The role and timing of palliative medicine consultation for women with gynecologic malignancies: Association with end of life interventions and direct hospital costs

https://doi.org/10.1016/j.ygyno.2013.10.025Get rights and content

Highlights

  • Timely palliative medicine consultation is associated with improved quality of end of life care.

  • Decreased direct hospital costs are associated with timely palliative medicine consultation.

Abstract

Objective

Aggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies.

Methods

A retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥ 30 days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission < 3 days. Inpatient direct hospital costs were calculated for the last 30 days of life from accounting records. Data were analyzed using Fisher's Exact, Mann–Whitney U, Kaplan–Meier, and Student's T testing.

Results

49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0–3) versus 2 (range 0–6) p = 0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30 days of life were lower for patients with timely consultation, $0 (range 0–28,019) versus untimely, $7729 (0–52,720), p = 0.01.

Conclusions

Timely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.

Introduction

Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.” [1] Palliative care is often confused with hospice care. The important difference is that palliative care is appropriate at any age and any stage in a serious illness and can be provided along with curative treatment [2]. The multidisciplinary palliative care team (physician, nursing, social work, chaplaincy) focuses on the patient and family throughout the trajectory of illness from diagnosis to death [3], [4].

In 2012 the American Society of Clinical Oncology asserted that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.” [5] The provisional clinical opinion cited seven randomized controlled trials (RCTs) demonstrating improvement in symptoms, quality-of-life (QOL), patient satisfaction, reduced caregiver burden, more appropriate referral and use of hospice, reduced use of futile intensive care and other invasive care and improved survival [5], [6], [7], [8], [9], [10], [11], [12]. The most compelling of these trials, by Temel et al., found improved QOL and mood for patients with metastatic lung cancer who had early as opposed to usual palliative care. As a secondary finding, these authors proved that early consultation resulted in less intensive oncologic interventions at the end of life with prolonged survival [12]. The impact of combined standard oncology care and palliative care on metrics of QOL and cost has not been previously reported for women with gynecologic malignancies.

Evidence suggests that palliative care consultations in patients at the end of life decrease costs while improving QOL. In a report of palliative care consultation team hospital cost savings, projected savings in New York State alone for Medicaid beneficiaries are up to $252 million annually if every hospital with 150 or more beds had a fully operational palliative care consultation team (defined as multidisciplinary, operating for more than 5 years, and trained in preferred practices for palliative and hospice care recommended by the National Quality Forum) [13]. However, there is a paucity of data on the impact of a palliative medicine consultation on these costs for women with gynecologic malignancies.

A composite metric of aggressiveness of care at the end-of-life (ACE) reported by Earle et al. has been used as a point of reference for many palliative care studies [14]. Increased ACE scores are indicative of poor end of life care [15]. These metrics include admission to the intensive care unit (ICU) within 30 days of death, hospital admission more than 14 days in the last 30 days of life, more than one hospital admission during the past 30 days of life, more than one emergency room visit during the last 30 days of life, death in an acute care setting, initiation of a new chemotherapy during the last 30 days of life, last chemotherapy within 14 days of death, and hospice admission less than 3 days before death. These aggressive interventions were not associated with improvement in survival for women with ovarian cancer according to a report by Von Gruenigen et al. [16] However, timely palliative medicine, as defined by two weeks of exposure, was reported to decrease ACE scores in a Veteran's Affairs cancer population [17].

While the evidence from RCTs integrating standard oncology practice and palliative care is promising, the applicability of these trials to general gynecologic oncology practice is yet to be tested, reproduced, or proven. In particular the application of early consultation for ethnically and racially diverse women with poor socioeconomic resources has not been investigated. The optimal method of integration of palliative medicine into standard oncology care is unknown, and the intensiveness or “dose” has not yet been defined for optimal clinical impact with minimal resource utilization. The objective of our study was to retrospectively evaluate the impact of palliative medicine consultation on cost and quality of end of life care as measured by ACE for women with gynecologic malignancies.

Section snippets

Methods

Montefiore Medical Center is the largest hospital center in the Bronx, which has approximately 1.4 million persons. It is a 1062 bed, urban community academic medical center. Over 27% of Bronx residents have incomes below the poverty level and 32% of the Bronx population is foreign born. Montefiore Medical Center provides medical care to a highly diverse population: 48% of its patients are identified as Latino/Hispanic, 31% as African American. English is the second language for more than half

Results

Data were collected from patients who died from June 5, 2005 until February 7, 2010. 49% of patients had an inpatient palliative medicine consultation, and the median number of days from consultation to death was 16 days (range 0–159 days) (Table 1). 18% of patients had palliative medicine consultation more than 30 days before death, with the median number of days from consultation until death being 63 days (33–159) in this group. The shortest time from diagnosis until consultation was 24 days, with

Discussion

Palliative medicine consultation resulted in lower ACE scores when compared to patients who did not receive a timely palliative medicine consultation. Patients who had timely consultations had decreased interventions in all domains except for emergency department visits. This may implicate a deficit in adequate outpatient palliative medicine resources for attention to symptoms. While ACE scores have been utilized as benchmark metrics for evaluation of healthcare systems' resources for

Conflict of interest statement

No conflict of interest.

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  • Cited by (0)

    A portion of this work was presented at the 2013 Annual Meeting of the Society of Gynecologic Oncologists. This work was supported in part by the Albert Einstein Cancer Center through its NCI Cancer Center Support Grant (P30CA013330) and NIH (K12CA132783-03).

    1

    Montefiore Medical Center, Albert Einstein College of Medicine, Department of Obstetrics, Gynecology and Women's Health, 3332 Rochambeau Ave, Bronx, NY 10467, USA. Fax: + 1 718 920 6313.

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