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Palliative Care Programs Lead to Cost Savings
By John Gever, MedPage Today
September 8, 2008
Treatment for seriously ill patients cost dramatically less when palliative-care teams in hospitals matched their therapeutic strategies with goals set by patients.
In eight hospitals with such palliative-care programs, adjusted direct costs per admission were $1,696 lower for patients discharged alive compared with others receiving usual care (P=0.004), reported R. Sean Morrison, M.D., of Mount Sinai School of Medicine, and colleagues in the Sept. 8 issue of Archives of Internal Medicine.
The direct-cost savings worked out to an adjusted $174 per day (P<0.001) from a mean of $830 per day under usual care, the researchers said.
Even greater savings were achieved among patients who died -- $374 per day in direct costs (P<0.001) and $4,908 per admission (P=0.003). Usual care cost a mean of $1,484 per day for patients who died.
The researchers said that "usual care" often includes "low-yield, burdensome, and high-cost tests and treatments including ICU stays."
Earlier studies had found that such unnecessary treatments were less common under palliative care programs, but they had not quantified the cost savings.
Palliative care consultation, they said, "fundamentally shifts the course of care off the usual hospital pathway and in doing so, significantly reduces costs."
Dr. Morrison said in an interview that conventional care "is not overtreatment, but treatment not matched to goals."
Palliative care teams interview patients and their families early in treatment to identify what they want from therapy. They also help with day-to-day care of patients.
For example, Dr. Morrison said, a patient with advanced congestive heart failure, diabetes, and other comorbidities may prefer treatments that emphasize improving quality of life over prolonging life. Such a patient might then be spared critical-care unit admissions and long hospital stays and the associated costs, Dr. Morrison said.
He emphasized that the palliative care programs included in the study were not primarily about end-of-life care. Most patients included in the study were discharged alive, he pointed out.
Nearly one-third of all hospitals and 70% of those with more than 250 beds had palliative care programs in 2005, according to the American Hospital Association.
In the study, Dr. Morrison and colleagues examined records of more than 48,000 patients with hospital stays of seven to 30 days from 2002 to 2004. The patients were treated at three academic medical centers and five community hospitals.
The researchers conducted separate analyses on patients discharged alive and those who died in hospital.
Among patients who left the hospital alive, the analyses included 2,630 who had palliative care consultations and 18,427 who received usual care, matched for demographic variables and medical condition.
Similarly, 2,278 patients who died in hospital after receiving palliative care were matched with 2,124 patients who died under usual care.
There were no differences in mean length of stay between groups in either analysis.
In the former group, Dr. Morrison and colleagues found that palliative care consultations led to laboratory cost reductions of $424 per admission (P<0.001). Moreover, among patients admitted to ICUs, costs of treatment in the unit were $5,178 lower (P<0.001).
Among patients who died, palliative care was associated with reductions of $1,544 in pharmacy costs (P=0.04) and $926 in lab tests (P=0.003) per admission. ICU costs were lower by $6,613 per admission (P<0.001) with palliative care.
Dr. Morrison and colleagues found similar results when, in patients receiving palliative care consultations, the researchers calculated the costs of services before the consultation and used them to project what costs would have been under usual care.
The projected costs of $11,787 and $22,301 per admission for patients discharged alive and for those who died, respectively, did not differ significantly from the actual costs of $11,140 and $22,674, the researchers said.
Dr. Morrison said the palliative care teams' ongoing involvement in patient care was critical to their success.
He acknowledged that "paper documentation" of patients' wishes and treatment goals was not sufficient to prevent them from receiving unwanted tests and therapies.
He also said the palliative care approach can lighten the workload of other specialists. For example, palliative care professionals can help cancer patients deal with pain problems, which otherwise might require an oncologist's time.
The authors noted that "this was not a randomized trial, and it is possible that the cost differences resulted from unmeasured differences between the two groups."
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