SAN FRANCISCOA high-volume specialist palliative care unit (PCU)
set up to improve end-of-life care for patients at Medical College of Virginia
hospitals met patient goals for care and generated a profit for the hospital,
despite caring for many indigent patients.
"We found that an inpatient PCU unit staffed by a
high-volume specialist team provided significant benefits not only to patients
and families, but also to physicians," Thomas J. Smith, MD, told Oncology
Dr. Smith, who developed the special inpatient care program, is chairman of the
division of hematology/oncology at Medical College of Virginia Hospitals.
"Under the usual arrangements for hospice care, the
patient is transferred out of the hospital near the end of life," Dr.
Smith explained. "That means that the oncologist who may have cared for
the patient for the past 3 years is no longer the person responsible for that
care. That is unfair both to the patient and to the doctor. Moving dying
patients out of the hospital toward the end of life also means that we have no
chance to teach our residents how to provide good end-of-life care."
The key elements to this approach are a high-volume (11 bed)
unit, staff trained in palliative care and coordinated by a specially trained
nurse or nurse practitioner, and a supportive group of physicians throughout
the hospital who use the PCU for their patients.
"We opened a dedicated 11-bed inpatient PCU May 2000
staffed by a high-volume specialist team delivering standardized care with
clinical practice guidelines. We hoped that the PCU would improve outcomes and
costs for patients in need of symptom control and end-of-life care," Dr.
Cost of Care
Data presented at the American Society of Clinical Oncology
meeting in May 2001 assessed the effect of the PCU on cost of care of patients
who died in the 6 months after the PCU opened. The investigators compared daily
charges and costs of the 5 days prior to PCU transfer to the stay in the PCU.
Charges and costs per day for the PCU were compared for
intensive care units (ICU), routine hospital, and all non-PCU units. To control
for potential differences in patients or in goals of care, a case-control study
was done with a subgroup of 38 PCU patients matched by diagnosis and age to
contemporary patients who died outside the PCU and were cared for by other
medical or surgical teams.
The PCU admitted 237 patients from May to December 2000. Of the
first 137 patients, 68 had both regular inpatient and PCU stays. About 52% of
the PCU patients had cancer. The next most common diagnoses were vascular
events, AIDS, and organ failure.
"Daily charges and costs were reduced by 66% overall and
by 74% for medications and diagnostics (P < 0.0001 for all, comparing
each to the PCU). In addition, the variation in daily charges and costs was
reduced significantly," Dr. Smith reported. "In some cases, the
cost/day in the PCU would be low enough to be covered by the Medicare hospice
The case control study showed that PCU care reduced daily
charges from $5,304 to $2,172 (P = 0.005), reduced direct costs from
$1,441 to $632 (P = 0.004), and reduced total costs from $2,538 to
$1,095 (P = 0.009).
Dr. Smith said that patient and family satisfaction with care
in the PCU remained high. The researchers concluded that appropriate care of
medically complex terminally ill patients in a high-volume, specialized unit
significantly lowers cost.
Dr. Smith’s advice for physicians who would like to establish
PCUs at their own hospitals is twofold. "Standardize everything you do.
Use clinical care algorithms, especially for managing pain, dyspnea, fever, and
delirium," he said. "Also, begin each case by discussing the goal of
care with the family and patient, right up front. Ask both patient and family
what they would like to accomplish in the remaining time and set your care plan
Reimbursement is an ongoing concern, but Dr. Smith expects that
to improve. "Some insurance companies only want to reimburse at the
nursing home rate for inpatient PCU services, but we think that may
change," he said. "Insurers are all aware of recent suits against
doctors for failing to provide adequate palliative care, and it is only a
matter of time until an insurance company gets sued for not providing adequate
pain control or end-of-life care."
Cost Savings Challenged
Declan Walsh, MD, the discussant for the report and director,
the Harry R. Horvitz Center for Palliative Medicine, at the Cleveland Clinic
Foundation, challenged the assumption that cost savings are particularly
important for in-hospital end-of-life care. "Why should palliative care be
cheap?" he asked. "When you recruit a cardiologist, the first thing
he or she says is not, ‘I’m here to save your institution money.’ Why can’t
palliative care also be expensive, if it is so important?"
Transferring patients to hospice programs is widely seen as an
answer to providing quality end-of-life care, but Dr. Walsh said that many
hospice programs in the United States "are in big trouble." Patients
are typically sent to hospice only shortly before death, mainly because
admission often requires a judgment that the patient has a life expectancy of 6
months or less. The resulting brief average length of stay has created
increasing financial problems for many hospice programs, along with high staff
"Hospice and other palliative care programs must be
needs-based," Dr. Walsh said, "not just for patients who sign a paper
saying they are going to die in the next 6 months."