Hospital Palliative Care Programs Raise Grade to B in New Report Card on Access

A recent survey that graded the 50 states on access to palliative care bumped the United States up a grade, to a B from a C in 2008. Despite the rapid growth of hospital-based palliative care programs, the survey nonetheless reports ongoing barriers to access: too few trained professionals, knowledge gaps in symptom relief, and the need for new reimbursement models.

The 2011 survey, carried out by the Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC) at the Mount Sinai School of Medicine, both in New York City, examined data taken primarily from the American Hospital Association Annual Survey Database for 2009. Of the 2489 hospitals with 50 or more beds surveyed, 63% had palliative care programs. Of hospitals with more than 300 beds, 85% had palliative care teams (http://www.capc.org/reportcard/).

Seven states and the District of Columbia received an A grade, meaning that more than 80% of hospitals surveyed in those states reported having palliative care programs. Twenty-five states received B grades, indicating that 61% to 80% of hospitals had such programs. C's went to 12 states where 42% to 60% of hospitals had programs; 4 states received D’s, with programs in 28% to 38% of hospitals; and F's went to Delaware and Mississippi, each with 20% of hospitals surveyed having programs.

States that made substantial gains since 2008 included Nevada, where the percentage increased from 23% to 69%; Mississippi, up from 10% to 20%; and Alabama, up from 16% to 28%.

Hospitals with 300 or more beds were the most likely to have palliative care programs, while for-profit, public, and sole community provider hospitals were the least likely. Access to palliative care also varied widely among various regions of the country. For example, 73% of hospitals with 50 or more beds in the Northeast reported having programs, compared with 51% in the South.

Lead author R. Sean Morrison, MD, director of the NPCRC, said that just as every hospital has an emergency department and intensive care units or beds, so should they have palliative care services for adults and children with serious illnesses.

“I think that by 2020, we will be at a point where 100% of our 300-plus-bed hospitals will have a palliative care team, and [more than] 80% of our smaller hospitals will have a palliative care [program],” said Morrison.

He said data show that palliative care can cut hospital costs and improve the quality of care. In a study of Medicaid patients in 4 New York hospitals, Morrison and his colleagues showed that patients who received palliative care incurred $6900 less in a given admission than those who received usual care (Morrison RS et al. Health Aff [Millwood]. 2011;30[3]:454-463). If every New York hospital with 150 or more beds had properly trained teams that provided palliative services within routine patient care, the study estimated statewide Medicaid savings between $84 million and $252 million annually within 5 years.

A study of 151 patients with metastatic non–small cell lung cancer, which usually has a prognosis of less than 1 year, showed that those who received palliative care had less depression and better scores on a quality-of-life scale than those who received usual care. Patients who were given palliative care early in their illness received less aggressive end-of-life care, but their median survival was 2.7 months longer than patients receiving usual care (Temel JS et al. N Engl J Med. 2010;363[8]:733-742).

According to the CAPC, an estimated 90 million Americans have serious or life-threatening illnesses. That number is expected to double in 25 years as baby boomers age. About 6 million people in the United States currently could benefit from receiving palliative care.

Since 2000, the prevalence of palliative care teams in US hospitals with at least 50 beds has increased by 138%, according to the survey. That growth is among the factors that prompted the Joint Commission, which accredits about 4500 US hospitals, to launch a new certification program in palliative care. Accredited inpatient acute care hospitals offering complete, around-the-clock palliative care services are eligible for certification. The program, which has been available since September 1, does not require a dedicated unit or beds.

“The field of palliative care has been changing,” said Mark Chassin, MD, MPH, president of the Joint Commission. “It has been moving away from its initial association with the care of the dying to a much broader effort to help patients with a variety of serious illnesses.”

Chassin said the new certification program has attracted a lot of attention. “Dozens of organizations have told us they’ve been waiting for this to be launched.”

Despite the field's rapid growth, Morrison said that a lack of Medicare-funded fellowship training programs in leading medical centers can hinder hospitals seeking to establish palliative care teams—which may include physicians, specially trained nurse practitioners, social workers, and hospital chaplains.

“In my medical center, we have 5 palliative medicine fellows, and all 5 are supported through philanthropy,” said Morrison. “There needs to be a congressional act to readjust the cap on fellowship training, particularly for this specialty. It needs to be addressed now, but it's not on the radar screen for Congress.”

Confusion between palliative care and hospice care is another obstacle. “When we did a focus group with physicians, they not only said, ‘Oh, I know what it is,’ but they defined it as end-of-life care. That's a big barrier to us because the patients who need palliative care are not dying. That's what hospice is about,” Morrison said.

Chassin agreed. “Among general practice and internal medicine physcicians there is confusion, and among the general public there is confusion,” he said, noting that the Joint Commission has a separate accreditation program for hospice organizations.

The shortage of training opportunities and misconceptions about the specialty translate into a lack of practicing palliative medicine physicians. The survey reports that 2887 US physicians are board-certified in palliative medicine. This means that 1 palliative medicine physician is available for every 1200 patients with serious or life-threatening illnesses, compared with ratios of 1 cardiologist for every 71 patients with myocardial infarction and 1 oncologist for every 141 patients newly diagnosed as having cancer. All physicians who care for seriously ill patients should be trained in the core principles of palliative medicine to ensure good communication with patients and family members and proper pain treatment, according to the survey.

Some midcareer physicians are pursuing additional training to enter the field. Among them is David Giansiracusa, MD, who for 23 years was on the rheumatology faculty at the University of Massachusetts in Worcester. After caring for dying patients and losing his wife to ovarian cancer, Giansiracusa said he felt rheumatology, from a clinical perspective, had become “a bit limiting.”

Giansiracusa completed a palliative care fellowship at Massachusetts General Hospital, Boston, in 2004 and took a position in the palliative care unit at the Dana-Farber Cancer Institute, also in Boston. In 2007, he moved on to work in palliative medicine at the Maine Medical Center in Portland. He now is the part-time medical director for clinical integration at Maine Health, a not-for-profit integrated health care system based in Portland.

In palliative medicine, he said, “the care [is] much more holistic, and attention is directed not only to the medical aspects of evaluation and care, but also to the emotional, psychological, and spiritual aspects.”

One of the continuing goals for educational programs in palliative care, he said, is teaching medical students and physicians to have more “balanced” dialogues with patients and their families. That means asking about worries and fears.

“It's not only about what is available in medical care,” he said. “Clinicians often find it easier to recommend a more aggressive form of therapy than to have a serious conversation about what's happening.”