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.
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
- 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 Funnycancershirts.com)
David 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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5 Responses to “Palliative Care in Cancer Centers - Horses of many different colors”
March 18, 2010
Hi
I am still learning to navigate this blog so you may have posted this elsewhere. Just read Tuesday's Jane Brody article in the NYT SCIENCE TIMES about her husband's death. It is a beautiful and poignant story and one that supports all she has been writing about end of life and palliative issues for several years. She has been one of the greatest proponents of palliative care in the media.
Laurie Lyckholm
March 19, 2010
I just finished reading the JAMA article, and though it was informative, and I'm sure they did the best job anybody could do with a survey, I wasn't sure what to take from it. I wasn't too pleased with their definition of a palliative care service as having at least 1 physician "with dedicated time to the provision of palliative care (with or without board certification)" especially at this time when palliative care specialization is moving toward fellowship-trained, and board certified physicians. When people can't even agree with what palliative care is, what is "the provision of palliative care" supposed to mean?
I guess I was hoping to see a sort of Flexner Report for palliative care, something that showed not all palliative care is the same across institutions, to highlight the need for standardization, in terms of structure, process, outcome, etc. This I'm sure will come one day in the form of Joint Commission standards for palliative care. It would also be interesting to see the variation at non-cancer centers, which I realize is beyond the scope of this study.
March 26, 2010
As I reviewed this article, some points struck me.
1. Executives of National Cancer Institute (NCI) cancer centers were more likely to indicate limited institutional budget (not statistically significant) and poor reimbursement (p=.01) as the biggest barriers to palliative care access. Non-NCI cancer centers more often cited limited trained palliative care staff (p=0.3). Only about 20% of the executives of both types of centers reported “palliative care available but not used” as a barrier. These were the perceptions of the executives of the centers, though—I wonder whether providers would agree with this? In my experience,” palliative care available but not used” has been the largest barrier to early integration into cancer centers. As Christian points out, could this be a factor of our “fighting disease” and only invoking palliative care as a last resort?
2. Executives for both types of centers believe that program effectiveness for pain management and palliative care services have improved over the past five years in their programs (p<.001), but there were no measures of program effectiveness actually included in this particular study to validate those perceptions.
3. NCI cancer centers report more plans to increase palliative care physicians (p=.005), physician assistants (p=0.3), and staff nurses (p=0.4) over the next five years when compared with non-NCI centers. Both types of centers reported pain consultation as the primary service provided. NCI centers tended more often to assess and manage psychiatric disorders, obtain advance directives/DNR orders, deal with ethical issues, make referrals to hospice or other agencies, develop a comprehensive care plan, provide psychosocial support, and provide other symptom management (although there was not a statistical significance between the groups on those items).
92% of the NCI centers report having a palliative care physician present vs. 74% of non-NCI centers (p=.04). 50% of the NCI centers had a palliative care leader with professional background in palliative medicine vs. 6% in the non-NCI centers (p-.001) The median of full-time equivalent positions for palliative care physicians was 1 for both types of programs, but virtually none of the physicians had >20% protected time for palliative care. How much time do medical oncologists have during a routine office visit for all the above aspects of palliative care if they must also examine a patient, review labs/x-rays, and prescribe additional therapies during the same visit? (cont.)
March 26, 2010
(cont.)4. NCI centers had dedicated palliative care outpatient clinics in 54% of centers, compared with 20% in non-NCI centers (p=.001). The median number of days from referral to death for outpatients in non-NCI centers was 41 (28-54) and increased to 90 days (84-120) at NCI centers. While this is certainly an improvement over the typical median length of stay in hospice programs, it still falls short of what I believe is the goal to truly integrate palliative care into an earlier phase of cancer treatment. Again, does this point to a cultural tendency to work toward “save” rather than prioritizing palliative care as a routine part of cancer treatment?
In the best case scenario, palliative care would be as integral to cancer treatment visits as lab assessment or x-rays. I believe this fits with the goal of the American Society of Clinical Oncology for full integration of palliative care into cancer treatment by 2020.
What if all patients automatically received a palliative care consultation at diagnosis and then had a follow-up visit with the palliative care team at subsequent appointments to the cancer center (just like having vital signs taken or labs drawn)? If palliative care were prescribed as one of the first interventions for any patient diagnosed with cancer, what might that look like? Would we see effects on improved satisfaction with care and symptom control measures? Would there be an increase in time of referral to death for those patients who eventually die from the disease?
Of course, to meet such goals there will need to be more providers trained specifically re: palliative medicine (even if not all providers will practice primarily in the field). Palliative care modules in oncology training should be considered an integral part of training if palliative care is to become an integral part of comprehensive cancer treatment.
March 27, 2011
(cont.)4. NCI centers had dedicated palliative care outpatient clinics in 54% of centers, compared with 20% in non-NCI centers (p=.001). The median number of days from referral to death for outpatients in non-NCI centers was 41 (28-54) and increased to 90 days (84-120) at NCI centers. While this is certainly an improvement over the typical median length of stay in hospice programs, it still falls short of what I believe is the goal to truly integrate palliative care into an earlier phase of cancer treatment. Again, does this point to a cultural tendency to work toward “save” rather than prioritizing palliative care as a routine part of cancer treatment?
In the best case scenario, palliative care would be as integral to cancer treatment visits as lab assessment or x-rays. I believe this fits with the goal of the American Society of Clinical Oncology for full integration of palliative care into cancer treatment by 2020.
What if all patients automatically received a palliative care consultation at diagnosis and then had a follow-up visit with the palliative care team at subsequent appointments to the cancer center (just like having vital signs taken or labs drawn)? If palliative care were prescribed as one of the first interventions for any patient diagnosed with cancer, what might that look like? Would we see effects on improved satisfaction with care and symptom control measures? Would there be an increase in time of referral to death for those patients who eventually die from the disease?
Of course, to meet such goals there will need to be more providers trained specifically re: palliative medicine (even if not all providers will practice primarily in the field). Palliative care modules in oncology training should be considered an integral part of training if palliative care is to become an integral part of comprehensive cancer treatment.
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