Eli's Hospice Insider

Published on Wed Sep 22, 2010 PDF

The current reimbursement system throws a wrench in replicating beneficial findings.

Receiving early palliative care improves quality of life and increases longevity, or so found a study published in the August 2010 issue of the New England Journal of Medicine. This news had everyone from NPR to USA Today talking -- but what do the findings really say about palliative care and hospice?

The basics: In a study of lung cancer patients, participants who received early palliative care instead of just standard oncology treatment had "significant improvements in both quality of life and  mood," says the study headed up by Massachusetts General Hospital researchers in Boston. And "patients receiving early palliative care had less aggressive care at the end of life but longer survival" -- about two months longer.

Patients receiving palliative care were in hospice programs longer, says the study.

Study participants were broken up into two groups " one which received only usual oncologic care and one which had early palliative care integrated into their oncologic care. Those receiving early palliative care not only fared better in physical well-being and functional well-being scores at the 12 week mark, they also a lower incidence of depression.

"Palliative care prolongs life? Really?" asked Alex Smith, assistant professor of medicine in the division of geriatrics at the University of California, San Francisco, on the GeriPal blog (www.geripal.org).

The study raises a key question, Smith says: Are the survival differences between patients who received early palliative care and those who did not due to avoiding aggressive care or due to improved symptom care? Or is the difference due to differences in mood? "If the survival benefit was due to avoidance of chemo, maybe the palliative care team isn't so necessary," Smith postulates. "On the other hand, you could argue it was the quality of the communication and clarification of goals in the palliative care group that led to less chemotherapy." In the end, Smith concludes that the survival results from a combination of factors "including less depression, less pain, less hospitalization, and less chemotherapy." But which one is the dominant factor won't be clear until more research is done.

Don't miss: "The primary outcomes related to symptom control and well-being were improved with pallaitive care," Smith notes. And this is "potentially more important than the survival story" which has garnered so much interest from the popular press. 

Study Strikes a Blow at Misconceptions

The study findings get to the heart of "two important misconceptions that may lead to underutilization of palliative care services," says Lyle Fettig, MD, palliative care physician at Indiana University in Indianapolis, on the Palimed blog (www.pallimed.org).

Misconception # 1: Primary providers already provide palliative care as part of what they do and so there is no need for additional services. The current study indicates otherwise, and backs up past studies which underlined the benefit of palliative care interventions, Fettig says. It's possible that primary providers, such as oncologists, could provide "discrete parts of the [palliative care] intervention" and achieve the same outcomes, Fettig says. But, "the lens through which palliative care physicians see patients is inherently different from the lens of the oncologist. While one might be able to borrow the other's lens momentarily, it's conceivable that due to the complexity of advanced medical illness, there's value in both being on hand regardless of how oncologists are trained or reimbursed."

Misconception # 1: Palliative care equals "giving up." While the survival result needs to be replicated in further studies, it dovetails with past research that indicates palliative care's seeming ability to lengthen life. But the reason for this "possible effect is quite unclear," Fettig says.

The study's design -- employing "a single, tertiary care site with a specialized group of thoracic oncology providers and palliative care clinicians" limits the potential to apply the results "to other care settings or patients with other types of cancer," says Tim Cousounis, managing director of the DAI Palliative Care Group on the Palliative Care Success blog (http://palliativemedicine.blogspot.com).

Tightly integrated healthcare delivery organizational models like the one this study focused on are few and far between, Cousinis points out. And "in most communities, palliative care has been viewed as an alternative to curative care, not as concurrent care." Moreover, today's health care system doesn't encourage or facilitate "the close coordination and collaboration among providers necessary to replicate this study's findings," he says. Furthermore, Cousounis theorizes that "reimbursement for these palliative care services was not an issue."

Bottom line: "The current reimbursement system, which rewards more procedures and aggressive care, surely does not encourage coordination," Cousounis says.

Editors note: Read the NEJM study here: www.nejm.org/doi/full/10.1056/NEJMoa1000678.

Take a look at Smith's musings in the study here: www.geripal.org/2010/08/palliative-care-prolongs-life.html.

See Fettig's post regarding the study here: www.pallimed.org/2010/08/game-changer-early-palliative-care-for.html.

Find Cousounis' post at: http://palliativemedicine.blogspot.com/2010/08/spreading-message-and-scienceof.html.

See more industry response in Palliative Care Grand Rounds 2.9 hosted on the American Association of Hospice and Palliative Medicine's blog at

www.bsource.com/clients/aahpm/blog/?p=843.