Cost savings associated with US hospital palliative care consultation programs

BACKGROUND

Hospital palliative care consultation teams have been shown to improve care for adults with serious illness. This study examined the effect of palliative care teams on hospital costs.

METHODS

We analyzed administrative data from 8 hospitals with established palliative care programs for the years 2002 through 2004. Patients receiving palliative care were matched by propensity score to patients receiving usual care. Generalized linear models were estimated for costs per admission and per hospital day.

RESULTS

Of the 2966 palliative care patients who were discharged alive, 2630 palliative care patients (89%) were matched to 18,427 usual care patients, and of the 2388 palliative care patients who died, 2278 (95%) were matched to 2124 usual care patients. The palliative care patients who were discharged alive had an adjusted net savings of $1696 in direct costs per admission (P = .004) and $279 in direct costs per day (P < .001) including significant reductions in laboratory and intensive care unit costs compared with usual care patients. The palliative care patients who died had an adjusted net savings of $4908 in direct costs per admission (P = .003) and $374 in direct costs per day (P < .001) including significant reductions in pharmacy, laboratory, and intensive care unit costs compared with usual care patients. Two confirmatory analyses were performed. Including mean costs per day before palliative care and before a comparable reference day for usual care patients in the propensity score models resulted in similar results. Estimating costs for palliative care patients assuming that they did not receive palliative care resulted in projected costs that were not significantly different from usual care costs.

CONCLUSION

Hospital palliative care consultation teams are associated with significant hospital cost savings.

Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect

PURPOSE

Previous studies report that early palliative care is associated with clinical benefits, but there is limited evidence on economic impact. This article addresses the research question: Does timing of palliative care have an impact on its effect on cost?

PATIENTS AND METHODS

Using a prospective, observational design, clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011. The sample for economic evaluation was 969 patients; 256 were seen by a palliative care consultation team, and 713 received usual care only. Subsamples were created according to time to consult after admission. Propensity score weights were calculated, matching the treatment and comparison arms specific to each subsample on observed confounders. Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within subsamples.

RESULTS

Earlier consultation is associated with a larger effect on total direct cost. Intervention within 6 days is estimated to reduce costs by -$1,312 (95% CI, -$2,568 to -$56; P = .04) compared with no intervention and intervention within 2 days by -$2,280 (95% CI, -$3,438 to -$1,122; P < .001); these reductions are equivalent to a 14% and a 24% reduction, respectively, in cost of hospital stay.

CONCLUSION

Earlier palliative care consultation during hospital admission is associated with lower cost of hospital stay for patients admitted with an advanced cancer diagnosis. These findings are consistent with a growing body of research on quality and survival suggesting that early palliative care should be more widely implemented.

Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis

IMPORTANCE

Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations.

OBJECTIVE

To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness.

DATA SOURCES

Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017.

STUDY SELECTION

Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders.

DATA EXTRACTION AND SYNTHESIS

Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis.

MAIN OUTCOMES AND MEASURES

Total direct hospital costs.

RESULTS

This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer.

CONCLUSIONS AND RELEVANCE

The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.

Moving upstream: a review of the evidence of the impact of outpatient palliative care

BACKGROUND

There is good evidence for the efficacy of inpatient palliative care in improving clinical care, patient and provider satisfaction, quality of life, and health care utilization. However, the evidence for the efficacy of nonhospice outpatient palliative care is less well known and has not been comprehensively reviewed.

OBJECTIVE

To review and assess the evidence of the impact of outpatient palliative care.

METHODS

Our study was a review of published, peer-reviewed outcomes research, including both observational studies and controlled trials of nonhospice outpatient palliative care services. We assessed patient, family caregiver, and clinician satisfaction; clinical outcomes including symptom management, quality of life, and mortality; and heath care utilization outcomes including readmission rates, hospice use, and cost.

RESULTS

Four well-designed randomized interventions as well as a growing body of nonrandomized studies indicate that outpatient palliative care services can: 1) improve patient satisfaction, 2) improve symptom control and quality of life, 3) reduce health care utilization, and 4) lengthen survival in a population of lung cancer patients.

CONCLUSIONS

The available evidence supports the ongoing expansion of innovative outpatient palliative care service models throughout the care continuum to all patients with serious illness.

Cost and non-clinical outcomes of palliative care

Although palliative care is rarely profitable by itself, palliative care in hospitals is associated with significant reductions in per diem costs and total costs, and can generate substantial savings to the health system by "cost avoidance." Palliative care alongside usual care in recent randomized outpatient trials has maintained or improved the quality of care while generating substantial cost savings. The data are mixed about the impact of palliative care consultation on inpatient length of stay and are related to local patterns of care, consultation, and assumption of control of the course of care. In collecting and presenting the data to administrators and others, we have found that the simplest approach is the most effective-for example, presenting a few clinical outcomes alongside cost-saving data.

Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities

Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.

Effect of a Home-Based Palliative Care Program on Healthcare Use and Costs

Objectives

To evaluate the nonclinical outcomes of a proactive palliative care program funded and operated by a health system for Medicare Advantage plan beneficiaries.

Design

Observational, retrospective study using propensity‐based matching.

Setting

A health system in southern California.

Participants

Individuals who received the intervention between 2007 and 2014 (n = 368) were matched with 1,075 comparison individuals within each of four disease groups: cancer, chronic obstructive pulmonary disease, heart failure, and dementia. All were known to be dead at the time of the retrospective study, were Medicare Advantage beneficiaries, and had 2 years of usage data before death. Median age at death for each disease group was older than 80.

Intervention

Home‐ and clinic‐based palliative care (PC) services provided by a multidisciplinary team.

Measurements

Outcomes included hospital costs, other healthcare costs, readmission rates, hospital admissions and bed days, intensive care unit use in final 30 days of life, and death within 30 days of an admission.

Results

Intervention participants in all four disease groups had less hospital use and lower hospital costs nonintervention participants, which drove lower overall healthcare costs. In the final 6 months of life, healthcare costs for the intervention groups stayed largely the same from month to month, whereas costs for comparison participants increased dramatically.

Conclusion

In the context of an alternative payment model in which the provider was “at risk” of bearing the costs of care, a proactive PC program helped to avoid the escalation in hospital use and costs commonly seen in the final months of life.

Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: Where do cost-savings come from?

BACKGROUND

Studies report cost-savings from hospital-based palliative care consultation teams compared to usual care only, but drivers of observed differences are unclear.

AIM

To analyse cost-differences associated with palliative care consultation teams using two research questions: (Q1) What is the association between early palliative care consultation team intervention, and intensity of services and length of stay, compared to usual care only? (Q2) What is the association between early palliative care consultation team intervention and day-to-day hospital costs, compared to a later intervention?

DESIGN

Prospective multi-site cohort study (2007-2011). Patients who received a consultation were placed in the intervention group, those who did not in the comparison group. Intervention group was stratified by timing, and groups were matched using propensity scores.

SETTING/PARTICIPANTS

Adults admitted to three US hospitals with advanced cancer. Principle analytic sample contains 863 patients ( n_UC = 637; n_{PC EARLY} = 177; n_{PC LATE} = 49) discharged alive.

RESULTS

Cost-savings from early palliative care accrue due to both reduced length of stay and reduced intensity of treatment, with an estimated 63% of savings associated with shorter length of stay. A reduction in day-to-day costs is observable in the days immediately following initial consult but does not persist indefinitely. A comparison of early and late palliative care consultation team cost-effects shows negligible difference once the intervention is administered.

CONCLUSION

Reduced length of stay is the biggest driver of cost-saving from early consultation for patients with advanced cancer. Patient- and family-centred discussions on goals of care and transition planning initiated by palliative care consultation teams may be at least as important in driving cost-savings as the reduction of unnecessary tests and pharmaceuticals identified by previous studies.

Palliative Care Benchmarks from Academic Medical Centers

INTRODUCTION

Palliative care is growing in the United States but little is known about the quality of care delivered.

OBJECTIVE

To benchmark the quality of palliative care in academic hospitals.

DESIGN

Multicenter, cross-sectional, retrospective chart review conducted between October 1, 2002 and September 30, 2003.

SETTING

Thirty-five University HealthSystem Consortium (UHC) academic hospitals across the United States.

PARTICIPANTS

A total of 1596 patient records.

INCLUSION CRITERIA

(1) adults, (2) high-mortality diagnoses: selected cancers, heart failure, human immunodeficiency virus (HIV), and respiratory conditions requiring ventilator support, (3) length of stay (LOS) more than 4 days, and (4) two prior admissions in the preceding 12 months.

MAIN OUTCOME MEASURES

Compliance with 11 key performance measures (KPM) derived from practice standards, literature evidence, and input from a multidisciplinary expert committee. Analyses examined relationships between provision of the KPM and specific outcomes.

RESULTS

Wide variability exists among academic hospitals in the provision of the KPM (0%-100%). The greater the compliance with KPM, the greater the improvement in quality outcomes, cost and LOS. Assessment of pain (96.1%) and dyspnea (90.2%) was high, but reduction of these symptoms was lower (73.3% and 77.2%). Documentation of prognosis (33.4%), psychosocial assessment (26.2%), communication with family/patient (46%), and timely planning for discharge disposition (53.4%) were low for this severely ill population (16.8% hospital mortality). Only 12.9% received a palliative care consultation.

CONCLUSIONS

The study reveals significant opportunities for improvement in the effective delivery of palliative care. Care that met KPM was associated with improved quality, reduced costs and LOS. Institutions that benchmarked above 90% did so by integrating KPM into daily care processes and utilizing systematized triggers, forms and default pathways. The presence of a formalized palliative care program within a hospital system had a positive effect on the achievement of KPM, whether or not formal consultation occurred. Hospitals need to develop systematic methods to improve access to palliative care.

Funding models in palliative care: Lessons from international experience

BACKGROUND

Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them.

AIM

To assess national models and methods for financing and reimbursing palliative care.

DESIGN

Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms.

RESULTS

Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs.

CONCLUSION

Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.

The Business Case for Palliative Care: Translating Research Into Program Development in the U.S

Specialist palliative care (PC) often embraces a "less is more" philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC.

Palliative care consultation and hospital length of stay

It has frequently been claimed that palliative care (PC) consultation services reduce hospital length of stay (LOS). We review 12 published studies comparing patients receiving PC or similar intervention and patients receiving usual care with regard to average total hospital LOS. None of the six observational studies showed LOS impact. Three of the four quasi-experiments and one of the two randomized controlled trials reported LOS reduction for at least one subsample. Reduced LOS was demonstrated only for decedents in intensive care unit-based interventions using experimental or quasi-experimental research designs. PC program leaders are cautioned against promising that their inpatient consultations will reduce the length of those admissions because this may be nearly impossible for a typical hospital-based PC program to demonstrate using observational data. Research to date has been handicapped by designs and methods not suitable for detecting an impact on LOS. Only three studies included survivors and decedents and disaggregated them in analysis and interpretation, despite profound differences in the meaning and implications of reduced LOS for survivors and decedents. Recommendations for future studies include conceptualizing, analyzing, and reporting outcomes separately for survivors and decedents; strengthening study design to reduce the likelihood of failing to detect actual LOS impact; using methods that allow for creation of a reasonable comparison group; and addressing the fundamental problem that LOS is both a predictor and criterion variable in observational studies of palliative care consultation services.

Making the Case for Palliative Care at the System Level: Outcomes Data

BACKGROUND

A recent trend in health care is to integrate palliative care (PC) programs across multiple hospitals to reduce variation, improve quality, and reduce cost.

OBJECTIVE

The study objective was to demonstrate the benefits of PC for a system.

METHODS

The study was a descriptive study using retrospective medical records in seven federated hospitals where PC developed differently before system integration. Measured were length of stay (LOS), mortality, readmissions, saved intensive care unit (ICU) days, cost avoidance, and hospice referrals.

RESULTS

PC services within the first 48 hours of admission demonstrate a shorter LOS (5.08 days), reduced costs 40% ($2,362 per day), and decreased mortality (1.01 versus 1.10) for one hospital. Readmissions at 30, 60, and 90 days after a PC consult decreased (61.5%, 47.0%, and 42.1%, respectively). Annual pre- and postprogram referrals to hospice increased (65 to 107). Using modified matched pairs, LOS of PC patients seen within 48 hours of admission average 1.67 days less compared to non-PC patients. LOS for ICU patients with PC services in the ICU within the first 48 hours decreased by 1.12 days. Overall cost avoidance was 1.5 times total cost for PC programs systemwide. One pilot project using a full-time physician in the ICU reduced cost more than $600,000, with 315 saved ICU days, annualized. Systemwide, 69.3% of all referrals to hospice were made by the PC service.

CONCLUSION

Early involvement of PC services emerged as advantageous to the net benefit. Given that health care's changing landscape will increasingly include bundled payment and risk holding strategies to improve quality and reduce cost in health care systems, systemwide PC will play a vital role.

Practical guidelines for developing new palliative care services: resource management

The data are relatively clear cut that palliative care improves quality of life and symptom control, improves quality of care by reducing aggressive but unsuccessful end of life care, and reduces costs. That should be an easy message to deliver to the public, health care administrators, payers, and governments. In fact, the arguments to develop palliative care services must be clear and concise, and make the clinical and financial case for the services that the palliative care team wants to deliver. Here, we discuss some of the types of models including consult services, outpatient programs, and inpatient units; the important components; some easy to use screening tools; components of the consultation team; a model medical record that increases "prompts" to do best palliative care; and data to report to supervisors.

Hospital mortality rates: how is palliative care taken into account?

CONTEXT

Using mortality rates to measure hospital quality presumes that hospital deaths are medical failures. To be a fair measure of hospital quality, hospital mortality measures must take patient-level factors, such as goals of care, into account.

OBJECTIVES

To answer questions about how hospital mortality rates are computed and how the involvement of hospice or palliative care (PC) are recognized and handled.

METHODS

We analyzed the methods of four entities: Centers for Medicare & Medicaid Services "Hospital Compare;" U.S. News & World Report "Best Hospitals;" Thomson-Reuters "100 TopHospitals;" and HealthGrades.

RESULTS

All entities reviewed rely on Medicare data, compute risk-adjusted mortality rates, and use "all-cause" mortality. They vary considerably in their recognition and handling of cases that involved hospice care or PC. One entity excludes cases with prior hospice care and another excludes those discharged to hospice at the end of the index hospitalization. Two entities exclude some or all cases that were coded with the V66.7 "Palliative Care Encounter" International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code.

CONCLUSION

Proliferation of, and variability among, hospital mortality measures creates a challenge for hospital administrators. PC and hospice leaders need to educate themselves and their hospital administrators about the extent to which these mortality rates take end-of-life care into account. At the national level, PC and hospice leaders should take advantage of opportunities to engage these mortality raters in conversation about possible changes in their methods and to conduct further research on this topic.

Using Length of Stay to Control for Unobserved Heterogeneity When Estimating Treatment Effect on Hospital Costs with Observational Data: Issues of Reliability, Robustness, and Usefulness

OBJECTIVE

To evaluate the sensitivity of treatment effect estimates when length of stay (LOS) is used to control for unobserved heterogeneity when estimating treatment effect on cost of hospital admission with observational data.

DATA SOURCES/STUDY SETTING

We used data from a prospective cohort study on the impact of palliative care consultation teams (PCCTs) on direct cost of hospital care. Adult patients with an advanced cancer diagnosis admitted to five large medical and cancer centers in the United States between 2007 and 2011 were eligible for this study.

STUDY DESIGN

Costs were modeled using generalized linear models with a gamma distribution and a log link. We compared variability in estimates of PCCT impact on hospitalization costs when LOS was used as a covariate, as a sample parameter, and as an outcome denominator. We used propensity scores to account for patient characteristics associated with both PCCT use and total direct hospitalization costs.

DATA COLLECTION/EXTRACTION METHODS

We analyzed data from hospital cost databases, medical records, and questionnaires. Our propensity score weighted sample included 969 patients who were discharged alive.

PRINCIPAL FINDINGS

In analyses of hospitalization costs, treatment effect estimates are highly sensitive to methods that control for LOS, complicating interpretation. Both the magnitude and significance of results varied widely with the method of controlling for LOS. When we incorporated intervention timing into our analyses, results were robust to LOS-controls.

CONCLUSIONS

Treatment effect estimates using LOS-controls are not only suboptimal in terms of reliability (given concerns over endogeneity and bias) and usefulness (given the need to validate the cost-effectiveness of an intervention using overall resource use for a sample defined at baseline) but also in terms of robustness (results depend on the approach taken, and there is little evidence to guide this choice). To derive results that minimize endogeneity concerns and maximize external validity, investigators should match and analyze treatment and comparison arms on baseline factors only. Incorporating intervention timing may deliver results that are more reliable, more robust, and more useful than those derived using LOS-controls.

Prospective Cohort Study of Hospitalized Adults With Advanced Cancer: Associations Between Complications, Comorbidity, and Utilization

BACKGROUND

Inpatient hospital stays account for more than a third of direct medical cancer care costs. Evidence on factors driving these costs can inform planning of services, as well as consideration of equity in access.

OBJECTIVE

To measure the association between hospital costs, and demographic, clinical, and system factors, for a cohort of adults with advanced cancer.

DESIGN

Prospective multisite cohort study.

SETTING

Four medical and cancer centers.

PATIENTS

Adults with advanced cancer admitted to a participating hospital between 2007 and 2011, excluding those with dementia. Final analytic sample included 1020 patients.

METHODS

With receipt of palliative care controlled for, the associations between hospital cost and patient factors were estimated. Factors covered the domains of demographics (age, sex, race), socioeconomics and systems (education, insurance, living will, proxy), clinical care (diagnoses, complications deemed to pose a threat to life or bodily functions, comorbidities, symptom burden, activities of daily living), and prior healthcare utilization (home help, analgesic prescribing).

OUTCOME MEASURE

Direct hospital costs.

RESULTS

A major (markedly abnormal) complication (+$8267; P < 0.01), a minor but not a major complication (+$5289; P < 0.01), and number of comorbidities (+$852; P < 0.01) were associated with higher cost, and admitting diagnosis of electrolyte disorders (-$4759; P = 0.01) and increased age (-$53; P = 0.03) were associated with lower cost.

CONCLUSIONS

Complications and comorbidity burden drive inhospital utilization for adults with advanced cancer. There is little evidence of sociodemographic associations and no apparent impact of advance directives. Attempts to control growth of hospital cancer costs require consideration of how the most resource-intensive patients are identified promptly and prioritized for cost-effective care. Journal of Hospital Medicine 2017;12:407-413.

Does Modality Matter? Palliative Care Unit Associated With More Cost-Avoidance Than Consultations

CONTEXT

Inpatient palliative care (PC) is associated with reduced costs, but the optimal model for providing inpatient PC is unknown.

OBJECTIVES

To estimate the effect of palliative care consultations (PCCs) and care in a palliative care unit (PCU) on cost of care, in comparison with usual care (UC) only and in comparison with each other.

METHODS

Retrospective cohort study, using multinomial propensity scoring to control for observed confounding between treatment groups. Participants were adults admitted as inpatients between 2009 and 2015, with at least one of seven life-limiting conditions who died within a year of admission (N = 6761).

RESULTS

PC within 10 days of admission is estimated to reduce costs compared with UC in the case of both PCU (-$6333; 95% CI: -7871 to -4795; P < 0.001) and PCC (-$3559; 95% CI: -5732 to -1387; P < 0.001). PCU is estimated to reduce costs compared with PCC (-$2774; 95% CI: -5107 to -441; P = 0.02) and length of stay compared with UC (-1.5 days; -2.2 to -0.9; P < 0.001). The comparatively larger effect of PCU over PCC is not observable when the treatment groups are restricted to those who received PC early in their admission (within six days).

CONCLUSION

Both PCU and PCC are associated with lower hospital costs than UC. PCU is associated with a greater cost-avoidance effect than PCC, except where both interventions are provided early in the hospitalization. Both timely provision of PC for appropriate patients and creation of more PCUs may decrease hospital costs.

Phase I Cancer Trials and Palliative Care: Antagonism, Irrelevance, or Synergy?

This article synthesizes the presentations and conclusions of an international symposium on Phase 1 oncology trials, palliative care, and ethics held in 2014. The purpose of the symposium was to discuss the intersection of three independent trends that unfolded in the past decade. First, large-scale reviews of hundreds of Phase I trials have indicated there is a relatively low risk of serious harm and some prospect of clinical benefit that can be meaningful to patients. Second, changes in the design and analysis of Phase I trials, the introduction of "targeted" investigational agents that are generally less toxic, and an increase in Phase I trials that combine two or more agents in a novel way have changed the conduct of these trials and decreased fears and apprehensions about participation. Third, the field of palliative care in cancer has expanded greatly, offering symptom management to late-stage cancer patients, and demonstrated that it is not mutually exclusive with disease-targeted therapies or clinical research. Opportunities for collaboration and further research at the intersection of Phase 1 oncology trials and palliative care are highlighted.

Characteristics of palliative care consultation at an academic level one trauma center

BACKGROUND

The current status of palliative care consultation for trauma patients has not been well characterized. We hypothesized that palliative care consultation currently is requested for patients too late to have any clinical significance.

METHODS

A retrospective chart review was performed for traumatically injured patients' ≥18 years of age who received palliative care consultation at an academic medical center during a one-year period.

RESULTS

The palliative care team evaluated 82 patients with a median age of 60 years. Pain and end of life were the most common reasons for consultation; interventions performed included delirium management and discussions about nutritional support. For decedents, median interval from palliative care consultation to death was 1 day. Twenty seven patients died (11 in the palliative care unit, 16 in an ICU). Nine patients were discharged to hospice.

CONCLUSIONS

Most consultations were performed for pain and end of life management in the last 24 h of life, demonstrating the opportunity to engage the palliative care service earlier in the course of hospitalization.

Economic outcomes in palliative and end-of-life care: current state of affairs

The status of economic research in palliative care is evaluated. Significant limitations are observed in research to date. Recommendations are made for broadening the scope of economic enquiry in palliative care.