Cost Savings from Palliative Care Teams and Guidance for a Financially Viable Palliative Care Program

To quantify the cost savings of palliative care (PC) and identify differences in savings according to team structure, patient diagnosis, and timing of consult

Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses

Background. Single-disease-focused treatment and hospital-centric care are poorly suited to meet complex needs in an era of multimorbidity. Understanding variation in palliative care’s association with treatment choices is essential to optimizing interdisciplinary decision making in care of complex patients. Aim. To estimate the association between palliative care and hospital costs by primary diagnosis and multimorbidity for adults with one of six life-limiting conditions: heart failure, chronic obstructive pulmonary disease (COPD), liver failure, kidney failure, neurodegenerative conditions including dementia, and HIV/AIDS. Methods. Data from four studies (2002–2015) were pooled to provide an analytic dataset of 73,304 participants with mean costs $10,483, of whom 5,348 (7$2666; 95% confidence interval [CI]: −$3440 to −$1892), neurodegenerative conditions (−$3523; −$4394 to −$2651), COPD (−$1613; −$2217 to −$1009), kidney failure (−$3589; −$5132 to −$2045), and liver failure (−$7574; −$9232 to −$5916). The association for liver failure patients was statistically significantly larger than for any other disease group. Cost-saving associations were also statistically larger for patients with multimorbidity than single disease for two of the six groups: neurodegenerative and liver failure. Conclusions. Heterogeneity in treatment effect estimates was observable in assessing association between palliative care and hospital costs for adults with serious life-limiting illnesses other than cancer. The results illustrate the importance of careful definition of palliative care populations in research and practice, and raise further questions about the role of interdisciplinary decision making in treatment of complex medical illness. </jats:p

Efficiency in Adult Spinal Deformity Surgery: A Multicenter Comparison of Resource Use

Introduction Decision makers and payers are placing increasing scrutiny on the costs and outcomes associated with complex spine surgery. To justify higher cost practice patterns, there must be evidence of additional patient benefit; however, little is currently known regarding the variation in resources used and associated outcomes in complex spine surgeries. Our study examines multicenter variability in patient-level surgical resource use, including implants, biologics, and length of stay, alongside health-related quality-of-life (HRQoL) improvements following adult spinal deformity (ASD) surgery. Material and Methods This is a retrospective analysis of a multicenter prospective database of consecutive patients with ASD. HRQoL outcomes were calculated from the ODI, SRS-22, and SF-36 domain scores. Changes in HRQoL were estimated as the difference between baseline and 2-year values. Patient-level surgical resources included blood use, bone morphogenetic protein (BMP), volume (ccs), length of stay (LOS), and implants. Patients were classified by sagittal modifier and analyzed across centers. The three sagittal modifier types are defined as follows: mild (SVA &lt; 4 cm, PT &lt; 20 degrees, PI–LL within 10 degrees), moderate (at least 1 of SVA 4–9.5 cm, PT 20–30 degrees; PI–LL 10–20 degrees, and no severe modifiers); and severe (at least 1 of SVA &gt; 9.5 cm, PT &gt; 30 degrees, PI–LL &gt; 20 degrees). Statistical analysis was performed using analysis of variance (ANOVA) and multivariable regression methods comparing HRQoL outcomes and resource use across center, considering the overall patient cohort and each modifier group. Results Baseline and 2-year HRQoL data were available for 226 surgical patients with ASD, with an average age of 56 (range, 18–84 years) years who were predominantly female ( N = 189, 84%). Significant differences were found in the average 2-year change in HRQoL across centers, however, this difference becomes insignificant after controlling for patients within the same major modifier groups ( p &gt; 0.05). Significant differences were found across centers in average resources used per surgery ( p &lt; 0.05), with only LOS not reaching significance ( p &gt; 0.05). Significant differences were found in average BMP and screw use across all modifier groups. After accounting for clinical, demographic, and regional characteristics at the patient level, variation among centers persisted in both screw use and total BMP volume with no corresponding statistical differences in HRQoL outcomes. Conclusion The use of additional surgical resources does not appear to impact 2-year HRQoL outcomes following surgery for ASD. To improve efficiency in ASD surgery, standardization of physician practice patterns and resource use could help curb costs without negatively impacting patient HRQoL. </jats:sec

Economics of Palliative Care for Hospitalized Adults With Serious Illness

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 studieswere 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 &lt; .001). In the stratified analyses, there was a reduction in costs for the cancer (-4251; 95%CI, -4664 to -3837; P &lt; .001) and noncancer (-2105; 95%CI, -2698 to -1511; P &lt; .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. Estimatesmay 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 guidelinesmay reduce costs for hospitalized adults with serious and complex illnesses.</p

20190630__online_supp – Supplemental material for Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses

Supplemental material, 20190630__online_supp for Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses by Peter May, Charles Normand, Egidio Del Fabbro, Robert L. Fine, R. Sean Morrison, Isabel Ottewill, Chessie Robinson and J. Brian Cassel in MDM Policy & Practice</p