Palliative Care in Oklahoma: Looking Back, Looking Forward Jeffrey Alderman, M.D. Associate...
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Transcript of Palliative Care in Oklahoma: Looking Back, Looking Forward Jeffrey Alderman, M.D. Associate...
Palliative Care in Oklahoma:Looking Back,
Looking Forward
Jeffrey Alderman, M.D.Jeffrey Alderman, M.D.
Associate ProfessorAssociate Professor
Director, Palliative Medicine Director, Palliative Medicine
OU College of Medicine – TulsaOU College of Medicine – Tulsa
ObjectivesObjectives
• Learn about the current state of Palliative Learn about the current state of Palliative Care in OklahomaCare in Oklahoma
• Understand the benefits/pitfalls of Understand the benefits/pitfalls of Inpatient Palliative Care ConsultationInpatient Palliative Care Consultation
• Explore reasons why physicians have Explore reasons why physicians have difficulty with Advance Directivesdifficulty with Advance Directives
• Learn what you can do to help patients Learn what you can do to help patients receive appropriate Palliative Carereceive appropriate Palliative Care
Case Study: Zelda S.Case Study: Zelda S.
• Zelda is 73 years old.Zelda is 73 years old.
• She has DM-2, Stage III CKD, and She has DM-2, Stage III CKD, and worsening PVDworsening PVD
• She has been admitted to St. John 4 She has been admitted to St. John 4 times in the last 6 months with times in the last 6 months with symptoms from her ischemic leg.symptoms from her ischemic leg.
Case Study: Zelda S.Case Study: Zelda S.
• Zelda is widowed, but Zelda is widowed, but has 3 children and 5 has 3 children and 5 grandchildren.grandchildren.
• Her true love is golf.Her true love is golf.
• Her goal of care is to Her goal of care is to continue playing golf continue playing golf for as long as for as long as possible.possible.
Case Study: Zelda S.Case Study: Zelda S.
• Zelda’s golf playing is limited by pain.Zelda’s golf playing is limited by pain.
• Social Isolation. Social Isolation.
• Unclear if Zelda can continue to live alone.Unclear if Zelda can continue to live alone.
• Unclear if Zelda ever executed an Advance Unclear if Zelda ever executed an Advance DirectiveDirective
How can we help Zelda?How can we help Zelda?What if Zelda lives in Oklahoma?What if Zelda lives in Oklahoma?
How Does Your State Rate?
Oklahoma
F
0%
20%
40%
60%
80%
100%
Hosp
itals
wit
h a
Pro
gra
m
Oklahoma South Region United States 8/43 401/983 1294/2452 www.capc.org
State by State Report Card
TULSA WORLDSaturday October 4, 2008
State gets failing health-care grade
BY KIM ARCHER (World Staff) Writer
Oklahoma is failing to care adequately for the sickest of its residents and is one of only three states in the country to receive an “F” for access to palliative care, according to a report released Thursday Alabama and Mississippi also received failing grades, according to the study by the Center to Advance Palliative Care and the National Palliative Care Research Center. The study appears in the October issue of the Journal of Palliative Medicine. Palliative care refers to treatment that concentrates on reducing the severity of symptoms rather than striving to halt, delay or cure the disease itself. The goal is to prevent and relieve suffering and improve a patient’s quality of life. Nineteen percent of Oklahoma’s hospitals with 50 beds or more have a palliative care program, the report said. Most are in larger hospitals in Tulsa and Oklahoma counties.
What was measured?
• Patient access to palliative care services in hospitals
• Patient access to board-certified palliative medicine physicians
• Medical student access to clinical training in palliative medicine
• Physician access to specialty-level training in palliative medicine
Morrison, RS. et al. AMERICA’S CARE OF SERIOUS ILLNESS: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. Center to Advance Palliative Care/National Palliative Care Research Center , 2008, p.14
Why did we fail?
• Clearly too few Oklahoma hospitals have Palliative Care Programs
• Too few Board-Certified Palliative Care Physicians
• Not enough Palliative Care Education for Medical Students
• No Fellowship Training Programs
Conclusions
• More Oklahoma Hospitals need to develop Palliative Care Programs
• More Oklahoma clinicians need training in Palliative Medicine
• We must educate the next generation of providers in Palliative Care
University of Oklahoma -St. John Medical Center
Palliative Care Service
University of OklahomaSt. John Palliative Care Service
• Started in October 2004 - CAPC
• Interdisciplinary Team
• Inpatient Consults
• Close relationship with Hospice
St. John Palliative Care IDTSt. John Palliative Care IDT
University of OklahomaSt. John Palliative Care Service
• The Clinical Imperative• The Financial Imperative• Patient/Family Satisfaction• Coordination of Care across
Venues of Care• The Educational Imperative
• The Quality Imperative• Effective, Patient-centered, Timely, Efficient and
Equitable
Education
OU School of Community Medicine in Tulsa
• 130 Faculty
• 70 – 80 MSIII and MSIV Students
• 54 Internal Medicine Residents
Curriculum in Palliative Care
• All Senior Internal Medicine Residents spend 60 clinical hours rotating on the Palliative Care Service
• All Residents attend 7 didactic lectures
• All complete online training in pain and non-pain symptom management
Stanford Curriculum
• Introduction to Palliative Medicine• Pain Management• Non-Pain Symptom Management• Communication in Palliative Care• Legal Issues• Terminal Care• Palliative Care Health Care Policy
Clarehouse
Curriculum in Palliative Care
• All Medical Students spend ~9 clinical hours rotating on the Palliative Care Service
• All Medical Students attend 3 didactic lectures
Future Directions
• No formal measurement of Palliative Care Training
• Exploring pre/post rotation testing tools
• Expand training to the College of Nursing
CONSULT SERVICE
Demographic Data
Service Cases
2008 Consults Requested 354
2007 Consults Requested 286
2006 Consults Requested 250
2005 Consults Requested 119
Consult Numbers
0
5
10
15
20
25
30
35
40
Con
sults
/Mon
th
Patient Volume
0
5
10
15
20
25
30
35
40
Con
sults
/Mon
th
Patient Volume
Disease Cases
Patients Seen 354
Average Age 67.9
Age Range 20 - 98
% Female 53%
Referring Physicians 100
Admission DRG’s 118
ICU Referrals 10.2%
% Expiring at St. John 31.1%
% Entering Hospice After Discharge 33.3%
Patient Demographics
Disease Cases
% Medicare 72.0%
% Medicaid 15.5%
% Commercial Insurance 6.0%
No Payor Source 6.5%
Patient Payor Source
Disease Cases %
Cancers 140 39.5
Cardiovascular Diseases 64 18.1
Pulmonary Diseases 37 10.5
Neurodegenerative Diseases 28 7.9
Bone Disease/Fractures 26 7.3
Infectious Diseases 21 5.9
Gastrointestinal Diseases 18 5.1
Renal Diseases 10 2.8
Other Diseases 10 2.8
Background Illness
Number %
Pain Management 139 39.3
Direction of Care 109 30.8
Terminal Care 64 18.1
Non-Pain Symptom Management
40 11.3
Other 2 0.6
Reason for Consult
Nephrology 1%OB/GYN <1%Emergency Med 1%Neurosurgery 1%Cardiology 2%Non-OU Internal Med 27%Family Medicine 5%Cardiovasc. Surgery 1%Hospitalists 20%General Surgery 1%Oncology 5%OU Internal Med 35%
Referring Physicians
LTAC/SNF – 9.9%Other – 2.7%
Expired – 31.1%
Clarehouse* – 2.3%
Nursing Home – 14.7%Home – 39.3%
*’Clarehouse’ is a hospice home in Tulsa, providing care to patients in the last month of life
Discharges
Clinical Outcomes
Initial Evaluation Final Evaluation
Severe
Mod.
Mild
None
Reported Pain Scores
130 Patients seen on the SJMC Palliative Care Consult Service: Oct 2005 – Oct 2006
212 Patients
212 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
Initial Evaluation Final Evaluation
Severe
Mod.
Mild
None
Initial Evaluation Final Evaluation
OU/St. John Mt. Sinai Hospital, NYC*
Comparison of Pain Scores
212 Patients 3707 Patients
*Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
Initial Evaluation Final Evaluation
Severe
Mod.
Mild
None
Reported Dyspnea Scores
112 Patients
112 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007
Initial Evaluation Final Evaluation
Severe
Mod.
Mild
None
Initial Evaluation Final Evaluation
OU/St.John Mt. Sinai Hospital, NYC* 112 Patients 2219 Patients
Comparison of Dyspnea Scores
*Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.
Agitation 61.1% Reduction
Nausea 82.1% Reduction
Constipation 67.3% Reduction
Dry Mouth 62.9% Reduction
Insomnia 75.9% Reduction
Other Clinical Outcomes
Satisfaction Outcomes
Question: ExcellentVery Good
Good Fair Poor
Degree to which pain was controlled 68.4% 15.8% 7.9% 5.3% 2.6%
Degree to which symptoms (other than pain) were controlled
77.1% 11.4% 5.7% 2.9% 2.9%
Degree to which team addressed Emotional needs
71.4% 14.3% 7.1% 3.6% 3.6%
Degree to which team addressed Spiritual needs
76.9% 15.4% 0.0% 3.8% 3.8%
Degree to which team included you in decisions about care
71.0% 22.6% 6.5% 0.0% 0.0%
Degree to which team treated you with respect and dignity
73.5% 20.6% 5.9% 0.0% 0.0%
Degree to which team addressed your overall well-being & comfort
63.9% 19.4% 2.8% 5.6% 8.3%
Degree to which discharge process was smooth/hassle free
62.1% 24.1% 0.0% 10.3% 3.4%
Overall assessment of Palliative Care team 68.6% 14.3% 14.3% 0.0% 2.9%
Telephone Survey of 67 patients/families following discharge date of at least 30 days. Patients were picked at random. Responses from 43 completed surveys are recorded above.
• 83 – 94% responded very favorably, reporting ‘excellent’ or ‘very good.’ satisfaction with Palliative Care at St. John
Satisfaction Results
• We received our highest scores in the areas of ‘treatment with dignity,’ ‘inclusion of patients in decisions about care’ and ‘addressing spiritual needs.’
• The highest number of negative comments focused on the discharge process from the hospital.
Satisfaction Results
Financial Outcomes
Service Cases LOS
Usual Care 1329 11.1
Palliative Care 130 8.5
Savings/Case 2.6 days
Length-of Stay-Savings 2008
Year Days Saved
2008 918
2007 1730
2006 931
2005 188
Length-of-Stay Savings
Service Cases Charges/Case
Usual Care 1329 $44,602
Palliative Care 130 $30,153
Savings/Case $14,449
Charge Avoidance - 2008
$2,000.00
$2,500.00
$3,000.00
$3,500.00
$4,000.00
$4,500.00
UsualCare
PalliativeCare
Mean Charges Per Day11 Days Prior to Death
11 10 9 8 7 6 5 4 3 2 1Days Before Death
Ch
arg
es/D
ay
Year Charges Saved
2008 $5,114,847
2007 $3,062,573
2006 $3,911,365
2005 $619,750
Charge Avoidance
Putting it Together,LOS and Cost Savings
Total Days Saved 2004 - 2008
3,767
Total Charges Saved 2004 - 2008
$12,618,554
Year Days Saved Charges Saved
2009 1343 $5,089,942
2010 1544 $5,852,808
2011 1775 $6,728,228
Looking Ahead into the Future…
Assume 15% Annual Growth Rate
Should the Palliative Care Team See Every Patient in
the Hospital?
Proactive palliative care in the medical ICU: effects on length of stay for selected
high-risk patients
Norton SA, Quill TE, et al. Critical Care Medicine
2007; 35:1530-1535
17-bed medical ICU at a tertiary care hospital in Rochester, New York.
Primary Outcome: LOS
ICU admission following a current hospital stay 10 days or longer– Age >80 years with 2 or more life-threatening
comorbidities– Active metastatic cancer– Status post cardiac arrest;– Intracerebral hemorrhage requiring mechanical
ventilation
Study Design
Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
Optional PC Consult Required PC Consult
Mortality in the ICU
55 59
0
20
40
60
80
100
% M
ort
ality
Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
P > 0.10
17.7 17.6
9
16.3
0
5
10
15
20
25
30
35
40
Ho
spit
al D
ays
Total Days = 26.7
Non ICU Days
Total Days = 33.9
ICU Days
Required PC Consult Optional PC Consult
Length of Stay
Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
Conclusions
• Mandatory ICU Palliative Care Consultation reduced ICU stay over 7 days, without substantially changing mortality.
• Non-ICU Hospital LOS did not decrease with the intervention
Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535
Bottom Line
• “Blanket” Palliative Care Consultation can substantially reduce ICU days
• Implied in the study is significant cost savings, but not explicitly reported.
• More analysis could reveal clinical outcomes, satisfaction level, and referral patterns
The Oklahoma Advance The Oklahoma Advance DirectiveDirective
a document only a a document only a lawyer could love…lawyer could love…
Advance DirectivesAdvance Directives
•Statement of one’s wishes regarding End-of-Life Care
•Only goes into effect when patients permanently lose decision-making capacity
•Allows one to opt out of life-sustaining care and/or Artificial Nutrition and Hydration
• Cumbersome document poorly understood by physicians and patients
• Only executed by 15 - 20% of eligible patients
Gillick, et al., Ann Int Med. 1995;123:621-624
OKLAHOMA ADVANCE DIRECTIVE
FOR HEALTH CARE
If I am incapable of making an informed decision regarding my health care, I direct my health careproviders to follow my instructions below.
I. Living WillIf my attending physician and another physician determine that I am no longer able to makedecisions regarding my medical treatment, I direct my attending physician and other health careproviders, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forthbelow:
1. If I have a terminal condition, that is, an incurable and irreversible condition that even withthe administration of life-sustaining treatment will, in the opinion of the attending physicianand another physician, result in death within six (6)
Advance DirectivesAdvance Directives
• Surveys show that patients prefer their physicians to address Advance Directives in a controlled setting (e.g. office)
• In reality, most Advance Directives are completed at a point of crisis, such as in a hospital during a critical illness
Advance DirectivesAdvance Directives
Rodriguez, KL, et al., Soc Sci Med. 2006;62:125-133Lo B, et al., Am J Geriatr Cardiol. 2004;13:316-320
Behold: The MismatchBehold: The Mismatch
•When surveyed, a majority of patients expect their Primary Care Physician to address Advance Care Planning.
•Physicians generally do not solicit their patients about completing Advance Directives
Tierney, et al. J Gen Intern Med 2001:16;32-40Lurie, N. et al. J Am Geri Soc 1992:40;1205-8
Office Screening/Prevention Office Screening/Prevention
•Diabetes Screening•Lipid Screening•PAP Smears•Mammography•Colonoscopy•PSA/DRE•Smoking Cessation Counseling
•Advance Directive Completion•Alcohol/Drug Abuse Screening
Why is this conversation missing Why is this conversation missing in Primary Care?in Primary Care?
•Thinking about dying is uncomfortable•Patients value invincibility•Physicians value cure•Physicians lack training •Legally complicated process (Missteps = Lawsuit)
•Ethical hornet’s nest•Religious Implications•Time Issues•Portability Issues
Tulsky J, et al. Ann Intern Med 1998:129;441-449
Can Residents be Trained to Can Residents be Trained to Address Advance Directives?Address Advance Directives?
Study CharacteristicsStudy Characteristics
•10 Internal Medicine Residents
•100 Clinic Patients
•All patients had to have at least one chronic illness to meet entry criteria
•Baseline survey of 100 random charts revealed zero AD’s
Study DesignStudy Design
•IRB approved, prospective survey trial
•Residents were surveyed about their baseline knowledge, skills, attitudes and comfort using Advance Directives with patients.
•Residents received 2-hour training period, reviewing all aspects of Advance Directives
Study DesignStudy Design
•Once trained, each resident encouraged 10 of their ‘at-risk’ continuity patients to complete an Advance Directive
•At the conclusion of the study, residents were re-surveyed about their knowledge, skills, attitudes and comfort using Advance Directives with patients.
0
1
2
3
4
5
6
7
8
9
10
Knowledge Skill Attitude Comfort
Pre-intervention Post-intervention
p < 0.001
p < 0.001p = 0.004
p < 0.001
Results: ResidentsResults: Residents
ConclusionsConclusions
•Residents significantly improved their knowledge, skills, attitudes, and comfort with Advance Directives in the Outpatient setting
•Patients demonstrated a strong interest in completing Advance Directives
Implications from the StudyImplications from the Study
The authors hoped that residents would apply their research experience to engage future patients in completing Advance Directives in the Outpatient setting.
Did they?
Epi-PhenomenonEpi-Phenomenon
Following the “conclusion” study period, Residents were secretly observed over a period of an additional 6 months
Not one advance directive was completed in that period.
Bottom Line:Bottom Line:
•Despite intensive training, many barriers are stacked against physicians engaging their patients in meaningful conversations about Advance Directives
•The doctor’s office is probably not the right place for patients to complete Advance Directives
Helping Zelda:
What can we do?
What Zelda Needs:What Zelda Needs:
•Pain Management
•Restoration of Function
•Assistance with making difficult decisions
•Workup and Treatment for Depression
•Transition to appropriate venue of care
•Advance Directive
What you can do:What you can do:
•Be a patient advocate
•Recognize and treat patient suffering• Physical Suffering• Emotional Suffering• Social Suffering• Spiritual Suffering
What you can do:What you can do:
•Talk to your colleagues – do they recognize suffering?
•Learn what resources your community offers in geriatrics and palliative care services
What you can do:What you can do:
•If Palliative Care is not in your community, encourage leadership to explore growth opportunities
•www.capc.org
What you can do:What you can do:
• Complete EPEC/ELNEC training
• Become certified in Palliative Medicine
• Educate local providers, hospitals, and nursing homes to about Palliative Care
What you can do:What you can do:
• Familiarize yourself with the Oklahoma laws regarding Advance Directives
• Encourage patients to execute Advance Directives, if they have not already done so.
Thank YouThank You