Making the case for outpatient palliative care for cancer patients at a safety-net hospital.

Abstract

310 Background: Prior research has shown that patients who receive earlier, outpatient palliative care (OP PC) have improved end-of-life care compared to patients who receive only inpatient palliative care (IP PC). We examined the need, expected impact and feasibility of providing OP PC to patients with cancer seen at our hospital, which offers IP PC but not OP PC. Methods: Retrospective cohort study of patients cared for at our urban, safety-net hospital who died of cancer between July 2010 and June 2013. We used cancer registry data to identify decedents and claims data to evaluate utilization patterns, contacts with our IP PC service, and cost of care in the final 6 months of life. Results: In the analysis period 403 patients died of cancer, 307 of whom were admitted to the hospital in the 6 months preceding death. On average patients were admitted 1.9 times, with 39% having multiple admissions. Average length of stay was 10.47 days. Nearly half of all patients were admitted to the hospital in the final month of life (181/403), and 21% of those (38/181) had multiple admissions. One third of patients died in the hospital and another 4% died within 3 days of hospital discharge. Direct costs per admission averaged $22,275. The IP PC service had contact with 178 patients; 44% of the entire decedent population and 58% of those who were hospitalized. In 60% of cases the initial contact with the PC team took place in the final month of life. We determined that 33% of patients had multiple inpatient and or outpatient encounters 90-180 days prior to death, pointing to an expected annual clinic volume of about 50 patients. Annual costs for staffing a clinic that could follow 50 patients for an average of 4 months were estimated at $88,290. We assumed that providing OP PC would reduce utilization of inpatient services by 40% (38 avoided admissions), with resulting avoided direct costs of $846,450. Conclusions: At our facility cancer patients often receive aggressive EOL care. Our IP PC team sees many of these patients, but most contacts occur days-weeks prior to death. Though many patients present very late in the course of illness, a substantial number have multiple health system contacts >3 months prior to death, and could be referred to an OP PC clinic.