1. Palliative Care – A Luxury you cannot afford? James Hallenbeck, MD Assistant Professor of Medicine Director, Palliative Care Services VA Palo Alto HCS

2. Agenda Review data regarding where veterans die, associated costs and correlations Review data regarding where veterans die, associated costs and correlations Encourage you to think about barriers to the expansion of palliative care in VA Encourage you to think about barriers to the expansion of palliative care in VA Challenge the assumption that palliative care is a luxury we cannot afford Challenge the assumption that palliative care is a luxury we cannot afford

3. Palliative Care in the VA VA is the largest unified healthcare system in the country VA is the largest unified healthcare system in the country 28% of Americans dying each year are veterans (more than die from all cancers annually) 28% of Americans dying each year are veterans (more than die from all cancers annually) VA is a potential model for universal healthcare of an aged, chronically ill population VA is a potential model for universal healthcare of an aged, chronically ill population Unified database for analysis Unified database for analysis Important to study because…

4. Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

5. Questions for VA and for You Should VA invest in palliative care? Should VA invest in palliative care? Is such care “cost-effective”? Is such care “cost-effective”? Could adequate dollars be cost-shifted or avoided to justify such an investment? Could adequate dollars be cost-shifted or avoided to justify such an investment? Why is there such variance across VA regions and facilities? Why is there such variance across VA regions and facilities? Is palliative care is luxury the VA cannot afford, or can the VA not afford not to have palliative care?

6. Good News Good News Establishment of hospice treating specialty 2002 Establishment of hospice treating specialty 2002 Interprofessional Palliative Care Fellowship 2002 Interprofessional Palliative Care Fellowship 2002 Mandated palliative care consult teams 2003 Mandated palliative care consult teams 2003 Accelerated Administrative and Clinical Training (AACT) initiative 2002- Accelerated Administrative and Clinical Training (AACT) initiative 2002- Establishment of Hospice-Veteran Partnerships (HVPs) 2002- Establishment of Hospice-Veteran Partnerships (HVPs) 2002-

7. Examples of Palliative Care Interventions Palliative care consultation teams Palliative care consultation teams Palliative care clinics Palliative care clinics Nursing home hospice programs Nursing home hospice programs Active management of home hospice programs Active management of home hospice programs Palliative care training programs for students, residents, palliative care fellowships Palliative care training programs for students, residents, palliative care fellowships

8. Challenges Assumption: Something “nice” like palliative care must be a luxury we cannot afford Assumption: Something “nice” like palliative care must be a luxury we cannot afford Zero-Sum Game and Life-Boat Triage Zero-Sum Game and Life-Boat Triage To spend more on palliative care in the short run means to spend less on something else To spend more on palliative care in the short run means to spend less on something else Competing missions Competing missions Institutional Inertia Institutional Inertia

9. Management Argument: “We cannot afford palliative care” Assumptions- Assumptions- We have no choice as to where veterans die or how much it costs We have no choice as to where veterans die or how much it costs Palliative care services would just be an additional expense without true cost savings Palliative care services would just be an additional expense without true cost savings Even if it would be “nice” to have… Even if it would be “nice” to have…

10. SHOW ME DATA! The skeptical manager says…

11. Initial Questions: What do people want toward the end- of-life? What do people want toward the end- of-life? What constitutes good care? What do they get What constitutes good care? What do they get Where do people die? Where do people die? What do they die from? What do they die from? How much does it cost? How much does it cost? How much variability exists in the above parameters How much variability exists in the above parameters And what accounts for this variability? And what accounts for this variability?

12. WHAT DO PEOPLE WANT? What would be most important to you?

13. Steinhauser K et. al., Factors considered important at the end of life by patients, family, physicians, and other care providers JAMA, 2000; 284(19):.2476-2482

15. Where do people die?

16. Major Site: Acute Care Hospital Traditionally, people died in their homes. Only a few decades ago, the hospital was considered the “place where people went to die,” and was avoided by many, including the dying, for that very reason. Now, perhaps ironically, that the hospital is seen as being for short-term care, people enter more readily – and die there more often. Richard A. Kalish

17. Honoring Veterans’ Preferences at the End-of-Life

18. Patient Preferences for Site of Death Home vs. Hospital or Nursing Home Pritchard, R. S., E. S. Fisher, et al. (1998). "Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment." J Am Geriatr Soc 46(10): 1242-50. “Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics.”

19. Palliative and End- of-Life Care in the VA Early Findings

20. Patient Demographics VA Inpatient Deaths FY00 47% over age 75 47% over age 75 45% married 45% married Median annual income < $10,000 Median annual income < $10,000 25% no reported income 25% no reported income 35% Service Connected 35% Service Connected Many veterans dying as inpatients have poor social support structures

21. Average Cost per Day for Terminal Admissions FY00

22. Non-Hospice Percent Total Costs Acute Care VA Palo Alto FY00 0% Mental Health 21% Medical Procedures

23. Palo Alto Hospice Costs FY00 13% Mental Health 2% Medical Procedures NOTE: THIS PIE ALMOST 1/3 SIZE OF PRIOR PIE

24. MOST CAUSES OF DEATH IN ACUTE CARE PREDICTABLE AND NOT SIGNIFICANTLY DIFFERENT FROM HOSPICE

26. Responses from Managers… “Doesn’t prove anything” – differences may have arisen from: “Doesn’t prove anything” – differences may have arisen from: Referral and selection biases: (hospice patients more end-stage, preferred less aggressive/expense care) Referral and selection biases: (hospice patients more end-stage, preferred less aggressive/expense care) “You don’t know our patients - they want more aggressive care based on… different illnesses, age, ethnicity etc.” “You don’t know our patients - they want more aggressive care based on… different illnesses, age, ethnicity etc.”

27. Background Message: ‘Immutable patient variables predominantly determine where patients die and how much it costs’ ‘Immutable patient variables predominantly determine where patients die and how much it costs’ Implication: Changing the system will make little difference Implication: Changing the system will make little difference And thus status-quo is maintained

28. Patient vs. System Variables Patient variables Patient variables Age Age Gender Gender Race Race Income Income Diseases (DRG) Diseases (DRG) Proximity/distance to care venues Proximity/distance to care venues Preferences for care Preferences for care System variables Total hospital beds ICU beds Nursing Home beds Availability of Palliative Care Consult Team Dedicated PC beds Geographic locations of hospitals and PC units

29. Demographics and Associated Costs of Dying for Enrolled Veterans Preliminary Findings James Hallenbeck, MD James Breckenridge, PhD Co-Principal Investigators VA Palo Alto HCS Susan Ettner, PhD, UCLA, Susan Ettner, PhD, UCLA, Karl Lorenz, MD, UCLA David Draper, PhD. U.C. Santa Cruz David Draper, PhD. U.C. Santa Cruz Co-investigators Co-investigators Funded by the Robert Wood Johnson Foundation

30. Study Purposes Archeological – A “dig” in VA databases Archeological – A “dig” in VA databases Where veterans die Where veterans die Demographic and system correlates with terminal venue Demographic and system correlates with terminal venue Patterns of care across venues Patterns of care across venues Economic – Examining relationship between care patterns and cost of care Economic – Examining relationship between care patterns and cost of care Costs of care in different venues Costs of care in different venues Instrumental variable analysis: comparing costs of deaths in dedicated palliative care beds to deaths elsewhere Instrumental variable analysis: comparing costs of deaths in dedicated palliative care beds to deaths elsewhere

31. Methodology Population: All veterans during FY 00-02 with at least one institutional stay: 849,489 individuals Population: All veterans during FY 00-02 with at least one institutional stay: 849,489 individuals Veterans who died during this time period: 172,086 (20%) Veterans who died during this time period: 172,086 (20%) Last institutional venue: Last institutional venue: ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed ICU, Acute Care (non-ICU), Nursing Home, Other, Dedicated Palliative Care Bed Analyze associated demographics and costs Analyze associated demographics and costs

33. In Hospital Deaths Dartmouth Atlas: www.dartmouthatlas.org/

34. 41% of Acute Care Deaths in ICU 39% of acute care deaths for Pts 65+ n = 79,389

36. Controlling for Charlson Co-morbidity Index, HCUP/CCS Diagnosis-based Risk adjustment, Age, Sex, Race and Distance Nearest VA

37. p =.002, r = -.64

38. Plots facility nursing home deaths per 1000 patients in the study population against ICU deaths as a percentage of all institutional deaths and deaths within 30 days of discharge r= -.52, p=000

39. What do people die from in ICUs?

40. ICU Terminal Stay ICD9 Codes Diagnosis Freq % Diagnosis Freq % Diagnosis Freq %

41. How much does it cost?

42. Cost per Day Terminal Stays AverageMedian Average LOS ICU$1624$140610.7 Acute$641$53610.3 NHC$253$230* PalliativeCare$278$26224 n = 79,389

43. Direct Costs of Care for Last Six Months and Last Year of Life Institutional Costs Outpatient & Fee Costs Total Direct Costs Six Months $743,162,000$159,604,000$902,766,000 OneYear$966,439,000$204,832,000$1,172,237,000 > 10% VA clinical budget spent for 10% VA clinical budget spent for <1.5% VA enrolled population in the last year of life…

44. Costs of Terminal Stays Annual direct DSS costs of terminal admits: $387,367,000 67% of costs in acute care

46. How can we put this all together?

47. National Trends Affecting Terminal Venues Decreasing acute care workload Decreasing acute care workload 55% decrease in # of acute beds 1994-98* 55% decrease in # of acute beds 1994-98* (ADC down 23% FY02 vs. FY97) (ADC down 23% FY02 vs. FY97) A proportional increase in ICU workload, as percentage of acute workload A proportional increase in ICU workload, as percentage of acute workload VA nursing homes: Mandate to keep high ADC VA nursing homes: Mandate to keep high ADC * Ashton: N Engl J Med, Volume 349(17).October 23, 2003.1637-1646

48. ICU Beds as Percentage Acute Care Beds 1972 All Hosp 1990 VA Med/Surg 1992 All Hosp 2001 VA Med/Surg 2001Japan % Acute Care 2.5%<6%8.6%21%1%

50. Acute Care Triage: Up, Down or Out Non-ICU acute care less a venue for treatment than for triage Non-ICU acute care less a venue for treatment than for triage Patients triaged “up” to ICU or “down” (to nursing homes) or “out” discharged to home/non- VA care Patients triaged “up” to ICU or “down” (to nursing homes) or “out” discharged to home/non- VA care Imperative to “decompress” acute care beds using nursing home beds in conflict with mandate to maintain high ADC. Imperative to “decompress” acute care beds using nursing home beds in conflict with mandate to maintain high ADC. Like squeezing the middle of a tube of toothpaste…

51. An Impacted System Dying veterans tend to follow other sick veterans Dying veterans tend to follow other sick veterans A greater proportion go to ICU and get “stuck” there, even if dying is eventually recognized, perhaps because of a lack of reasonable, alternative venues A greater proportion go to ICU and get “stuck” there, even if dying is eventually recognized, perhaps because of a lack of reasonable, alternative venues Dying veterans at risk for discharge without appropriate or adequate services such as home hospice Dying veterans at risk for discharge without appropriate or adequate services such as home hospice

52. Perhaps… A Field of Dreams…

53. SUMMARY System variables are major factors in determining where and how veterans die System variables are major factors in determining where and how veterans die Significant cost-savings/cost-avoidance can be realized by incorporating palliative care into VA healthcare systems Significant cost-savings/cost-avoidance can be realized by incorporating palliative care into VA healthcare systems Palliative care is not a luxury, but should be a standard of care that should be incorporated into all venues in which seriously-ill patients are treated within VA Palliative care is not a luxury, but should be a standard of care that should be incorporated into all venues in which seriously-ill patients are treated within VA Evidence Suggests: