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IAD 06-060 – HSR&D Study

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IAD 06-060
Hospital Costs and Utilization of Veterans Receiving Palliative Versus Usual Care
Joan D Penrod PhD MSW MA
James J. Peters VA Medical Center, Bronx, NY
Bronx, NY
Funding Period: March 2007 - April 2009

BACKGROUND/RATIONALE:
The predominant non-hospice palliative care (PC) delivery model in the U.S. is the interdisciplinary in-patient palliative care consultation team (PCCT). The VHA mandates all facilities to have an interdisciplinary PCCT. Little is known about cost effects of PC consultation.

OBJECTIVE(S):
The research objectives of the study are:
1. To compare total direct, pharmacy and laboratory costs of hospitalized veterans with advanced illnesses who receive PC versus UC, adjusting for the treatment selection effect.
2. To compare the probability of ICU admission and length of stay (LOS) for hospitalized veterans with advanced illnesses who receive PC versus UC, adjusting for the treatment selection effect.

METHODS:
This is an observational, retrospective cost study (VA payer perspective). The sample includes patients admitted to all acute care facilities in VISN 3 FY 05 & FY 06 with ICD-9 codes for: metastatic solid tumor, central nervous system malignancies, metastatic melanoma, locally advanced head and neck cancer, locally advanced pancreatic cancer, HIV/AIDS and at least one the following secondary diagnoses: hepatoma, cirrhosis, lymphoma, cachexia or other cancer, congestive heart failure or chronic obstructive pulmonary disease and either two or more hospitalizations or an ICU admission. Data were derived from the VA Medical SAS inpatient dataset and DSS National Data Extracts. The key independent variable indicated whether the patient received PC. Predictors included patient demographics, LOS, diagnoses, enrollment category and death. We used nonlinear instrumental variables (IV) estimation with simulated likelihood methods in GLM cost models and bivariate probit for ICU admission. Patients' attending MD was the identifying instrument for selection into palliative care.

FINDINGS/RESULTS:
Hospital total direct, pharmacy, nursing, laboratory, and radiological costs were $464, $51, $182, $49 and $11 lower per day (p<0.01 in all cases), respectively, for patients receiving palliative (n=606) compared to usual care (n=3321). PC patients were 43.7 percentage points (p<0.001) less likely to be admitted to ICU.

IMPACT:
Costs of hospital care were significantly lower for PC compared to UC patients with advanced disease. Less frequent use of ICU by PC patients seen is a major source of cost differences. PC has been shown to improve patient and family outcomes. Our results suggest both a cost and quality incentive to expand PC programs.

PUBLICATIONS:

Journal Articles

  1. Garrido MM, Deb P, Burgess JF, Penrod JD. Choosing models for health care cost analyses: issues of nonlinearity and endogeneity. Health services research. 2012 Dec 1; 47(6):2377-97.
  2. Penrod JD, Deb P, Dellenbaugh C, Burgess JF, Zhu CW, Christiansen CL, Luhrs CA, Cortez T, Livote E, Allen V, Morrison RS. Hospital-based palliative care consultation: effects on hospital cost. Journal of palliative medicine. 2010 Aug 1; 13(8):973-9.
  3. Luhrs CA, Penrod JD. End-of-life care pathways. Current opinion in supportive and palliative care. 2007 Oct 1; 1(3):198-201.
  4. Penrod JD, Deb P, Luhrs C, Dellenbaugh C, Zhu CW, Hochman T, Maciejewski ML, Granieri E, Morrison RS. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. Journal of palliative medicine. 2006 Aug 1; 9(4):855-60.
Journal Other

  1. Penrod J, Morrison RS, Meier DE. Studying the effectiveness of palliative care. JAMA : the journal of the American Medical Association. 2008 Sep 3; 300(9):1022-3; author reply 1023-4.
Conference Presentations

  1. Penrod JD, Garrido MM. Depression and anxiety assessment and treatment in Veterans receiving palliative care. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2011 Nov 18; Boston, MA.
  2. Penrod JD, Deb P, Zhu CW, Luhrs C, Livote E, Allen V, Morrison RS. Cost and Utilization Effects of Hospital-based Palliative Care Consultation. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.
  3. Penrod JD, Deb P, Dellenbaugh C, Zhu CW, Luhrs C, Livote E, Allen V, Morrison RS. Cost Savings Associated with Hospital-Based Palliative Care Consultation. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.


DRA: Health Systems
DRE: none
Keywords: Cost, End-of-life, Utilization patterns
MeSH Terms: none

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