Making the case for outpatient palliative care for cancer patients at a safety-net hospital.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 310-310
Author(s):  
Heather A. Harris ◽  
Anne Kinderman ◽  
Kathleen Kerr
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Average Length ◽  
Safety Net ◽  
Direct Costs ◽  
Cost Of Care ◽  
Initial Contact ◽  
Course Of Illness ◽  
Cancer Registry Data ◽  
Safety Net Hospital

310 Background: Prior research has shown that patients who receive earlier, outpatient palliative care (OP PC) have improved end-of-life care compared to patients who receive only inpatient palliative care (IP PC). We examined the need, expected impact and feasibility of providing OP PC to patients with cancer seen at our hospital, which offers IP PC but not OP PC. Methods: Retrospective cohort study of patients cared for at our urban, safety-net hospital who died of cancer between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns, contacts with our IP PC service, and cost of care in the final 6 months of life. Results: In the analysis period 403 patients died of cancer, 307 of whom were admitted to the hospital in the 6 months preceding death. On average patients were admitted 1.9 times, with 39% having multiple admissions. Average length of stay was 10.47 days. Nearly half of all patients were admitted to the hospital in the final month of life (181/403), and 21% of those (38/181) had multiple admissions. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. The IP PC service had contact with 178 patients; 44% of the entire decedent population and 58% of those who were hospitalized. In 60% of cases the initial contact with the PC team took place in the final month of life. We determined that 33% of patients had multiple inpatient and or outpatient encounters 90-180 days prior to death, pointing to an expected annual clinic volume of about 50 patients. Annual costs for staffing a clinic that could follow 50 patients for an average of 4 months were estimated at $88,290. We assumed that providing OP PC would reduce utilization of inpatient services by 40% (38 avoided admissions), with resulting avoided direct costs of $846,450. Conclusions: At our facility cancer patients often receive aggressive EOL care. Our IP PC team sees many of these patients, but most contacts occur days-weeks prior to death. Though many patients present very late in the course of illness, a substantial number have multiple health system contacts >3 months prior to death, and could be referred to an OP PC clinic.

Feasibility of outpatient palliative care for oncology patients within the safety net.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 38-38
Author(s):  
Heather A. Harris ◽  
Anne Kinderman ◽  
Kathleen Kerr
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Safety Net ◽  
Direct Costs ◽  
Late Presentation ◽  
Cost Of Care ◽  
Oncology Patients ◽  
Course Of Illness ◽  
Safety Net Hospital ◽  
Utilization Patterns

38 Background: Palliative care (PC) combined with standard oncology care has been shown to improve patient outcomes and reduce health care costs. In safety-net systems, where limited resources mandate containing costs across settings, outpatient PC (OP PC) could be an important tool for improving quality while lowering costs. Multiple studies have shown that oncology patients cared for in safety net systems often present very late in the course of illness, raising concerns about the proportion of patients who could be referred to an OP PC clinic. To address this question we analyzed utilization patterns among cancer patients cared for at our facility to examine the need for and expected net costs of an OP PC service. Methods: Retrospective cohort study of oncology patients cared for at an urban, safety-net hospital who died between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns and cost of care in the final 6 months of life. Results: Among the 403 cancer patients who died in the study period we found heavy, late utilization of inpatient (IP) services: 307 (76%) were admitted to the hospital in the 6 months preceding death, 45% in the final month of life. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. While late presentation was common, 133 (33%) patients had multiple health system encounters 91-180 days prior to death: early enough to be referred to an OP PC clinic. We modeled clinic costs assuming an annual volume of 50 patients, to be followed monthly for the last 4 months of life by a physician-nurse-social worker team. Annual staffing costs were estimated at $88,290. Prior research has shown that utilization of IP services in the final month of life is 40% lower amongst patients who receive early OP PC. Using that value, we estimated that providing OP PC to 50 patients annually would avoid 38 hospitalizations, with resulting avoided direct costs of $846,450. Conclusions: This feasibility study reveals that OP PC in the safety net can provide substantial return on investment, even if such services are only used by a subset of oncology patients who present earlier in their disease course.

Abstract C41: Palliative care consults in terminal cancer patients dying in a safety-net hospital: Are they underutilized?

2014 ◽  
Author(s):  
Rebecca L. Wiatrek ◽  
Zeinab I. Alawadi ◽  
Debbie F. Lew ◽  
Melanie E. Zuo ◽  
Jeanette G. Ferrer ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Safety Net ◽  
Terminal Cancer ◽  
Safety Net Hospital ◽  
Terminal Cancer Patients

Palliative care and end-of-life health care utilization of pancreatic cancer patients at an urban safety-net hospital.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 489-489
Author(s):  
Nizar Bhulani ◽  
M. Elizabeth Paulk ◽  
Arjun Gupta ◽  
Kiauna Donnell ◽  
Valorie Harvey ◽  
...  
Keyword(s):  
Health Care ◽  
Pancreatic Cancer ◽  
Palliative Care ◽  
Intensive Care ◽  
Health Care Utilization ◽  
End Of Life ◽  
Cancer Patients ◽  
Safety Net ◽  
Care Utilization ◽  
Safety Net Hospital

489 Background: There has been an increase in Palliative care utilization in cancer patients. We examined trends of palliative care and intensive care utilization in pancreatic cancer patients in an urban setting safety net hospital. Methods: This is a retrospective analysis of pancreatic cancer patients seen at the Parkland Health and Hospital System between January 1999 and September 2016. Cancer cases and receipt of palliative care were identified from prospectively maintained registries. Health care utilization including intensive care unit (ICU) was reviewed. All statistical analysis was done using IBM SPSS version 24. Results: We identified 455 new diagnoses of pancreatic cancer, mean age 61 years, 227 (50%) female and 228 (50%) white. Of these, 277 (61%) received palliative care ever. Patient who received palliative care were more likely to be younger (mean age, 59.3+-12 vs 62.8 +- 12 years) and have stage 4 disease vs stage 1-3 disease (p 0.006, and p 0.003 respectively). There was no statistically significant difference in palliative care utilization between gender and ethnicity groups. 140 patients had a DNR order and 29 required ICU admission at any point. A first contact with palliative care consult was obtained < = 7 days before death for 29 (10%) patients, < = 30 days before death for 86 (31%) patients, 30-60 days before death for 50 (18%) and more than 60 days before death for 141 (51%) patients. Patients receiving palliative care were more likely to have a DNR status (p < 0.001) but had no difference in ICU use within the last 30 days of life (p 0.285). Conclusions: The rate of palliative care in patients with pancreatic cancer in this cohort from a safety net hospital is higher than nationally reported studies. Most patients received palliative care > 30 days before death. While patients received early palliative care, it did not result in reduced ICU care. Factors influencing ICU care utilization near the end of life need further study.

Growth factor use and rate of neutropenic complications in breast cancer patients treated with dose-dense paclitaxel: A 5-year experience from a safety net hospital.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 6527-6527
Author(s):  
Racha Halawi ◽  
Kavi Patel ◽  
Ethan Tobias ◽  
Samira K. Syed ◽  
Nisha Unni ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Growth Factor ◽  
Cancer Patients ◽  
Safety Net ◽  
Cost Of Care ◽  
Breast Cancer Patients ◽  
Safety Net Hospital ◽  
Grade 3 ◽  
Dose Dense ◽  
The Cost

6527 Background: The NCCN guidelines recommend growth factor (G-CSF) support to reduce the risk of febrile neutropenia and maintain dose density in patients receiving dose dense chemotherapy. We retrospectively reviewed growth factor utilization with dose dense paclitaxel (ddT) in breast cancer patients treated at our institution. Methods: Electronic medical records of patients treated at Parkland Health and Hospital System between 2012-2017 for breast cancer with dose dense adriamycin and cyclophosphamide (ddAC) followed by ddT were reviewed. Data on patient characteristics as well as G-CSF use and neutropenic complications were collected. Results: Two-hundred sixty eight patients received a total of 1019 cycles of ddT. Only one physician in the practice routinely prescribed G-CSF after ddT. The majority of ddT cycles were administered without G-CSF support (781 vs 238 cycles). There were no episodes of neutropenic fever in either group. The rate of grade 3/4 neutropenia was 2.1 % with G-CSF support (all grade 3), and 2.7% without G-CSF support (85% grade 3), p = 0.61. Treatment delays were longer in patients who did not receive G-CSF support, but this difference was not statistically significant (mean of 4 vs 2.2 days, p = 0.07). The number of cycles needed to treat to prevent 1 episode of grade 3/4 neutropenia was 167. Based on Medicare average sales price (ASP) for pegfilgrastim, routine use of G-CSF in our patient population would have added over $3.6M to the cost of care over the study period. Conclusions: Our results show a similarly low rate of neutropenic complications in patients receiving dose dense paclitaxel with or without G-CSF support. Therefore routine use of G-CSF with this regimen is not warranted. Judicious use of expensive medications such as G-CSF would reduce the cost of care and financial toxicity to patients, and promote high value care.

Abstract 230: Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Jeffrey P Chidester ◽  
Sandeep R Das ◽  
Rebecca Vigen
Keyword(s):  
Internal Medicine ◽  
Decision Making ◽  
Safety Net ◽  
Cost Of Care ◽  
Care Hospital ◽  
Care Clinic ◽  
Significant Difference ◽  
Safety Net Hospital ◽  
Out Of Pocket Costs ◽  
Clinic Visits

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p < 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p <0.005]) Knowledge of cost of care was not an often-considered factor in decision making (27% “Often” or “Always” [43 of 159]). There was no significant difference in response by year of training. Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

Impact of palliative care consults on racial disparity in do-not resuscitation (DNR) orders at an urban safety net hospital.

2018 ◽  
Vol 36 (15_suppl) ◽  
pp. 10027-10027
Author(s):  
Nizar Bhulani ◽  
Arjun Gupta ◽  
M. Elizabeth Paulk ◽  
Kiauna Donnell ◽  
Valorie Harvey ◽  
...  
Keyword(s):  
Palliative Care ◽  
Racial Disparity ◽  
Safety Net ◽  
Safety Net Hospital ◽  
Urban Safety ◽  
Dnr Orders

Palliative care and end-of-life health utilization in elder patients with pancreatic cancer.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 488-488
Author(s):  
Nizar Bhulani ◽  
Ang Gao ◽  
Arjun Gupta ◽  
Jenny Jing Li ◽  
Chad Guenther ◽  
...  
Keyword(s):  
Health Care ◽  
Pancreatic Cancer ◽  
Intensive Care Unit ◽  
Palliative Care ◽  
Intensive Care ◽  
Health Care Utilization ◽  
End Of Life ◽  
Cancer Patients ◽  
Cost Of Care ◽  
Care Utilization

488 Background: Prospective trials have shown that palliative care is associated with improved survival and quality of life, with lower rate of end-of-life health care utilization and cost. We examined trends in palliative care utilization in older pancreatic cancer patients. Methods: Pancreatic cancer patients with and without palliative care consults were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database between 2000 and 2009. Trend of palliative care use was studied. Emergency room and Intensive Care utilization and costs in the last 30 days of life were assessed. Statistical analyses were performed with SAS version 9.4 (SAS Institute, Inc., Cary, NC). Results: Of the 72205 patients with pancreatic cancer, 3383 (4.1%) received palliative care. The proportion of patients receiving palliative care increased from 1.8% in 2000 to 7.8% in 2009 (p for trend < 0.001). Patients with palliative care were more likely to be Asian and women. Of those who received palliative care, 73% received it in the last 30 days of life, and only 11% at least 12 weeks before death. The average number of visits to the ED in the last 30 days of life were significantly higher for patients who received palliative care (0.93±0.62) versus those who did not (0.79±0.61), p < 0.001, and had a significantly higher cost of care ($1317 vs $842, p < 0.001). Intensive care unit length of stay in the last 30 days of life did not differ between patients who did and did not receive palliative care (1.14 days vs 1.04 days, p 0.08). Intensive care unit cost of care was significantly higher for patients with palliative care compared to their counterparts ($5202.641 vs $3896.750, p < 0.001). Conclusions: Palliative care use for pancreatic cancer patients has increased between 2000 and 2009 in this study of Medicare patients. However, it was largely offered close to the end of life and was not associated with reduced health care utilization or cost. Early palliative care referral may be more beneficial.

Use of palliative care among patients with metastatic breast cancer at a safety net hospital.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 117-117
Author(s):  
Sita Bushan ◽  
Hsiao Ching Li ◽  
Samira K. Syed ◽  
Nisha Unni ◽  
Navid Sadeghi
Keyword(s):  
Breast Cancer ◽  
Palliative Care ◽  
Metastatic Breast Cancer ◽  
Hormone Receptor ◽  
Medical Oncology ◽  
Metastatic Breast ◽  
Safety Net ◽  
Hospital System ◽  
Advanced Directives ◽  
Safety Net Hospital

117 Background: Palliative Care (PC) has been shown to improve quality of life in lung cancer patients, and ASCO recommends it as an adjunct to standard oncologic care. Data regarding the use of PC in other cancers and in disadvantaged populations is scant. We studied the patterns of use of PC in patients with metastatic breast cancer (MBC) at a safety net hospital. Methods: Electronic health records (EHR) of 234 patients who were diagnosed with MBC from 2010 to 2016 at Parkland Health and Hospital System (PHHS) were reviewed, and data on demographics, diagnostics, treatments, and palliative care elements were collected. Results: 105 of 234 (44.8%) patients with MBC were referred to PC, either as outpatients, inpatients, or both. The average time from the first visit with medical oncology to placement of an outpatient referral to PC was 390 days. Of the 79 patients with outpatient referrals to palliative care, we have hormone receptor status on 50. 12 of these patients had triple negative breast cancer; 30 had hormone receptor positive breast cancer. 77 (32% of all patients) patients had formal documentation of advanced directives (AD) in the EHR. Of these, 69 (89.6%) had seen PC. 133 patients have died, and 37 (27.8% of expired patients) died at the Parkland Hospital. Among the 96 patients who did not die in the hospital, 73 (76%) patients had some discussion of hospice prior to death. Conclusions: Less than half of patients with MBC at PHHS were referred to PC, and among those who are, referrals are placed late in the disease course, on average, more than one year after the first medical oncology visit. Lack of a sustained relationship with PC results in truncated goals of care discussions. As a result, most patients do not have formal documentation of AD in the EHR. Furthermore, they do not benefit from discussions with PC that could guide the management of their malignancy while they still have therapeutic options. Instead, patients discuss hospice with their providers toward the end of life, only when they are no longer candidates for cancer directed therapies. Although the use of PC resources at PHHS does not meet clinical guidelines, it is consistent with data from other studies showing inadequate use of PC resources among patients with advanced cancer.

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