Dr. Khatcheressian and colleagueshave nicely reviewedboth barriers to palliative andsupportive care and remedies.
Dr. Khatcheressian and colleagues have nicely reviewed both barriers to palliative and supportive care and remedies. Suboptimal Cancer Care
There has been little improvement in palliative practices. The major barrier to such improvement is in the process of care rather than the structure that influences outcomes. Structure alone does not change practice. In our own experience, even though established guidelines for pain management have been published, 80% of patients initially seen in palliative consultation have been subjected to opioid dosing errors. The most common error is failure to give around-the-clock opioids for chronic pain. Advance directives, resuscitation, and psychosocial issues are addressed in only 30% before palliative consultation. The goals of oncology care have been largely based on cure: Disease modification and tumor response are the primary objectives, while patient response and symptom management are considered secondary and less important. The current philosophy of disease is one of "pathology" rather than suffering experienced by the patient. A disproportionate amount of cancer funding is spent on tumor biology and translational therapeutic research, and few funds are directed to the science of symptom management and supportive care. Philanthropic efforts such as The Susan G. Komen Breast Cancer Foundation's Race for the Cure help public awareness of cancer but do little to psychologically support those who are not cured, because they promote the same paradigm. Our culture is the culture of cure and the policymakers follow suit. The present structure of institutional care is another expression of this paradigm. Few cancer centers have implemented palliative and supportive care services although numerous studies support the clinical and financial benefit of palliative services.[3,5-9] There is little incentive for palliative referrals but an economic incentive to continue expensive antitumor therapy beyond the point of patient benefit. Capitated reimbursement limits targeted palliation (radiation, bisphosphonates, and erythropoietic agents) and hospice support when patients need it the most. Systematic assessment of cancer symptoms is time-consuming. Oncologists are rarely trained in validated assessment tools, and few use them in routine practice. Patients volunteer only a minority of the symptoms that may be revealed through systematic review with a checklist. Psychosocial interventions that support families and patients are frequently delayed and not reimbursable. Convincing Clinical Trials That Improve Outcomes
Dr. Khatcheressian and colleagues have nicely outlined the clinical outcome benefits of palliative services. In our own experience, the financial benefits of palliative vs nonpalliative services can be measured through the use of the all patient-refined diagnosis- related group (APR-DRG). We compared 11 peer institutions similar to The Cleveland Clinic but without comprehensive palliative inpatient services. Patients on the palliative inpatient unit had a $7,500 reduction in charge per hospitalization. In addition, by using a template for documentation of symptoms and complications of advanced disease, an increased severity of illness and case mix index can be documented through the APR-DRG, leading to improved reimbursement compared with the usual documented history and physical examination. Commonly observed symptoms such as anorexia, cachexia, and fatigue tend to be underdocumented, which will influence case mix index reimbursement. Ways to Make Symptoms Visible
A change in structure and accountability for the process of care will change practice. The first step in this direction is to establish regular symptom assessment and treatment guidelines at the point of care. Most assessment tools balance comprehensiveness with burden. There are no perfect symptom assessment tools. Most have only one to two questions for pain, and none assess early satiety- a common symptom in cancer patients. However, documentation of symptoms in a problem list and on an admission template improves symptom control.[9,10] Computerized assessment and guideline reminders may facilitate documentation and symptom control. Evidence-based guidelines create standards for quality care assurance and provide a basis for research in symptom management. Guidelines are evidenced-based for many supportive therapies such as antiemetics, bisphosphonates, and recombinant erythropoietin. Unfortunately, few evi- dence-based guidelines exist for managing symptoms.[12,13] Although most guidelines are based on expert opinion and clinical experience, they are still valuable in clinical practice.[ 14] Well developed randomized controlled trials to develop evidencebased guidelines are rare in palliative medicine but are of growing interest. Quality assessment starts with symptom guidelines and algorithms, which hold physicians accountable by feedback and audit. Such algorithms will improve symptom recognition and communication. Point-of-care clinical practice guidelines will hopefully improve the efficiency and quality of care,[16,17] but this is yet to be researched in palliative medicine. The development, dissemination, and implementation of guidelines for symptom management-even if not evidence-based-will be the first step in the research into processes and outcomes of care vital to advancing the field of palliation.
The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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