The business of palliative medicine - part 5: service utilization in a comprehensive integrated program

The aim of palliative medicine is to provide multidisciplinary comprehensive care in advanced illness. Patient and family utilization of various product service lines offered by the Harry R Horvitz Center for Palliative Medicine at the Cleveland Clinic Foundation was studied. Newly referred patients were followed up prospectively until 85% had either died or been lost to follow-up. Demographic, clinical, and referral data were recorded; subsequent product service line utilization was updated daily. The total study period was 171 days, and 238 patients entered. Acute care inpatient unit, outpatient clinic visits, and 24-hour phone contacts were the most frequently used product service lines. Patients had a median of 3 contacts (range, 1 to 27) with individual service lines. Multiple palliative medicine product service lines were utilized often, with repeated use of the individual service lines. A comprehensive integrated palliative medicine program is necessary to fully meet the complex needs of those with advanced disease.     

The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel comprehensive integrated program

The Cleveland Clinic is a large multispecialty group practice. The need for a palliative care program was identified and the program started in 1987. A key concept has been that the existing structure of hospice care as defined by Medicare is insufficient to address the needs of patients with incurable disease. The field of palliative medicine implies physician expertise in several key areas: (1) communication; (2) decision-making; (3) management of complications; (4) symptom control; (5) care of the dying; and (6) psychosocial care. The development of the program (the first in the United States) since 1987 has put in place the following major services, listed consecutively: (1) hospital consultation service; (2) outpatient clinics; (3) acute care inpatient service; (4) hospice and home care service; (5) acute-care palliative medicine inpatient unit; and (6) hospice inpatient facility. Program development has meant that a new program has been introduced approximately every 18 months since the start of the program. This has considerable implications for staffing, the management of change, and competition for scarce resources within a contracting health care budget. The staffing of the program has focused on developing specialized attending physicians using a multidisciplinary approach dedicated to enhancing the role of nursing in the field. The major budgeted areas are (1) the acute-care palliative medicine unit, and (2) the hospice and home care service. Specific commitment has been made to research and education because of the desire to develop an intellectual basis for the practice of palliative medicine. This requires structured activities in both areas with a systematic approach to research and education. The complexity of developing a service should not be underestimated. There has been consistent support for the program by senior leadership within the Cleveland Clinic Foundation, including the cancer center. The major lessons learned during program development have been: (1) to focus on quality of patient care; (2) to commit to academic endeavor in research and education; (3) to secure institutional commitment to program development; (4) to establish a positive, proactive, businesslike approach; (5) to defend budget and personnel, albeit within a difficult time in health care; and (6) to commit to success, i.e., never promise anything on which you do not deliver. The future development of post-acute-care services serving predominantly the chronically ill elderly population suggest an expanded administrative and conceptual role for the future development of palliative medicine to help serve the needs of the aging population in the United States.     

The business of palliative medicine--Part 3: The development of a palliative medicine program in an academic medical center

Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.     

Associations between Outpatient and Inpatient Service Use among Persons with HIV Infection: A Positive or Negative Relationship?

Objective. To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions.
Data Sources. Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States.
Study Design. This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001. Numbers of inpatient admissions and outpatient visits were calculated for each patient for each 3-month period, from 2001 through 2004.
Analysis. Negative binomial and logistic regression analyses using random-effects models examined the effects of inpatient admissions and outpatient visits in the previous period on inpatient and outpatient service utilization, controlling for background characteristics and HIV disease stage.
Results. For 3-month periods, between 5 and 9 percent of patients had an inpatient admission. The linear association between number of outpatient visits and any inpatient admission in the subsequent period was positive (adjusted odds ratio=1.05; 95 percent confidence interval [CI]=1.04, 1.06). However, patients with zero prior outpatient visits had significantly greater admission rates than those with one prior visit. Hospitalization rates were also higher among those with a prior hospitalization and those with more advanced HIV disease.
Conclusions. These results suggest a J-shaped relationship between outpatient use and inpatient use among persons with HIV disease. Those in worse health have greater utilization of both inpatient and outpatient care. However, having no outpatient visits may also increase the likelihood of subsequent hospitalization. Although outpatient care cannot be justified as a cost-saving mechanism, maintaining regular clinical monitoring of patients is important.     

Utilization of acute inpatient services for alcohol detoxification

This study indicates that the majority of patients admitted to VA hospital for medical detoxification could have those services provided on an outpatient or less intensive basis. However, inpatient medical detoxification services appear to be appropriate for those alcoholics at risk for potential life-threatening complications of withdrawal such as delirium tremens, or those with concurrent associated medical conditions such as pancreatitis, gastrointestinal bleeding, or complications of cirrhosis. Data were obtained from a national random sample of hospitalizations in Department of Veterans Affairs (VA) inpatient medical and surgical units. Medical records for 144 alcoholismrelated medical admissions to 35 VA medical centers were reviewed using the Appropriateness Evaluation Protocol (AEP), a clinically based utilization review instrument widely used in the private sector. The medical records for the admission and each day of medical/surgical inpatient stay were reviewed using clinical criteria for the appropriateness of acute inpatient care as opposed to lower levels of care. Opinions expressed in this article are those of the authors and do not reflect the views of the Department of Veterans Affairs, the University of Arkansas for Medical Sciences, Xavier University, or the University of Michigan.     

A day in the life: a case series of acute care palliative medicine--the Cleveland model

Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.     

Comparison of anticoagulation clinic patient outcomes with outcomes from traditional care in a family medicine clinic

BACKGROUND: Giving patients oral anticoagulation therapy in an ambulatory clinic setting is associated with substantial risk of adverse outcomes leading to emergency department visits and unplanned inpatient admissions. This article describes an effectiveness study conducted in a well-characterized family practice setting that compares anticoagulation outcomes in patients managed by a traditional care model with outcomes obtained with an anticoagulation clinic model. METHODS: All study patients received continuous anticoagulation care at the Family Medicine of Southwest Washington (FMSW) clinic during the 1-year study period. The method was retrospective and used linked record review, including outpatient, inpatient, and emergency department records. Patients were divided into two groups as naturally observed: those treated in the clinic by traditional care compared with those treated in an anticoagulation clinic model. Data analyses compared the two groups in terms of patient demographics, anticoagulation control, and inpatient admissions and emergency department visits that were related to clotting or bleeding events. RESULTS: There were no differences in demographic variables between the anticoagulation clinic and traditional care groups. There was a statistically significant difference in anticoagulation control as measured by international normalized ratio (INR) values. The anticoagulation clinic group had fewer INR values outside the target range, +/- 0.1, than the traditional care group (40.4% vs 47.3% P = .022). The anticoagulation clinic group also had significantly fewer INR tests drawn more than 6 weeks apart than the traditional care group (3.7% vs 8.1% P = .01). There was no statistically significant difference in emergency department visit rates caused by adverse events. Inpatient admission rates for the anticoagulation clinic and traditional care groups were not statistically different; however, they were clinically different (4.7 vs 19.7 admissions per 100 patient years of therapy P = .15). CONCLUSIONS: More anticoagulation patients treated by the anticoagulation clinic model at FMSW received an INR test at least every 6 weeks than those treated by the traditional care model, and more of their INR results were within target range +/- 0.1 when compared with the traditional care model.     

An investigation into the use of palliative care services by patients with prostate cancer

The use of palliative services by prostate cancer patients was assessed in relation to other cancer patients and as a proportion of men diagnosed with prostate cancer. Retrospective analysis ofpalliative care referral and inpatient and outpatient activity was undertaken in respect to patients with nine types of cancer. A cohort of men diagnosed with prostate cancer in 1993 was followed for five years. The records of those that died during this period were reviewed to confirm if they had received hospice care. Of the 118 men dying of prostate cancer, 25.4 percent used hospice services, 23 percent used the hospice at home services (for an average of 68.8 days). while 7 percent used day-care services (for an average of 8.25 days). Prostate cancer patients formed the third largest cancer referral group to hospital-based palliative care services (9.5 percent). They had the third longest survival time from referral (3.8 months) and the oldest average age of death of any group. Lower than average inpatient stays, coupled with the highest average length of stay, led to the third highest use of inpatient services by patients with prostate cancer We concluded that the morbidity from prostate cancer leads to a high use of palliative services. This significant use of resources should be included in comparisons assessing and planning health care strategiesfor prostate cancer     

PMH2 Assessment of Health-Related Quality of Life During Treatment of Opiate Dependence using the Short Form-36

In the U.S., acute general hospitals increasingly provide treatment for patients with schizophrenia.
OBJECTIVE: To estimate the average annual cost of inpatient schizophrenia care per patient in an acute general hospital setting.
METHODS: Using ICD9 codes to identify disease and procedure-level data in five state (CA, FL, MA, MD, NC) acute care, all payer, discharge databases, an average cost per admission was estimated and combined with the frequency of admission calculated from the MA database to derive a mean annual acute care inpatient cost. Physician costs were calculated by applying 1997 Medicare fees to a resource use profile derived from the databases and published treatment recommendations. All costs are reported in 1997 US$, appropriately adjusted for medical inflation and cost-to-charge ratios.
RESULTS: Of 7.5 millions discharges, 73,000 were identified as having been admitted primarily due to schizophrenia. The average length of stay was 13.5 days, with 90% of time spent in a designated psychiatric bed. Over 90% were discharged within one month, most (∼80%) to home without documentation of further services. The mean cost per stay (including physician fees) was $8,963. Most (68%) patients had only one admission, and 96% had less than five in one year, leading to annual hospitalization cost per schizophrenic patient of $13,854.
CONCLUSIONS: Of schizophrenic patients admitted to an acute general hospital, the majority are admitted only once per year, spend their stay in a designated psychiatric unit bed, and are discharged within two weeks. Although these patients may have subsequent admissions to another type of inpatient facility, the majority are not transferred to such a facility at the time of discharge.     

Discrete choice experiment produced estimates of acceptable risks of therapeutic options in cancer patients with febrile neutropenia

ObjectiveTo use a discrete choice experiment (DCE) to describe patient/proxy tolerance for the number of clinic visits, and chances of readmission, intensive care unit admission, and mortality to accept oral outpatient management of low-risk febrile neutropenia.Study Design and SettingAdults and children aged 12–18 years with cancer and parents of pediatric cancer patients were asked to choose between outpatient oral and inpatient intravenous management of low-risk febrile neutropenia. Using a DCE, we varied the attribute levels with the outpatient option and kept them constant for the inpatient option.ResultsSeventy-eight adults, 153 parents, and 43 children provided responses. All four attributes significantly affected choices. The mean tolerance (95% confidence interval) for the number of clinic visits per week was 3.6 (2.2–4.8), 2.1 (1.1–3.2), and 4.3 (2.5–6.0) to accept outpatient management among adults, parents, and children, respectively. With thrice weekly clinic visits and 7.5% chance of readmission, probabilities of accepting the outpatient strategy were 50% (44–54%) for adults, 43% (39–48%) for parents, and 53% (46–59%) for children.ConclusionUsing a DCE, we determined that a 7.5% chance of readmission and clinic visits more frequently than thrice weekly are unlikely to be acceptable.     

Home management of childhood febrile illnesses in a rural community in Nigeria

OBJECTIVE: To assess the care given to febrile children under 5 years old at home prior to attending health facility. DESIGN: Cross sectional design. SETTING: Outpatient clinic of a government health facility. SUBJECTS: Two hundred mothers who brought their sick children to the outpatient department were interviewed. RESULTS: The ages of mothers ranged from 15 to 50 years (mean of 26.2 years). Most of them had formal education although below grade 12. Only 12.5% of them were full-time housewives. Others were engaged in self-employed occupations. Fifty-one percent of the children were females. Their ages ranged between 6 months and 5 years with a mean of 2.6 years. Over 60% of the children were suffering from symptoms of acute respiratory infections while 28% had symptoms of malaria. There was no significant difference between mothers' diagnosis and researchers' diagnosis (chi(2) = 0.199, P < 0.05). The duration of children's illnesses spanned from 1 to 60 days (mean of 4.8 days). Only one mother reported at the clinic within 24 h of the onset of the child's illness. Eighty-one percent had taken action before coming to clinic. They had used combinations of drugs namely antipyretics, antimalarials and antibiotics. The average amount spent on drugs was US$0.57. These drugs were purchased at local medicine stores. CONCLUSION: The findings indicate home use of drugs that were not prescribed by health professionals. There is therefore a strong need to give appropriate education and counselling to mothers/care givers and medicine vendors on early detection and proper home management of febrile illnesses.     

Unplanned admissions to inpatient psychiatric treatment and services received prior to admission

BackgroundInpatient bed numbers are continually being reduced but are not being replaced with adequate alternatives in primary health care. There is a considerable risk that eventually all inpatient treatment will be unplanned, because planned or elective treatments are superseded by urgent needs when capacity is reduced.Aims of the studyTo estimate the rate of unplanned admissions to inpatient psychiatric treatment facilities in Norway and analyse the difference between patients with unplanned and planned admissions regarding services received during the three months prior to admission as well as clinical, demographical and socioeconomic characteristics of patients.MethodUnplanned admissions were defined as all urgent and involuntary admissions including unplanned readmissions. National mapping of inpatients was conducted in all inpatient treatment psychiatric wards in Norway on a specific date in 2012. Binary logit regressions were performed to compare patients who had unplanned admissions with patients who had planned admissions (i.e., the analyses were conditioned on admission to inpatient psychiatric treatment).ResultsPatients with high risk of unplanned admission are suffering from severe mental illness, have low functional level indicated by the need for housing services, high risk for suicide attempt and of being violent, low education and born outside Norway.ConclusionSpecialist mental health services should support the local services in their efforts to prevent unplanned admissions by providing counselling, short inpatient stays, outpatient treatment and ambulatory outpatient psychiatry services.Implications for health policiesThis paper suggests the rate of unplanned admissions as a quality indicator and considers the introduction of economic incentives in the income models at both service levels.     

The impact of an outpatient heart failure clinic on hospital costs and admissions

This study of 216 congestive heart failure (CHF) patients at a large teaching hospital in south-central Ontario was undertaken to determine whether the patients managed in an outpatient heart failure clinic used fewer hospital resources (as expressed in number of admissions, complexity of admission, and length of stay (LOS)) than a matched cohort who were not managed in an outpatient clinic. Statistical significance of LOS opportunities could not be demonstrated (owing to sample size), however, the heart failure clinic is making a positive impact on all types of admissions (CHF and non-CHF) in terms of LOS and suggests that management in an outpatient setting for chronic disease states is important for acute care hospitals to consider.     

The epidemiology of diabetic acidosis: a population-based study

A 12-month epidemiologic study in 1979 and 1980 of all diabetic acidosis admissions to all acute care hospitals in Rhode Island detected 152 episodes occurring in 137 persons. Eleven per cent of diabetic acidosis admissions presented in coma and the overall death-to-case ratio was 9%. Newly diagnosed diabetes accounted for 20% of these episodes, while persons having multiple episodes during the year accounted for 15% of the admissions. The annual rate of diabetic acidosis was 46 per 10,000 diabetics. Highest rates of diabetic acidosis were found for the elderly, those admitted from nursing homes and those residing in one geographic area of the state. For known diabetics with an admission for acidosis, 87% were on insulin prior to admission and 81% were nonobese. Patients seldom contacted physicians prior to admission. Insulin dose or frequency was often (40%) changed in the two weeks prior to admission. Most of the known diabetic cases of acidosis had emergency admissions for diabetes in the three-year period prior to admission and few had any structured diabetic outpatient education. Infection and noncompliance were the most frequently identified precipitants of diabetic acidosis occurring in known diabetics.     

Containing mental health treatment costs through program design: a Massachusetts study.

A single site pre-post study of seriously mentally ill patients treated in a public mental health system shows that annual treatment costs can be substantially reduced with the use of day hospital treatment. Two cohorts of psychiatric patients--282 consecutive admissions to a traditional public inpatient unit in 1980, and 340 consecutive admissions to a combination of inpatient and day hospital care in 1984--were followed 12 months after admission. The substitution of the day hospital is made possible because the facility provided a dormitory residence for those who could not go home at night. Cost savings per hospital episode are about 31 per cent when the additional costs of day hospital and residence are considered. Cost shifting from inpatient to residential sites is noted, but overall mean annual costs, when all other treatment (including additional admissions), residential and family costs were included, are reduced. Readmission rates did not rise. The generalizability of the findings is limited to public mental health centers and state hospitals.     

Hydrocodone for cough in advanced cancer

Cough is a common symptom in advanced cancer. Hydrocodone is the antitussive of choice in our palliative medicine inpatient unit. We reviewed the pharmacy records for the use of hydrocodone for all cancer admissions to our unit from May 1996 to December 1998. Median treatment duration with hydrocodone was three days (range 1-18). Median maximum daily dose was 15 mg (range 5-100), and median total dose during the hospital stay was 32 mg (range 5-455). Lung cancer as a primary cancer site was strongly related to the use of hydrocodone. The highest median duration of treatment (five days) was for esophageal cancer and the highest median maximum daily dose (35 mg) and total dose (75 mg) were for treating kidney cancer. This retrospective review provides information regarding the use of hydrocodone on the palliative medicine unit of the Cleveland Clinic Foundation. Controlled trials are needed to evaluate the efficacy and safety of hydrocodone for cough in advanced cancer.     

The business of palliative medicine--part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center

In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.     

The Japan HOspice and Palliative Care Evaluation study (J-HOPE study): study design and characteristics of participating institutions

This article describes the study design and background data of participating institutions in the Japan HOspice and Palliative care Evaluation (J-HOPE) study. The J-HOPE study is a large nationwide survey about the dying experience of cancer patients. The primary aim of this article is to describe the design of the J-HOPE study for the bereaved family members of Japanese inpatient palliative care units and home hospices. Secondly, the aim was to describe characteristics of participating institutions. The authors conducted a cross-sectional questionnaire survey in 2007. One hundred Japanese inpatient palliative care units and 14 home hospices participated. The questionnaires were sent to 7955 bereaved family members of the Japanese inpatient palliative care units and 447 of the home hospices. The authors describe the structure of the Japanese inpatient palliative care units and home hospices, including type of staff, architectural structure, number of patients, and death. In addition, the authors describe available treatments at the Japanese inpatient palliative care units and home hospices.     

A feasibility study of home telemedicine for patients with cystic fibrosis awaiting transplantation

Sixteen patients with cystic fibrosis were randomized to either telemedicine or standard care alone. All patients were terminally ill. Patients in the telemedicine group had an ISDN line installed in their home and were given a videoconferencing unit connected to their home television set. Eleven subjects completed the baseline assessment and seven patients completed the study (4 on telemedicine and 3 in the control arm). Telemedicine patients had weekly videoconferences from home for a clinical assessment, psychological support and the opportunity for discussion with any member of the multidisciplinary team. A total of 71 home videoconferences were conducted during the study. Anxiety levels were measured before and after the conferences. After six months there were no significant differences in quality of life, anxiety levels, depression levels, admissions to hospital or clinic attendances, general practitioner calls or intravenous antibiotic use between the two groups. However, there was a significant improvement in perception of body image for those in the telemedicine group and the patients liked and valued the service. The use of telemedicine can enhance the support that a specialist unit can provide for the patient and their family, and may reduce outpatient clinic attendances.     

Evaluation of access,a primary care program for indigent patients: inpatient and emergency room utilization

We analyzed the impact of a program that provides indigent patients with free primary care on inpatient admissions, emergency room (ER) visits, and resulting charges in 91 patients before and after admittance into the program.There was a decrease in ER visits after enrolling in the program (1.89 versus 0.83 visits per year; p < 0.0001). This difference translated into mean ER charges of $1174 vs. $717 (p = 0.0007), and a decrease in charges of $41,587 per year. The charges for the program (outpatient visits and laboratory) were $23,141. Entry into the program had no effect on inpatient admissions, which averaged 0.07 admissions per year both before and after admission to the program.Indigent patients enrolled in a complimentary primary care program had significantly decreased per-year ER utilization rates and charges. The program had no effect on inpatient admissions. By conservative estimate, the program decreased ER charges by approximately $18,000 per year secondary to decreased ER utilization.