Tag Archive for: palliative care

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Resident’s podcast: Palliative care use amongst patients with bladder cancer

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Palliative care use amongst patients with bladder cancer

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

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Article of the week: Palliative care use amongst patients with bladder cancer

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community, a video produced by the authors and a visual abstract created by Charles Scott and Nurhan Abbud. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Palliative care use among patients with bladder cancer

Lee A. Hugar*, Samia H. Lopa*, Jonathan G. Yabes, Justin A. Yu, Robert M. Turner II*, Mina M. Fam*, Liam C. MacLeod*, Benjamin J. Davies*, Angela B. Smith§¶ and Bruce L. Jacobs*

 

*Department of Urology, Department of Medicine, Department of Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA, §Department of Urology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

 

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Fig. 1. Time from diagnosis to receipt of palliative care. The timing of palliative care receipt for those patients who received palliative care (n = 262). Strata with <11 patients were suppressed in accordance with SEER‐Medicare guidelines

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

 

 

 

Video: Palliative care use amongst patients with bladder cancer

Palliative care use amongst patients with bladder cancer

Abstract

Objectives

To describe the rate and determinants of palliative care use amongst Medicare beneficiaries with bladder cancer and encourage a national dialogue on improving coordinated urological, oncological, and palliative care in patients with genitourinary malignancies.

Patients and methods

Using Surveillance, Epidemiology, and End Results‐Medicare data, we identified patients diagnosed with muscle‐invasive bladder cancer (MIBC) between 2008 and 2013. Our primary outcome was receipt of palliative care, defined as the presence of a claim submitted by a Hospice and Palliative Medicine subspecialist. We examined determinants of palliative care use using logistic regression analysis.

Results

Over the study period, 7303 patients were diagnosed with MIBC and 262 (3.6%) received palliative care. Of 2185 patients with advanced bladder cancer, defined as either T4, N+, or M+ disease, 90 (4.1%) received palliative care. Most patients that received palliative care (>80%, >210/262) did so within 24 months of diagnosis. On multivariable analysis, patients receiving palliative care were more likely to be younger, female, have greater comorbidity, live in the central USA, and have undergone radical cystectomy as opposed to a bladder‐sparing approach. The adjusted probability of receiving palliative care did not significantly change over time.

Conclusions

Palliative care provides a host of benefits for patients with cancer, including improved spirituality, decrease in disease‐specific symptoms, and better functional status. However, despite strong evidence for incorporating palliative care into standard oncological care, use in patients with bladder cancer is low at 4%. This study provides a conservative baseline estimate of current palliative care use and should serve as a foundation to further investigate physician‐, patient‐, and system‐level barriers to this care.

Editorial: Palliative care in patients with bladder cancer: an opportunity for value improvement?

The concept of improving value in healthcare translates, in practical terms, to maximizing patient outcomes per dollar spent [1]. Palliative care has been shown to improve quality of life and possibly survival while reducing overall treatment costs amongst the seriously ill by as much as 33% per patient [2]. In this context, appropriate integration of palliative services within urological oncology care can serve as a mechanism for improving value in the field.

In this issue of BJUI, Hugar et al. [3] provide a valuable characterization of the current state of palliative care service utilization for patients with bladder cancer. Within a contemporary population of Medicare beneficiaries, the authors found receipt of palliative care services by only 4.1% of patients with advanced bladder cancer (defined as those with T4, N+, or M+ disease). Most interestingly, this value did not differ in a statistically significant manner from the rate of utilization amongst a broader cohort including all patients with muscle‐invasive (i.e. T2) bladder cancer collectively, nor did the rate of utilization vary by time.

These findings suggest that, generally, clinicians are not taking advantage of a high‐value service for patients with bladder cancer. Furthermore, the fact that utilization rates are not distinctly higher for those who meet criteria for early palliative care under American Society for Clinical Oncology guidelines (i.e. those with metastatic or locally advanced disease) indicates that barriers to adoption may be rooted in factors beyond simple recognition of advanced malignancy. Considered in the context of this study showing no momentum towards increasing adoption, one must consider what clinical or policy interventions could alter current utilization trends.

The authors appropriately identify that absence of physician buy‐in and a traditional lack of emphasis on cost‐conscious care are among the possible explanations for the low, flat utilization figures they observed. Indeed, fee‐for‐service reimbursement is generally oriented towards rewarding volume over quality and is known to encourage inefficiencies, high costs, service duplication, and a lack of care coordination. As such, a powerful corrective counterbalance to these forces could include restructuring reimbursement such that clinicians’ financial incentives become more closely aligned with patient outcomes and goals [4]. Palliative care is merely one of the high‐value services that stands to be more appropriately integrated into clinical practice under such reforms.

Value‐oriented alternative payment models, such as bundled payments, have been shown to improve coordination of care amongst providers [5]. And, in fact, there are already data suggesting that integration of palliative services into an improved care coordination environment yields improved outcomes. For example, a comprehensive care management plan known as the Aetna Compassionate Care Programme was shown to decrease lengths of inpatient hospitalization while resulting in overall end‐of‐life cost savings of 22% [6].

As the appropriate rate of palliative care utilization in muscle‐invasive bladder cancer remains open to debate, so too does the question of which interventions could assist in moving towards that level. In that sense, employing reimbursement incentives as a driver of more appropriate utilization of palliative care services should be viewed as but one of many potential approaches to improve the practice patterns illustrated in the present study. Future research will be necessary to better elucidate both the barriers to palliative care adoption as well as the most effective tactics to overcome them. The authors should be commended for providing the preliminary contextual data for these conversations, as urologists seek to integrate palliative services properly into high‐value care delivery for patients with advanced malignancy.

 

References

  1. Kaplan, RSPorter, MEHow to solve the cost crisis in health care. Harv Bus Rev 20118946– 52
  2. Brumley, REnguidanos, SJamison, P et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc 200755993– 1000
  3. Hugar, LLopa, SYabes, J et al. Palliative care use among patients with bladder cancer. BJU Int 2019123968– 75
  4. Miller, HDFrom volume to value: better ways to pay for health care. Health Aff (Millwood) 2009;281418– 28
  5. Bakker, DHStruijs, JNBaan, CB et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Aff (Millwood)201231426– 33
  6. Spettell, CMRawlins, WSKrakauer, R et al. A comprehensive case management program to improve palliative care. J Palliat Med 200912827– 32

 

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