Palliative care – which better aligns medical treatments with patients' goals and wishes, aggressively treats distressing symptoms, and improves care coordination – is associated with shorter hospital stays and lower costs, and shows its greatest effect among the sickest patients, according to a study. The meta-analysis was conducted in collaboration between scientists at the Icahn School of Medicine at Mount Sinai and Trinity College Dublin.
Palliative care is team-based care focused on improving quality of life and reducing suffering for people with serious illness and their families. It can be provided for people of any age and in concert with other treatment modalities.
The Mount Sinai/Trinity College study pooled data from six prior studies involving more than 130,000 adults between admitted to hospitals in the US between 2001 and 2015; of these patients, 3.6% received a palliative care consultation in addition to their other hospital care.
The investigation represents the largest and most rigorous study to date to demonstrate that palliative care – which has been previously shown to improve care quality, extend survival, and improve family well-being – is associated with reduced hospital stays and associated cost savings, particularly for patients with the most complex conditions.
The study found: hospitals saved on average $3,237 per patient, over the course of a hospital stay, when palliative care was added to their routine care as compared to those who didn't receive palliative care; palliative care was associated with a cost savings – per hospital stay – of $4,251 per patient with cancer and $2,105 for those with non-cancer diagnoses; and savings were greatest for patients with the highest number of co-existing illnesses.
"People with serious and complex medical illness account heavily for healthcare spending, yet often experience poor outcomes," says the lead study author, Dr Peter May, research fellow in health economics, Centre for Health Policy and Management, Trinity College Dublin. "The news that palliative care can significantly improve patient experience by reducing unnecessary, unwanted, and burdensome procedures, while ensuring that patients are cared for in the setting of their choice, is highly encouraging. It suggests that we can improve outcomes and curb costs even for those with serious illness."
Palliative care teams provide an extra layer of support to patients, and families of patients, with complex health needs. Palliative care provides expert pain and symptom management guidance in the treatment of serious illness as well as communicating care options before and after discharge.
While palliative care has seen a steady rise during the past 30 years, with several advanced centres for palliative care emerging in the US, including the Brookdale department of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, research suggests that acute care hospitals have not leveraged palliative care to its full potential.
The researchers found that the association of palliative care with less intense hospital treatment was most pronounced among those patients with a primary diagnosis of cancer than for those with a noncancer diagnosis, and for individuals with four or more comorbidities compared with those with two or fewer.
"The potential to reduce the suffering of millions of Americans is enormous," says study co-author Dr R Sean Morrison, Ellen and Howard C Katz chair, Brookdale department of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. "This study proves that better care can go hand in hand with a better bottom line."
Importance: Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations.
Objective: To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness.
Data Sources: Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017.
Study Selection: Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders.
Data Extraction and Synthesis: Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis.
Main Outcomes and Measures: Total direct hospital costs.
Results: This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (−$3237; 95% CI, −$3581 to −$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (−$4251; 95% CI, −$4664 to −$3837; P < .001) and noncancer (−$2105; 95% CI, −$2698 to −$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer.
Conclusions and Relevance: The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.
Peter May, Charles Normand, J Brian Cassel, Egidio Del Fabbro, Robert L Fine, Reagan Menz, Corey A Morrison, Joan D Penrod, Chessie Robinson, R Sean Morrison
[link url="http://www.mountsinai.org/about/newsroom/2018/better-care-of-sickest-patients-can-save-hospitals-money-says-largest-study-of-its-kind"]Mount Sinai Hospital/Mount Sinai School of Medicine material[/link]
[link url="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678833"]JAMA Internal Medicine abstract[/link]