IAHPC BOARD MEMBERS’ REPORTS

Earlier Access to Palliative Care: But How?
By Dr. Eduardo Bruera

During the last two years, a number of organizations including the American Society of Clinical Oncology and the American Academy of Hospice and Palliative Medicine have strongly advocated for earlier access to palliative care. A number of studies have shown that palliative care is capable of dramatically reducing physical and emotional distress among patients with cancer as well as other chronic progressive diseases such as AIDS, congestive heart failure, and neurological diseases.

In addition, patients referred to palliative care are less likely to receive inappropriately aggressive interventions near the end of their lives such as admissions to ICU, chemotherapy in the last two weeks of life, and are more likely to receive hospice care for longer periods of time. As a result, there is a significant reduction in utilization of healthcare services that reduces the overall cost of care. Finally, a recent study among patients with advanced lung cancer suggests that early access to palliative care might even improve survival as compared to conventional oncology care.

Unfortunately, the vast majority of patients are referred to palliative care during the last three to four weeks of life. This trend has not changed dramatically within the last five years. Except for highly integrated hospital and community programs such as the Edmonton Regional Palliative Care Program, the percentage of eligible patients in the rest of the world who access palliative care is only between 20 and 50%.

The majority of clinical teams are working at full capacity in the United States, Canada, Europe, as well as in most of the developed world. It is completely impossible for such teams to be able to dramatically increase both the number of patients seen and to reach out to these patients much earlier because it increases considerably the number of patient encounters prior to death.

In developing countries, the percentage of patients who access palliative care is lower and the timing of such access is later in the course of the disease than in the developed world.

How do we increase and provide earlier access to palliative care for patients in all regions?
One simple answer is to say we just can’t do that. However, it is possible to provide increased and earlier access for a large number of patients with a relatively small investment.

Palliative care programs are highly successful financially. The reimbursement for the delivery of palliative care services is excellent in countries such as the United States, Latin America, and Europe where fee for service exists. In other countries with global budgets, as well as in the previously mentioned countries, insurers receive large financial benefits when their clients access palliative care since it decreases payments for expensive laboratory tests, imaging, chemotherapy, targeted therapies, unnecessary invasive radiological procedures, dialysis, and intensive care unit admissions. In other words, increasing access to palliative care is a very wise financial investment for third party payers and as well as for institutions.

Specialists treating patients with diseases that most commonly require palliative care, such as oncologists, cardiologists, pulmonologists, and neurologists can greatly decrease the complexity and their time involved in the delivery of care by providing the patients and families early access to a palliative care specialist who will work side-by-side with them. This will allow them to increase their primary specialty practice as well as improve their professional satisfaction.

The leading institutions in each country are quite capable of changing the status quo. They can do so by re-engineering the flow of patients to much larger outpatient palliative care programs capable of following up patients referred early in an integrated manner (usually even on the same day) as the primary specialist.

This will require appropriate allocation of space, physician, and other disciplinary team members. It will need a considerable up-front investment.  However, those institutions capable of seeing the advantages of this practice will not only greatly enhance the quality and arguably even the quantity of life of their patients as well as the quality of life of their family members. They will also reap considerable financial benefits.

IAHPC has been at the forefront of promoting global access to palliative care. It is very gratifying to see that these efforts are starting to result in large scale adoption of our practices.

Dr. Eduardo Bruera has been a board member of the IAHPC since 2001; he was the chairperson during the period 2000-2004. He is the Chair, Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX. His bio may be found at: http://www.hospicecare.com/Bio/bruera.htm