JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 9, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0612
A Hospice-Hospital Partnership: Reducing Hospitalization Costs and 30-Day Readmissions among Seriously Ill Adults John C. Tangeman, MD, FACP,1 Carole B. Rudra, PhD, MPH,2 Christopher W. Kerr, MD, PhD,1 and Pei C. Grant, PhD1
Abstract
Background: Inpatient palliative care (IPC) has been associated with numerous clinical benefits. Observational and randomized studies of cost savings associated with IPC provide conflicting results, and the association with readmission is not well understood. Objective: We aimed to estimate the influence of IPC on hospitalization costs and readmission rates. Methods: We measured hospitalization costs and 30-day readmission rates among 1004 patients who received IPC at two western New York hospitals in 2012. Using propensity score matching, we compared outcomes among patients receiving palliative care with those among 1004 similar adults who were hospitalized during the same period and did not receive palliative care. Results: On average, cost per admission was $1,401 (13%) lower among patients receiving palliative care than comparison patients ( p < 0.05). Cost reductions were evident within intensive care and laboratory services. Readmission rates were significantly lower among palliative care patients discharged with hospice care (1.1%) than comparison patients (6.6%), but significantly higher among palliative care patients discharged to other locations (12.1%). Conclusions: Receipt of IPC appears to reduce hospitalization costs among adult western New Yorkers. Furthermore, care coordinated with postdischarge hospice services appears to substantially reduce the likelihood of readmission.
Introduction
T
here is a growing evidence base supporting the observation that inpatient palliative care (IPC) consultation services reduce length of stay (LOS) and hospital costs1–7 while concurrently increasing patient and provider satisfaction,8,9 improving symptom control,10 and increasing advance directive completion.11,12 In addition, studies have shown that IPC services reduce the likelihood of intensive care unit (ICU) readmission.13–15 There is, however, scant evidence supporting ongoing cost savings for those patients who survive to discharge. A recent retrospective study showed that receipt of hospice or home-based palliative care was associated with a lower rate of readmission when compared with usual care.16 Another propensity-matched study
examining home-based palliative care compared with usual care showed a lower probability of hospital readmission for those patients receiving palliative care.17 There are myriad new models of care emerging as health systems adapt to the Patient Protection and Affordable Care Act. Cost-effective postacute care models are becoming increasingly important as accountable care organizations mature and hospitals face financial penalties for 30-day readmissions. In many communities, hospice providers are the local experts in providing palliative and end-of life care and, as pointed out by Meier and colleagues, hospitals and hospice providers should partner to extend the care continuum into the home.18 The impact of palliative care programs administered by hospice providers has not been well examined. Therefore, in this study, a propensity-matched cohort
1
Center for Hospice and Palliative Care, Cheektowaga, New York. Rudra Research, LLC, Buffalo, New York. Accepted March 9, 2014.
2
1005
1006
was used to examine the hospitalization costs and 30-day readmission rate of patients seen by a hospice- and hospitalsponsored IPC service, regardless of payer source. Methods Setting and study population
This was a retrospective cohort study of adult patients who were admitted to two New York State hospitals (Millard Fillmore Suburban Hospital, a 265-bed facility in Williamsville, NY, or Buffalo General Medical Center, a 501-bed facility in Buffalo, NY) between January 1, 2012 and December 31, 2012 and who received IPC services during their hospitalizations. Enrolled palliative care patients received inpatient consultation from a palliative care team consisting of a palliative care physician or nurse practitioner, a hospice nurse liaison, and a hospital-based social worker. Palliative care patients in the upper fifth percentile of LOS were excluded because these patients may not be typical recipients of palliative services. IPC patients were matched to nonparticipating adult patients who were hospitalized at either facility during the same period. Matching was based on several demographic and admission characteristics routinely collected in hospital databases, described in detail below. This study was approved by the University at Buffalo Health Sciences Institutional Review Board.
TANGEMAN ET AL.
estimated using a logistic regression model with receipt of palliative care services as the outcome and the following characteristics as predictors: age, gender, marital status, race, insurance status, attending physician specialty, primary diagnosis, illness severity score, and LOS. These characteristics were modeled using sets of indicator variables defined by categories shown in Table 1. Within strata defined by vital status at discharge, palliative care patients were matched 1:1 to comparison patients using the nearest neighbor method.20 The largest acceptable difference in propensity scores between an IPC patient and his or her matched comparison patient was 20% of the score’s standard deviation (SD). Statistical analysis
Distributions of characteristics between IPC patients and propensity-matched non-IPC patients were compared. Differences in these distributions were tested using the v2 statistic. Average costs within both groups and the average (95% confidence interval [CI]) difference in costs between the two groups were calculated. Differences in overall costs per admission and per-day and subgroup-specific costs per admission were also calculated. The proportions of readmissions within 30 days of discharge were compared using the v2 statistic. Statistical significance was defined as p < 0.05 or a CI excluding the null difference of zero.
Outcomes and patient characteristics
Outcomes of interest were hospitalization costs and 30-day hospital readmissions. Total cost per admission and average cost per day within each admission were calculated overall and within subgroups according to service type, as captured by Universal Billing form 92 (UB-92) revenue codes in administrative databases. Cost subgroups included intensive care (UB-92 200–209), diagnostic imaging (320–329, 341, 350–359, 400–409, 610–619), laboratory (300–319), and pharmacy including intravenous therapy (250–269). Readmissions were defined as admissions to any of the following hospital units between 1 and 30 days after discharge from the first hospital stay: ICU, emergency room, telemetry cardiac, neuro-stepdown, medical stroke, intermediate care, cardiac care, and general nursing. Admissions to palliative care and rehabilitation units were not considered readmissions. Several patient characteristics were examined. Demographic characteristics at enrollment included age, gender, marital status, race, and insurance status. Admission characteristics included the specialty of the attending physician, primary diagnosis, all patient refined diagnosis related group (APR-DRG19) illness severity classification, LOS, discharge status, and utilization of a hospice ‘‘swing bed.’’ These variables were categorized as shown in Table 1. All information used in this analysis was extracted from hospital databases. Propensity score matching
Propensity scores were used to identify a comparison group of patients who did not receive palliative care but were otherwise comparable with regard to measured characteristics.20 Influences of palliative care participation may differ between patients who were discharged alive and those who died while hospitalized. Therefore, two propensity scores were estimated: one for patients discharged alive and another for patients who died in the hospital.4 Both scores were
Cost differences within subgroups
In secondary analyses, cost differences were examined to determine if differences were stronger after rather than before the initial palliative care consult, as would be expected if IPC reduced inpatient costs. Differences in average cost per day between IPC patients and comparison patients were plotted according to day of initial consult (IPC patients) or reference day (comparison members). The reference day was defined as the median day of initial consult among patients receiving palliative care within categorized LOS, ranging from day 6 among patients with 9- to 16-day stays to day 23 among patients with 30- to 43-day stays. A priori, this analysis was restricted to costs from 4 days before the initial consult through 4 days afterward within the subgroup of patients who were admitted for 9 days or longer. Costs differences were examined within subgroups defined by payer (Medicare, Medicare HMO, Medicaid, and commercial/other) for consistency. Finally, to examine whether relationships between palliative care and cost per day differed according to duration of hospitalization, average cost differences within subgroups defined by LOS were calculated. Sensitivity analyses
Inclusion of characteristics in the propensity score that are influenced by the exposure of interest may cause overmatching and biased estimates of the exposure’s effects. For instance, if IPC consults influence the LOS, inclusion of LOS in the propensity score is incorrect. However, the reverse relationship may exist: Patients with longer hospital stays may be more likely to be approached for or be amenable to palliative care services. LOS was positively associated with likelihood of receipt of IPC in this study population. LOS was therefore included as a covariate in the propensity score. In post hoc
REDUCING COSTS AND 30-DAY READMISSIONS
1007
Table 1. Frequency and Percent Distributions of Characteristics at Admission among Inpatient Palliative Care (IPC) Patients and Comparison Patients
Characteristic
IPC patients (n = 1004)
Comparison patients (n = 1004)
N
%
N
%
1.0 0.6 3.2 9.2 13.0 24.8 33.2 15.1
3 7 33 98 121 246 327 169
0.3 0.7 3.3 9.8 12.1 24.5 32.6 16.8
58.9 41.1
538 466
53.6 46.4
40.7
416
41.4
34.3 9.6 14.8 0.6
342 86 153 7
34.1 8.6 15.2 0.7
84.8 12.2 2.8 0.3
875 104 25 0
87.2 10.4 2.5 0.0
37.7 44.7 1.9 3.1 11.2 0.3 1.1
378 452 10 37 111 5 11
37.7 44.9 1.0 3.7 11.1 0.5 1.1
13.6
134
13.4
47.6 32.8 3.7 2.4
455 354 35 26
45.3 35.3 3.5 2.6
1.4 21.1 6.5 6.4 5.4 8.4 4.6 3.2 4.2 13.2 22.3
13 231 66 62 45 85 40 25 41 137 230
1.3 23.0 6.6 6.2 4.5 8.5 4.0 2.5 4.1 13.7 22.9
3.5
29
2.9
Age (years) 23–29 10 30–39 6 40–49 32 50–59 92 60–69 130 70–79 249 80–89 333 90–102 152 Gender Female 591 Male 413 Marital status Married or with 409 life partner Widowed 344 Divorced or separated 96 Single 149 Unknown 6 Race White 851 Black 122 Other 28 Unknown 3 Insurance status Medicare 379 Medicare HMO 449 Medicaid 19 Medicaid HMO 31 Commercial 112 Self-pay 3 Other 11 Attending physician specialty Family medicine 136 or pediatrics Internal medicine 478 Reference 329 Surgery 37 Other 24 Primary diagnosis Blood 14 Circulatory 212 Digestive 65 Endocrine 64 Genitourinary 54 Infection/parasite 84 Injury/poisoning 46 Musculoskeletal 32 Neoplasm 42 Respiratory 132 Symptoms, signs, 224 conditions Other 35 APR-DRG illness severity score
(continued)
Table 1. (Continued)
Characteristic 1 (minor) 2 (moderate) 3 (major) 4 (extreme) Length of stay (days)a 1–2 3–5 6–8 9–16 17–29 30–43 Discharge statusa Home, self-care Inpatient facility Skilled care Hospice at home Hospice facility Died in hospital Utilization of hospice ‘‘swing bed’’a
IPC patients (n = 1004)
Comparison patients (n = 1004)
N
%
N
%
7 113 404 480
0.7 11.3 40.2 47.8
113 102 443 454
0.5 10.2 44.1 45.2
114 244 195 270 132 49
11.4 24.3 19.4 26.9 13.1 4.8
170 255 156 243 129 51
16.9 25.4 15.5 24.0 12.9 5.1
76 8 289 136 207 288 105
7.6 0.8 28.8 13.5 20.6 28.7 10.5
260 36 409 8 3 288 4
25.9 3.6 40.7 0.8 0.3 28.7 0.4
a 2
v p < 0.05. APR-DRG, all patient refined diagnosis related group; HMO, health maintenance organization.
analyses, the impact of this decision was evaluated by using a comparison group identified from scores based on all predictors listed above, excluding LOS (using separate scores for patients discharged alive and those who died in the hospital). Similarly, receiving IPC services may be associated with likelihood of death during hospitalization. Therefore, the sensitivity of the results was also examined by using a comparison group identified from a single propensity score that did not include vital status at discharge as a stratifying characteristic or as a predictor. Results
During the study period, 1116 individuals received palliative care services during an inpatient stay. Thirty-five of these received IPC during multiple hospital stays; only the first stay was included in this analysis. About one-third (356) of patients died during their hospitalizations. This analysis excluded 54 participants who were admitted for 45 to 453 days. Another 58 participants, 48 of whom died while hospitalized, were also excluded due to a lack of well-matched comparison patients. These 58 excluded participants had longer hospitalizations than the deceased participants included in the analysis (17.2 days versus 10.3 days, on average), but were otherwise similar. The final analytic sample included 1004 IPC patients, of whom 288 died in the hospital, and their propensity-matched comparison group of equal size. Characteristics at admission were similar between IPC patients and matched comparison patients (Table 1). The distributions of categorized LOS were statistically significantly
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Table 2. Average Hospitalization Cost and Average (95% CI) Difference in Cost between Inpatient Palliative Care (IPC) Patients and Comparison Patients Cost Cost per admission ($) All patients Discharged alive Died in hospital Cost per day ($) All patients Discharged alive Died in hospital
Palliative care participants
Comparison patients
Palliative versus comparison
9713 8421 12,924
11,114 9653 14,748
- 1,401 ( - 2,481 to - 322) - 1,231 ( - 2,205 to - 257) - 1,824 ( - 4,636 to 988)
991 844 1,742
1,219 1,009 1,355
- 228 ( - 316 to - 140) - 164 ( - 234 to - 94) - 387 ( - 624 to - 151)
Both groups comprised 1004 individuals: 716 discharged alive and 288 who died in the hospital. CI, confidence interval.
different between the two groups: IPC patients were less likely to have stays < 3 days than comparison patients (11.3% versus 16.9%, respectively). However, average LOS was similar between IPC patients (mean – SD: 10.3 – 0.3 days) and comparison patients (9.8 – 0.3 days). Distributions of discharge status differed significantly between the two groups: IPC patients were considerably more likely to be discharged to hospice care at home (13.5% versus 0.8%) or a hospice facility (20.6% versus 0.3%) than comparison participants; distributions of those who died while hospitalized were identical by design. IPC patients were also more likely to utilize a hospice swing bed (10.5% versus 0.4%). Cost per admission was $1,401 lower, on average, among IPC patients than comparison patients (95% CI: $322 to $2,481 lower) (Table 2). The cost reduction was somewhat more pronounced among patients who died in the hospital ($1,824 lower among IPC patients) than those discharged alive ($1,231 lower). IPC was also associated with lower cost per day: $228 lower overall, $164 lower among those who died, and $387 lower among live discharges, on average. All differences except admission costs for those who died in the hospital were statistically significant. Costs for intensive care and laboratory services were lower among IPC patients than matched comparison patients ($492 and $109 lower, respectively) (Table 3). Diagnostic imaging and pharmacy costs were not strongly associated with the receipt of IPC services ($16 and $20 lower among participants, respectively). Relationships between IPC and service-specific costs were generally similar between patients discharged alive and those who died in the hospital. The difference in cost per day between IPC patients and comparison patients was most apparent on and after the day of initial consult (Fig. 1). Average cost per day was $101 lower in the 1 to 4 days before the initial consult and $233 lower 0 to 4 days after the consult among IPC patients versus comparison patients hospitalized for 8 to 43 days. A similar pattern was observed among patients hospitalized for 1 to 7 days (data not shown). This pattern was more pronounced among patients who died in the hospital than those discharged alive (data not shown). Overall, the likelihood of readmission did not differ between IPC patients and comparison patients (6.7% versus 6.6%, p = 0.92). However, IPC patients discharged to a hospice facility, hospice swing bed, or hospice at home were significantly less likely to experience a readmission than
comparison patients (1.1% versus 6.6%, p < 0.01). IPC patients discharged to home, skilled care, and other facilities had a significantly higher risk of readmission than comparison patients (12.1% versus 6.6%, p < 0.01). The relationship between IPC and cost per day was robust to our choice of propensity score estimator. Results did not change when using either scores unadjusted for LOS or a single score estimated from both live discharges and those who died in the hospital (data not shown). The relationship between cost per day and IPC was also generally consistent within subgroups defined by LOS and payer (data not shown). Discussion
This study adds to the evidence that IPC results in lower hospitalization cost regardless of vital status at discharge. The average cost reduction was 13% in this study, similar to the 11% reduction among New York State Medicaid recipients
Table 3. Average Service-Specific Costs and Average (95% CI) Difference in Costs per Admission between Inpatient Palliative Care (IPC) Patients and Comparison Patients: Overall and According to Discharge Status Cost per admission ($) Intensive care All patients Discharged alive Died in hospital Diagnostic imaging All patients Discharged alive Died in hospital Laboratory All patients Discharged alive Died in hospital Pharmacy All patients Discharged alive Died in hospital
IPC Comparison patients patients
Palliative versus comparison - 492 ( - 985 to 2) - 488 ( - 878 to - 97) - 500 ( - 1879 to 879)
2148 1397 4020
2640 1885 4520
288 283 376
304 253 357
614 520 847
722 616 987
- 109 ( - 175 to - 42) - 96 ( - 155 to - 37) - 139 ( - 312 to - 34)
599 528 777
620 546 802
- 20 ( - 109 to 68) - 18 ( - 98 to 62) - 25 ( - 259 to 208)
- 16 ( - 45 to 12) - 30 ( - 62 to 1) 20 ( - 41 to 80)
Both groups comprised 1004 individuals: 716 discharged alive and 288 who died in the hospital. CI, confidence interval.
REDUCING COSTS AND 30-DAY READMISSIONS
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FIG. 1. Average cost per day for inpatient palliative care (IPC) patients (black bars) and comparison patients (white bars) according to day from initial consult or reference day. Reference day within comparison patients is defined as the median day between admission and initial consult among IPC patients with similar length of stay; see text for details. Figure is based on data from 451 palliative care participants and 423 comparison patients who were hospitalized for 9 to 43 days and discharged alive or dead. observed by Morrison and coworkers.4 Relative cost savings shown here were also similar to the 14% reduction observed in a matched cohort study in a California academic medical center.3 In a matched cohort analysis of patients in two academic centers from 2005 to 2008, cost savings were 13% greater among IPC patients; however, cost savings were not apparent among patients with hospitalizations of 30 days or more.1 In contrast, we found no difference in cost savings according to LOS. In two separate observational studies of veterans receiving care at several hospitals from 2002 to 2006, Penrod et al. observed lower costs per day for patients receiving palliative care ($239 and $464 lower in their first and second studies, respectively).14,15 In their more recent study,15 nursing, laboratory, and radiology costs were lower among palliative care patients, although pharmacy costs were higher. There have been fewer examinations of the relationship between palliative care and 30-day risk of readmission. Enguidanos and colleagues16 showed that 10% of patients who received an IPC consultation were readmitted within 30 days of discharge. The rate of readmission was much lower within the subgroups that received outpatient hospice or palliative care follow-up after discharge (4.6% and 8.3%, respectively) than those patients discharged without in-home care (25.7%). The study was undertaken at a managed care medical center with a well-supported home-based palliative care team. Therefore, the results may not be applicable to many areas of the United States with a relative lack of home-based palliative care services outside of the Medicare Hospice Benefit. Ranganathan and coworkers,17 using a propensity matched cohort, recently showed a reduced risk of 30-day readmission via a home-based palliative care program. Neither IPC consultation nor hospice referral rates were examined in this study. In this current study, the overall likelihood of readmission did not differ between IPC patients and comparison patients
(6.7% versus 6.6%). IPC patients discharged with hospice care at home or to a hospice facility, however, had a much lower 30day readmission rate (1.1%) than IPC patients discharged to home, skilled care, or other facilities without hospice support (12.1%). Our study adds to the emerging evidence base suggesting that significant decreases in 30-day readmissions among IPC patients who survive to discharge can generally only be achieved via discharge with hospice care or homebased palliative care.16 In many communities, hospice programs are often the sole provider of home-based palliative care, usually under the Hospice Medicare Benefit. This study suggests that inpatient palliative programs should work closely with hospice programs when discharging eligible patients. This, and other studies,16,17,21,22 suggest the need for novel funding sources to support robust home-based palliative care offerings, outside the Hospice Benefit, to expand the palliative continuum to those patients still receiving active treatments or who have a prognosis > 6 months. Preliminary data (unpublished) from our center show significant cost reductions, hospital and emergency department avoidance, and more timely hospice referral among patients in a home-based palliative care program financially supported by a local commercial and Medicare Advantage insurance company. Our study population is larger than that examined in many previous studies, affording us power to detect differences in service-specific costs and to examine costs per day according to the timing of the initial consultation. The diversity of the analytic population, for example with regard to payer and primary diagnosis, is also a strength of this study. Because of our exclusion criteria, these results may not be generalizable to patients with longer hospitalizations. Furthermore, we were unable to identify appropriate comparison patients for about 5% of the patients. However, these exclusions were a small proportion of the total population of IPC patients.
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Therefore, to the extent that the patients at these two hospitals during the study period are representative of western New Yorkers, these results are likely applicable to the regional and possibly national population of adults who would choose to participate in IPC. Similarities in characteristics at admission suggest that palliative care participants were well matched to comparison patients. Additionally, our findings were robust to covariates included in the propensity score, suggesting that cost savings associated with palliative care were not mediated by LOS or vital status at discharge. Finally, cost differences between palliative care participants and comparison patients were strongest at and after the day of initial consult. This temporal specificity supports a causal relationship. However, as with any observational study, we cannot discount the possibility that unmeasured characteristics may have influenced both the likelihood of participation in palliative care and outcomes of interest. Such characteristics could account for part or all of the cost reductions and differences in readmission rates observed here. Furthermore, the higher rate of readmission among IPC patients who were not discharged to hospice services might reflect a selection bias among the IPC patients; the fact that a palliative care consult was requested, and hospice services declined, might indicate a patient, or family, with more aggressive, unrealistic goals. These limitations notwithstanding, these results suggest that participation in IPC reduces hospitalization costs and, combined with postdischarge hospice coordination, reduces the likelihood of readmission among adult western New Yorkers.
10.
Acknowledgments
15.
The authors gratefully acknowledge Joseph A. Bach and William D. Riemer of the Center for Hospice & Palliative Care for the coordination and acquisition of data needed to complete the study. The authors also wish to thank Carol Kopacz and Jennifer Graff of Kaleida Health (Buffalo, NY) for the provision of data, without which the study could not have been accomplished. Further, the authors thank Debra L. Luczkiewicz, MD, and Elizabeth Marks, MS, for editorial review of the manuscript.
6. 7. 8. 9.
11.
12. 13. 14.
16. 17.
18.
Author Disclosure Statement
No competing financial interests exist.
19.
References
1. Albanese TH, Radwany SM, Mason H, Gayomali C, Dieter K: Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital. J Palliat Med 2013;16:289–294. 2. Armstrong B, Jenigiri B, Hutson SP, Wachs PM, Lambe CE: The impact of a palliative care program in a rural Appalachian community hospital: A quality improvement process. Am J Hospice Palliat Care 2013;30:380–387. 3. Ciemins EL, Blum L, Nunley M, Lasher A, Newman JM: The economic and clinical impact of an inpatient palliative care consultation service: A multifaceted approach. J Palliat Med 2007;10:1347–1355. 4. Morrison RS, Dietrich J, Ladwig S, et al.: Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff 2011;30:454–463. 5. Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA: A high-volume specialist palliative care unit
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and team may reduce in-hospital end-of-life care costs. J Palliat Med 2003;6:699–705. Starks H, Wang S, Farber S, Owens DA, Curtis JR: Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med 2013;16:1215–1220. Wu FM, Newman JM, Lasher A, Brody AA: Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med 2013. Meo N, Hwang U, Morrison RS: Resident perceptions of palliative care training in the emergency department. J Palliat Med 2011;14:548–555. O’Mahony S, Blank AE, Zallman L, Selwyn PA: The benefits of a hospital-based inpatient palliative care consultation service: Preliminary outcome data. J Palliat Med 2005;8:1033–1039. Laguna J, Goldstein R, Allen J, Braun W, Enguidanos S: Inpatient palliative care and patient pain: Pre- and postoutcomes. J Pain Symptom Manage 2012;43:1051–1059. Sacco J, Deravin Carr DR, Viola D: The effects of the Palliative Medicine Consultation on the DNR status of African Americans in a safety-net hospital. American J Hospice Palliat Care 2013;30:363–369. Zaide GB, Pekmezaris R, Nouryan CN, et al.: Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care 2013;11:5–11. Gade G, Venohr I, Conner D, et al.: Impact of an inpatient palliative care team: A randomized control trial. J Palliat Med 2008;11:180–190. Penrod JD, Deb P, Dellenbaugh C, et al.: Hospital-based palliative care consultation: Effects on hospital cost. J Palliat Med 2010;13:973–979. Penrod JD, Deb P, Luhrs C, et al.: Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med 2006;9:855–860. Enguidanos S, Vesper E, Lorenz K: 30-day readmissions among seriously ill older adults. J Palliat Med 2012;15: 1356–1361. Ranganathan A, Dougherty M, Waite D, Casarett D: Can palliative home care reduce 30-day readmissions? Results of a propensity score matched cohort study. J Palliat Med 2013;16:1290–1293. Meier DE, Beresford L: Hospitals and hospices partner to extend the continuum of palliative care. J Palliat Med 2007;10:1231–1235. Pilotto A, Scarcelli C, D’Ambrosio LP, et al.: All patient refined diagnosis related groups: a new administrative tool for identifying elderly patients at risk of high resource consumption. J Am Geriatr Soc 2005;53:167–168. Rubin DB: Estimating causal effects from large data sets using propensity scores. Ann Intern Med 1997;127(8 Pt 2):757–763. Brumley R, Enguidanos S, Jamison P, et al.: Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc 2007;55:993–1000. Brumley RD, Enguidanos S, Cherin DA: Effectiveness of a home-based palliative care program for end-of-life. J Palliat Med 2003;6:715–724.
Address correspondence to: Pei C. Grant, PhD Center for Hospice and Palliative Care 225 Como Park Boulevard Cheektowaga, NY 14227 E-mail: [email protected]
A Hospice-Hospital Partnership: Reducing Hospitalization Costs and 30-Day Readmissions among Seriously Ill Adults John C. Tangeman, MD, FACP,1 Carole B. Rudra, PhD, MPH,2 Christopher W. Kerr, MD, PhD,1 and Pei C. Grant, PhD1
Abstract
Background: Inpatient palliative care (IPC) has been associated with numerous clinical benefits. Observational and randomized studies of cost savings associated with IPC provide conflicting results, and the association with readmission is not well understood. Objective: We aimed to estimate the influence of IPC on hospitalization costs and readmission rates. Methods: We measured hospitalization costs and 30-day readmission rates among 1004 patients who received IPC at two western New York hospitals in 2012. Using propensity score matching, we compared outcomes among patients receiving palliative care with those among 1004 similar adults who were hospitalized during the same period and did not receive palliative care. Results: On average, cost per admission was $1,401 (13%) lower among patients receiving palliative care than comparison patients ( p < 0.05). Cost reductions were evident within intensive care and laboratory services. Readmission rates were significantly lower among palliative care patients discharged with hospice care (1.1%) than comparison patients (6.6%), but significantly higher among palliative care patients discharged to other locations (12.1%). Conclusions: Receipt of IPC appears to reduce hospitalization costs among adult western New Yorkers. Furthermore, care coordinated with postdischarge hospice services appears to substantially reduce the likelihood of readmission.
Introduction
T
here is a growing evidence base supporting the observation that inpatient palliative care (IPC) consultation services reduce length of stay (LOS) and hospital costs1–7 while concurrently increasing patient and provider satisfaction,8,9 improving symptom control,10 and increasing advance directive completion.11,12 In addition, studies have shown that IPC services reduce the likelihood of intensive care unit (ICU) readmission.13–15 There is, however, scant evidence supporting ongoing cost savings for those patients who survive to discharge. A recent retrospective study showed that receipt of hospice or home-based palliative care was associated with a lower rate of readmission when compared with usual care.16 Another propensity-matched study
examining home-based palliative care compared with usual care showed a lower probability of hospital readmission for those patients receiving palliative care.17 There are myriad new models of care emerging as health systems adapt to the Patient Protection and Affordable Care Act. Cost-effective postacute care models are becoming increasingly important as accountable care organizations mature and hospitals face financial penalties for 30-day readmissions. In many communities, hospice providers are the local experts in providing palliative and end-of life care and, as pointed out by Meier and colleagues, hospitals and hospice providers should partner to extend the care continuum into the home.18 The impact of palliative care programs administered by hospice providers has not been well examined. Therefore, in this study, a propensity-matched cohort
1
Center for Hospice and Palliative Care, Cheektowaga, New York. Rudra Research, LLC, Buffalo, New York. Accepted March 9, 2014.
2
1005
1006
was used to examine the hospitalization costs and 30-day readmission rate of patients seen by a hospice- and hospitalsponsored IPC service, regardless of payer source. Methods Setting and study population
This was a retrospective cohort study of adult patients who were admitted to two New York State hospitals (Millard Fillmore Suburban Hospital, a 265-bed facility in Williamsville, NY, or Buffalo General Medical Center, a 501-bed facility in Buffalo, NY) between January 1, 2012 and December 31, 2012 and who received IPC services during their hospitalizations. Enrolled palliative care patients received inpatient consultation from a palliative care team consisting of a palliative care physician or nurse practitioner, a hospice nurse liaison, and a hospital-based social worker. Palliative care patients in the upper fifth percentile of LOS were excluded because these patients may not be typical recipients of palliative services. IPC patients were matched to nonparticipating adult patients who were hospitalized at either facility during the same period. Matching was based on several demographic and admission characteristics routinely collected in hospital databases, described in detail below. This study was approved by the University at Buffalo Health Sciences Institutional Review Board.
TANGEMAN ET AL.
estimated using a logistic regression model with receipt of palliative care services as the outcome and the following characteristics as predictors: age, gender, marital status, race, insurance status, attending physician specialty, primary diagnosis, illness severity score, and LOS. These characteristics were modeled using sets of indicator variables defined by categories shown in Table 1. Within strata defined by vital status at discharge, palliative care patients were matched 1:1 to comparison patients using the nearest neighbor method.20 The largest acceptable difference in propensity scores between an IPC patient and his or her matched comparison patient was 20% of the score’s standard deviation (SD). Statistical analysis
Distributions of characteristics between IPC patients and propensity-matched non-IPC patients were compared. Differences in these distributions were tested using the v2 statistic. Average costs within both groups and the average (95% confidence interval [CI]) difference in costs between the two groups were calculated. Differences in overall costs per admission and per-day and subgroup-specific costs per admission were also calculated. The proportions of readmissions within 30 days of discharge were compared using the v2 statistic. Statistical significance was defined as p < 0.05 or a CI excluding the null difference of zero.
Outcomes and patient characteristics
Outcomes of interest were hospitalization costs and 30-day hospital readmissions. Total cost per admission and average cost per day within each admission were calculated overall and within subgroups according to service type, as captured by Universal Billing form 92 (UB-92) revenue codes in administrative databases. Cost subgroups included intensive care (UB-92 200–209), diagnostic imaging (320–329, 341, 350–359, 400–409, 610–619), laboratory (300–319), and pharmacy including intravenous therapy (250–269). Readmissions were defined as admissions to any of the following hospital units between 1 and 30 days after discharge from the first hospital stay: ICU, emergency room, telemetry cardiac, neuro-stepdown, medical stroke, intermediate care, cardiac care, and general nursing. Admissions to palliative care and rehabilitation units were not considered readmissions. Several patient characteristics were examined. Demographic characteristics at enrollment included age, gender, marital status, race, and insurance status. Admission characteristics included the specialty of the attending physician, primary diagnosis, all patient refined diagnosis related group (APR-DRG19) illness severity classification, LOS, discharge status, and utilization of a hospice ‘‘swing bed.’’ These variables were categorized as shown in Table 1. All information used in this analysis was extracted from hospital databases. Propensity score matching
Propensity scores were used to identify a comparison group of patients who did not receive palliative care but were otherwise comparable with regard to measured characteristics.20 Influences of palliative care participation may differ between patients who were discharged alive and those who died while hospitalized. Therefore, two propensity scores were estimated: one for patients discharged alive and another for patients who died in the hospital.4 Both scores were
Cost differences within subgroups
In secondary analyses, cost differences were examined to determine if differences were stronger after rather than before the initial palliative care consult, as would be expected if IPC reduced inpatient costs. Differences in average cost per day between IPC patients and comparison patients were plotted according to day of initial consult (IPC patients) or reference day (comparison members). The reference day was defined as the median day of initial consult among patients receiving palliative care within categorized LOS, ranging from day 6 among patients with 9- to 16-day stays to day 23 among patients with 30- to 43-day stays. A priori, this analysis was restricted to costs from 4 days before the initial consult through 4 days afterward within the subgroup of patients who were admitted for 9 days or longer. Costs differences were examined within subgroups defined by payer (Medicare, Medicare HMO, Medicaid, and commercial/other) for consistency. Finally, to examine whether relationships between palliative care and cost per day differed according to duration of hospitalization, average cost differences within subgroups defined by LOS were calculated. Sensitivity analyses
Inclusion of characteristics in the propensity score that are influenced by the exposure of interest may cause overmatching and biased estimates of the exposure’s effects. For instance, if IPC consults influence the LOS, inclusion of LOS in the propensity score is incorrect. However, the reverse relationship may exist: Patients with longer hospital stays may be more likely to be approached for or be amenable to palliative care services. LOS was positively associated with likelihood of receipt of IPC in this study population. LOS was therefore included as a covariate in the propensity score. In post hoc
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Table 1. Frequency and Percent Distributions of Characteristics at Admission among Inpatient Palliative Care (IPC) Patients and Comparison Patients
Characteristic
IPC patients (n = 1004)
Comparison patients (n = 1004)
N
%
N
%
1.0 0.6 3.2 9.2 13.0 24.8 33.2 15.1
3 7 33 98 121 246 327 169
0.3 0.7 3.3 9.8 12.1 24.5 32.6 16.8
58.9 41.1
538 466
53.6 46.4
40.7
416
41.4
34.3 9.6 14.8 0.6
342 86 153 7
34.1 8.6 15.2 0.7
84.8 12.2 2.8 0.3
875 104 25 0
87.2 10.4 2.5 0.0
37.7 44.7 1.9 3.1 11.2 0.3 1.1
378 452 10 37 111 5 11
37.7 44.9 1.0 3.7 11.1 0.5 1.1
13.6
134
13.4
47.6 32.8 3.7 2.4
455 354 35 26
45.3 35.3 3.5 2.6
1.4 21.1 6.5 6.4 5.4 8.4 4.6 3.2 4.2 13.2 22.3
13 231 66 62 45 85 40 25 41 137 230
1.3 23.0 6.6 6.2 4.5 8.5 4.0 2.5 4.1 13.7 22.9
3.5
29
2.9
Age (years) 23–29 10 30–39 6 40–49 32 50–59 92 60–69 130 70–79 249 80–89 333 90–102 152 Gender Female 591 Male 413 Marital status Married or with 409 life partner Widowed 344 Divorced or separated 96 Single 149 Unknown 6 Race White 851 Black 122 Other 28 Unknown 3 Insurance status Medicare 379 Medicare HMO 449 Medicaid 19 Medicaid HMO 31 Commercial 112 Self-pay 3 Other 11 Attending physician specialty Family medicine 136 or pediatrics Internal medicine 478 Reference 329 Surgery 37 Other 24 Primary diagnosis Blood 14 Circulatory 212 Digestive 65 Endocrine 64 Genitourinary 54 Infection/parasite 84 Injury/poisoning 46 Musculoskeletal 32 Neoplasm 42 Respiratory 132 Symptoms, signs, 224 conditions Other 35 APR-DRG illness severity score
(continued)
Table 1. (Continued)
Characteristic 1 (minor) 2 (moderate) 3 (major) 4 (extreme) Length of stay (days)a 1–2 3–5 6–8 9–16 17–29 30–43 Discharge statusa Home, self-care Inpatient facility Skilled care Hospice at home Hospice facility Died in hospital Utilization of hospice ‘‘swing bed’’a
IPC patients (n = 1004)
Comparison patients (n = 1004)
N
%
N
%
7 113 404 480
0.7 11.3 40.2 47.8
113 102 443 454
0.5 10.2 44.1 45.2
114 244 195 270 132 49
11.4 24.3 19.4 26.9 13.1 4.8
170 255 156 243 129 51
16.9 25.4 15.5 24.0 12.9 5.1
76 8 289 136 207 288 105
7.6 0.8 28.8 13.5 20.6 28.7 10.5
260 36 409 8 3 288 4
25.9 3.6 40.7 0.8 0.3 28.7 0.4
a 2
v p < 0.05. APR-DRG, all patient refined diagnosis related group; HMO, health maintenance organization.
analyses, the impact of this decision was evaluated by using a comparison group identified from scores based on all predictors listed above, excluding LOS (using separate scores for patients discharged alive and those who died in the hospital). Similarly, receiving IPC services may be associated with likelihood of death during hospitalization. Therefore, the sensitivity of the results was also examined by using a comparison group identified from a single propensity score that did not include vital status at discharge as a stratifying characteristic or as a predictor. Results
During the study period, 1116 individuals received palliative care services during an inpatient stay. Thirty-five of these received IPC during multiple hospital stays; only the first stay was included in this analysis. About one-third (356) of patients died during their hospitalizations. This analysis excluded 54 participants who were admitted for 45 to 453 days. Another 58 participants, 48 of whom died while hospitalized, were also excluded due to a lack of well-matched comparison patients. These 58 excluded participants had longer hospitalizations than the deceased participants included in the analysis (17.2 days versus 10.3 days, on average), but were otherwise similar. The final analytic sample included 1004 IPC patients, of whom 288 died in the hospital, and their propensity-matched comparison group of equal size. Characteristics at admission were similar between IPC patients and matched comparison patients (Table 1). The distributions of categorized LOS were statistically significantly
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Table 2. Average Hospitalization Cost and Average (95% CI) Difference in Cost between Inpatient Palliative Care (IPC) Patients and Comparison Patients Cost Cost per admission ($) All patients Discharged alive Died in hospital Cost per day ($) All patients Discharged alive Died in hospital
Palliative care participants
Comparison patients
Palliative versus comparison
9713 8421 12,924
11,114 9653 14,748
- 1,401 ( - 2,481 to - 322) - 1,231 ( - 2,205 to - 257) - 1,824 ( - 4,636 to 988)
991 844 1,742
1,219 1,009 1,355
- 228 ( - 316 to - 140) - 164 ( - 234 to - 94) - 387 ( - 624 to - 151)
Both groups comprised 1004 individuals: 716 discharged alive and 288 who died in the hospital. CI, confidence interval.
different between the two groups: IPC patients were less likely to have stays < 3 days than comparison patients (11.3% versus 16.9%, respectively). However, average LOS was similar between IPC patients (mean – SD: 10.3 – 0.3 days) and comparison patients (9.8 – 0.3 days). Distributions of discharge status differed significantly between the two groups: IPC patients were considerably more likely to be discharged to hospice care at home (13.5% versus 0.8%) or a hospice facility (20.6% versus 0.3%) than comparison participants; distributions of those who died while hospitalized were identical by design. IPC patients were also more likely to utilize a hospice swing bed (10.5% versus 0.4%). Cost per admission was $1,401 lower, on average, among IPC patients than comparison patients (95% CI: $322 to $2,481 lower) (Table 2). The cost reduction was somewhat more pronounced among patients who died in the hospital ($1,824 lower among IPC patients) than those discharged alive ($1,231 lower). IPC was also associated with lower cost per day: $228 lower overall, $164 lower among those who died, and $387 lower among live discharges, on average. All differences except admission costs for those who died in the hospital were statistically significant. Costs for intensive care and laboratory services were lower among IPC patients than matched comparison patients ($492 and $109 lower, respectively) (Table 3). Diagnostic imaging and pharmacy costs were not strongly associated with the receipt of IPC services ($16 and $20 lower among participants, respectively). Relationships between IPC and service-specific costs were generally similar between patients discharged alive and those who died in the hospital. The difference in cost per day between IPC patients and comparison patients was most apparent on and after the day of initial consult (Fig. 1). Average cost per day was $101 lower in the 1 to 4 days before the initial consult and $233 lower 0 to 4 days after the consult among IPC patients versus comparison patients hospitalized for 8 to 43 days. A similar pattern was observed among patients hospitalized for 1 to 7 days (data not shown). This pattern was more pronounced among patients who died in the hospital than those discharged alive (data not shown). Overall, the likelihood of readmission did not differ between IPC patients and comparison patients (6.7% versus 6.6%, p = 0.92). However, IPC patients discharged to a hospice facility, hospice swing bed, or hospice at home were significantly less likely to experience a readmission than
comparison patients (1.1% versus 6.6%, p < 0.01). IPC patients discharged to home, skilled care, and other facilities had a significantly higher risk of readmission than comparison patients (12.1% versus 6.6%, p < 0.01). The relationship between IPC and cost per day was robust to our choice of propensity score estimator. Results did not change when using either scores unadjusted for LOS or a single score estimated from both live discharges and those who died in the hospital (data not shown). The relationship between cost per day and IPC was also generally consistent within subgroups defined by LOS and payer (data not shown). Discussion
This study adds to the evidence that IPC results in lower hospitalization cost regardless of vital status at discharge. The average cost reduction was 13% in this study, similar to the 11% reduction among New York State Medicaid recipients
Table 3. Average Service-Specific Costs and Average (95% CI) Difference in Costs per Admission between Inpatient Palliative Care (IPC) Patients and Comparison Patients: Overall and According to Discharge Status Cost per admission ($) Intensive care All patients Discharged alive Died in hospital Diagnostic imaging All patients Discharged alive Died in hospital Laboratory All patients Discharged alive Died in hospital Pharmacy All patients Discharged alive Died in hospital
IPC Comparison patients patients
Palliative versus comparison - 492 ( - 985 to 2) - 488 ( - 878 to - 97) - 500 ( - 1879 to 879)
2148 1397 4020
2640 1885 4520
288 283 376
304 253 357
614 520 847
722 616 987
- 109 ( - 175 to - 42) - 96 ( - 155 to - 37) - 139 ( - 312 to - 34)
599 528 777
620 546 802
- 20 ( - 109 to 68) - 18 ( - 98 to 62) - 25 ( - 259 to 208)
- 16 ( - 45 to 12) - 30 ( - 62 to 1) 20 ( - 41 to 80)
Both groups comprised 1004 individuals: 716 discharged alive and 288 who died in the hospital. CI, confidence interval.
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FIG. 1. Average cost per day for inpatient palliative care (IPC) patients (black bars) and comparison patients (white bars) according to day from initial consult or reference day. Reference day within comparison patients is defined as the median day between admission and initial consult among IPC patients with similar length of stay; see text for details. Figure is based on data from 451 palliative care participants and 423 comparison patients who were hospitalized for 9 to 43 days and discharged alive or dead. observed by Morrison and coworkers.4 Relative cost savings shown here were also similar to the 14% reduction observed in a matched cohort study in a California academic medical center.3 In a matched cohort analysis of patients in two academic centers from 2005 to 2008, cost savings were 13% greater among IPC patients; however, cost savings were not apparent among patients with hospitalizations of 30 days or more.1 In contrast, we found no difference in cost savings according to LOS. In two separate observational studies of veterans receiving care at several hospitals from 2002 to 2006, Penrod et al. observed lower costs per day for patients receiving palliative care ($239 and $464 lower in their first and second studies, respectively).14,15 In their more recent study,15 nursing, laboratory, and radiology costs were lower among palliative care patients, although pharmacy costs were higher. There have been fewer examinations of the relationship between palliative care and 30-day risk of readmission. Enguidanos and colleagues16 showed that 10% of patients who received an IPC consultation were readmitted within 30 days of discharge. The rate of readmission was much lower within the subgroups that received outpatient hospice or palliative care follow-up after discharge (4.6% and 8.3%, respectively) than those patients discharged without in-home care (25.7%). The study was undertaken at a managed care medical center with a well-supported home-based palliative care team. Therefore, the results may not be applicable to many areas of the United States with a relative lack of home-based palliative care services outside of the Medicare Hospice Benefit. Ranganathan and coworkers,17 using a propensity matched cohort, recently showed a reduced risk of 30-day readmission via a home-based palliative care program. Neither IPC consultation nor hospice referral rates were examined in this study. In this current study, the overall likelihood of readmission did not differ between IPC patients and comparison patients
(6.7% versus 6.6%). IPC patients discharged with hospice care at home or to a hospice facility, however, had a much lower 30day readmission rate (1.1%) than IPC patients discharged to home, skilled care, or other facilities without hospice support (12.1%). Our study adds to the emerging evidence base suggesting that significant decreases in 30-day readmissions among IPC patients who survive to discharge can generally only be achieved via discharge with hospice care or homebased palliative care.16 In many communities, hospice programs are often the sole provider of home-based palliative care, usually under the Hospice Medicare Benefit. This study suggests that inpatient palliative programs should work closely with hospice programs when discharging eligible patients. This, and other studies,16,17,21,22 suggest the need for novel funding sources to support robust home-based palliative care offerings, outside the Hospice Benefit, to expand the palliative continuum to those patients still receiving active treatments or who have a prognosis > 6 months. Preliminary data (unpublished) from our center show significant cost reductions, hospital and emergency department avoidance, and more timely hospice referral among patients in a home-based palliative care program financially supported by a local commercial and Medicare Advantage insurance company. Our study population is larger than that examined in many previous studies, affording us power to detect differences in service-specific costs and to examine costs per day according to the timing of the initial consultation. The diversity of the analytic population, for example with regard to payer and primary diagnosis, is also a strength of this study. Because of our exclusion criteria, these results may not be generalizable to patients with longer hospitalizations. Furthermore, we were unable to identify appropriate comparison patients for about 5% of the patients. However, these exclusions were a small proportion of the total population of IPC patients.
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Therefore, to the extent that the patients at these two hospitals during the study period are representative of western New Yorkers, these results are likely applicable to the regional and possibly national population of adults who would choose to participate in IPC. Similarities in characteristics at admission suggest that palliative care participants were well matched to comparison patients. Additionally, our findings were robust to covariates included in the propensity score, suggesting that cost savings associated with palliative care were not mediated by LOS or vital status at discharge. Finally, cost differences between palliative care participants and comparison patients were strongest at and after the day of initial consult. This temporal specificity supports a causal relationship. However, as with any observational study, we cannot discount the possibility that unmeasured characteristics may have influenced both the likelihood of participation in palliative care and outcomes of interest. Such characteristics could account for part or all of the cost reductions and differences in readmission rates observed here. Furthermore, the higher rate of readmission among IPC patients who were not discharged to hospice services might reflect a selection bias among the IPC patients; the fact that a palliative care consult was requested, and hospice services declined, might indicate a patient, or family, with more aggressive, unrealistic goals. These limitations notwithstanding, these results suggest that participation in IPC reduces hospitalization costs and, combined with postdischarge hospice coordination, reduces the likelihood of readmission among adult western New Yorkers.
10.
Acknowledgments
15.
The authors gratefully acknowledge Joseph A. Bach and William D. Riemer of the Center for Hospice & Palliative Care for the coordination and acquisition of data needed to complete the study. The authors also wish to thank Carol Kopacz and Jennifer Graff of Kaleida Health (Buffalo, NY) for the provision of data, without which the study could not have been accomplished. Further, the authors thank Debra L. Luczkiewicz, MD, and Elizabeth Marks, MS, for editorial review of the manuscript.
6. 7. 8. 9.
11.
12. 13. 14.
16. 17.
18.
Author Disclosure Statement
No competing financial interests exist.
19.
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Address correspondence to: Pei C. Grant, PhD Center for Hospice and Palliative Care 225 Como Park Boulevard Cheektowaga, NY 14227 E-mail: [email protected]
