Sunday, June 12, 2011
Last year, about this time, the New England Journal of Medicine (NEJM) rocked the world of Oncologists and Palliative Care Specialists, publishing an article about how early palliative care interventions not only add to quality of life, but also length of life. This year, NEJM published an equally provocative piece, a "Sounding Board" article that addresses the need to curve the cost of cancer care. Get ready Palliative Care colleagues to respond once again.
Thomas Smith and Bruce Hillner propose some changes to the current model of care:
Changing the Behavior of Oncologists:
- Shift surveillance testing from routine to evidence-driven (and symptom driven);
- Limit second and third line chemotherapies for metastatic solid-tumor disease to sequential monotherapies;
- Consider chemotherapy only for patients with high performance status (a-la-ECOG approach) - of course, with exceptions for patients with untreated, highly chemo-sensative disease, or with poor performance due to unrelated issues.
- Decrease use of white-cell-stimulating factors, and instead lower dose of chemotherapy in metastatic solid tumor treatments;
- When chemotherapy success is unlikely, symptom directed care (i.e. Palliative Care) should be provided. In other words, when cancer progresses despite three consecutive chemotherapy regimens, except for patients wishing to enroll in clinical trials, therapeutic intervention should shift to symptom-directed, non-chemotherapy care (aka Palliative Care Team).
- Acknowledge that these practice changes are needed, that we may be at risk of having the cost may drive out the ability to care;
- Have end-of-life discussions earlier - even though they are hard. Data now shows that while these discussions lead to a decrease the patients' severity of depression and anxiety, fewer ventilator-dependent deaths, and decreased aggressiveness of care, they also improves the health and well-being of surviving caregivers. Go figure, these conversations have a role in preventing illness and promoting health (in survivors). Despite this, in a recent study, few patients admitted to hospital with a cancer diagnosis had a discussion about advanced care planning or how they wished to be cared for at the end of life. Less than half of patients had discussed hospice with their physicians two months prior to their death.
- Expectations of outcomes need to be more realistic for patient and physician alike. We have known the data of how physicians as a whole are overly optimistic when it comes to prognostication. Well, because information is obtained from their physicians, patients tend to be as well. This influences decision-making and has implications for the quality of informed consent. After all, if I were to believe that an intervention had a chance of curing me, when in fact it may simply add some weeks or perhaps months, would my decision to forgo time with family and friends for hospitalizations and the hope for a cure change? The article suggests that many oncologists lack the skills of assessing prognosis and negotiating transitions of care from curative chemotherapy to palliative non-chemotherapy. Palliative care clinicians may be taking an increased role in facilitating these conversations and training the next generation of oncologists in these conversations.
- Compensation for cognitive services needs to be valued more, as compared with chemotherapy. Our current system now relies on over 50% of oncology compensation supported by chemotherapy sales. The current system does not adequately reimburse oncologists for some of their most important work: referrals to clinical trials, counseling about advanced-care-planning and code status, and other patient-centered and patient/family-valued work that is time-consuming. Innovations in healthcare delivery models to shift this paradigm may help sustain the workforce and improve patient care.
- Earlier and more thorough integration of palliative care into the overall cancer care is needed. As the author's so aptly put it, "Improved coordination of care that lets patients choose their course while not requiring an artificial switch from usual care to hospice will be a triple win: better quality and quantity of life plus meaningful cost savings."
- The need for cost-effectiveness studies as new drugs are rolled out.
From my perspective, these suggestions may help define practice guidelines for when and how to integrate palliative care, perhaps with automated referrals or integration of assessment into multi-disciplinary clinics for patients with metastatic solid tumors. I agree with the authors' statement that more fluid and early integration with eliminate the either-or mentality, the fear of abandonment, and eliminate the notion of "death panels." Instead, the often tainted name of our specialty may take on a new meaning, one of coordinated, concomitant care, that assures shared decision-making and good symptom management.
I for one, hope that this important essay influences the role that palliative care should take in the future of quality care, ACOs, and the healthcare debate.
Smith TJ, & Hillner BE (2011). Bending the cost curve in cancer care. The New England Journal of Medicine, 364 (21), 2060-5 PMID: 21612477