Wednesday, March 17, 2010

Palliative Care in Cancer Centers - Horses of many different colors

The third Palliative Care related article released for St. Patrick's (Palladius) day is a article that speaks to what many of us in the field know already:

Palliative Care is a chameleon: it looks different depending on the background of the institution.

But as the editor-in-chief of the Lancet has said: "It is not true, until it is published." Well JAMA has published a little bit of truth with the article: "Availability and Integration of Palliative Care at US Cancer Centers."  We have already known from CAPC data about a variability in access among states. This data helps underscore the variability in palliative care services, staffing, education and research at major cancer centers in the US.
I won't belabor the data here as it is relayed well in the abstract. But a few things impressed me about the study. It made a strong effort to differentiate between the simple question of 'Do you have a palliative care program?' which in a few institutions I have seen consists of a well stocked brochure rack and a single staff member (usually a nurse) who has 20 other job responsibilities that are prioritized by the administration above palliative care. Instead the authors focused on the structure, process and outcomes (also known as a Donabedian tripartite division, but of course you already knew that.)

Also a question to cancer center executive about barriers to palliative care seemed to be somewhat contradictory to other findings. Thee highest rated barriers (around 50-60%) were:
  • limited institutional budgets
  • poor reimbursement
  • limited trained palliative care staff
despite 89% of cancer centers surveyed claiming to have palliative care programs. And conversely very few center executives (less than 10%) reported the following as barriers:
  • limited palliative care needs
  • lack of evidence for palliative care
  • palliative care may increase mortality
  • palliative care may affect national rating
  • palliative care available but not utilized

So if I understand this right, 89% of cancer center executives have palliative care programs with staff who get paid from the budget but the around 60% feel the biggest barrier to getting palliative care access is that there is no budget/reimbursement or staff?

Couldn't be the culture of cure (see the media study), or the fact they are a tertiary referral center focused on the 'save'? Or the drive to get more patients enrolled in experimental drug trials which is a major source of funding/prestige? Or that palliative care may still not be well integrated into the culture?

I'm merely speculating here, but I think there is a juicy qualitative/anthropological study in this data.

One last thing...only 57% of NCI Cancer Centers had board certified palliative medicine physicians. And the data was collected in 2009. Come on people get board certified in hospice and pallaitive medicine this fall.

(Image from

ResearchBlogging.orgDavid Hui, MD, MSc, Ahmed Elsayem, MD, Maxine De La Cruz, MD, Ann Berger, MD, Donna S. Zhukovsky, MD, Shana Palla, MS, Avery Evans, Nada Fadul, MD J. Lynn Palmer, PhD; Eduardo Bruera, MD (2010). Availability and Integration of Palliative Care at US Cancer Centers JAMA, 303 (11), 1054-1061

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