in the US," explained May. "While its origins are in cancer care, it is increasingly recognized that palliative care teams have a role to play in treatment of nonmalignant conditions also."

Despite the rapid growth in palliative care in recent decades, studies repeatedly show that palliative care is accessed by a minority of patients with complex disease, he pointed out.

Often palliative care is given in the last few days or even last few hours of life. Dr Peter May

"Often palliative care is given in the last few days or even last few hours of life," he commented. "But our study shows substantial benefits of palliative care for a wide range of clinical groups, many of whom were not in an end-of-life phase. So there is much more work to be done to improve the integration of palliative care teams with other parts of hospital care."

Dr May was supported by the International Access, Rights and Empowerment Fellowship Program, which is funded by a grant from the Atlantic Philanthropies. Dr May's coauthors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online April 30, 2018. Abstract


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