The Growth of Palliative Care Programs in United States Hospitals

JOURNAL OF PALLIATIVE MEDICINE Volume 8, Number 6, 2005 © Mary Ann Liebert, Inc.

The Growth of Palliative Care Programs in United States Hospitals R. SEAN MORRISON, M.D.,1,2 CATHERINE MARONEY-GALIN, M.A., M.P.H.,1 PETER D. KRALOVEC,3 and DIANE E. MEIER, M.D.1

ABSTRACT Background: Palliative care programs are becoming increasingly common in U.S. hospitals. Objective: To quantify the growth of hospital based palliative care programs from 2000–2003 and identify hospital characteristics associated with the development of a palliative care program. Design and measurements: Data were obtained from the 2001–2004 American Hospital Association Annual Surveys which covered calendar years 2000–2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data. Results: Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor-profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than nonCatholic Church-operated hospitals and hospitals without hospice programs respectively. Conclusions: Our data suggest that although growth in palliative care programs has occurred throughout the nation’s hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals.

INTRODUCTION

A

LTHOUGH SURVEYS of healthy adults suggest that most would like to die at home,1 and despite the rapid growth of the hospice industry in the United States since 1982 when the Medicare

Hospice Benefit was enacted, most Americans still die in hospitals. In 2004, more than 50%2,3 of Americans with serious illness died in an acute care hospital and more than 90% of Medicare beneficiaries will be hospitalized in the year prior to death.4 In recognition of the importance hospitals

1Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and the Center to Advance Palliative Care, Mount Sinai School of Medicine New York, New York. 2Geriatric Research, Education, and Clinical Center, Bronx VA Medical Center, Bronx, New York. 3Health Care Data Center of the American Hospital Association, Chicago, Illinois.

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play in the care of persons with serious and advanced illness, a number of initiatives have focused on promoting the development of palliative care programs and practitioners in U.S. hospitals. In 2001, we published the first report of the prevalence of hospital-based palliative care

TABLE 1.

CHARACTERISTICS

Country region New England Middle Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific Other associated area Region size (persons) Nonmetropolitan 100,000 100,000–250,000 250,000–500,000 500,000–1 million 1–2.5 million 2.5 million Number of hospital beds 6–24 25–49 59–99 100–199 200–299 300–399 400–499 500 and over Critical care beds 0–14 15 or more Ownership Not for profit State, city, county For profit Federal-non-VA VA ACS cancer program No ACS cancer program ACGME residency program No ACGME residency program AAMC Council teaching hospital Not an AAMC council teaching hospital Catholic Church-operated Non-Catholic Church-operated Affiliated with a hospice Not affiliated with a hospice

OF

programs in the United States.5 In this study, we update this report by examining the growth of hospital based palliative care programs from 2000–2003 and expand upon it by identifying hospital characteristics that predict both the presence and development of a palliative care program.

HOSPITALS HAVING

A

PALLIATIVE CARE PROGRAM

2000 No (%) n 4156

2001 No (%) n 4064

2002 No (%) n 4163

2003 No (%) n 4221

48 90 102 121 22 62 66 42 55 0

(28) (23) (17) (20) (8) (10) (11) (14) (15) (0)

55 108 118 132 39 90 62 52 81 0

(31) (29) (20) (21) (11) (14) (11) (18) (19) (0)

68 116 142 140 40 125 69 74 105 0

(38) (31) (25) (23) (10) (20) (12) (25) (21) (0)

77 134 170 175 43 139 82 82 117 1

(43) (36) (28) (27) (11) (22) (14) (28) (23) (6)

165 14 58 67 70 126 112

(14) (33) (18) (19) (21) (22) (21)

201 18 75 67 79 154 143

(11) (40) (23) (20) (24) (28) (26)

236 19 84 83 93 188 176

(12) (42) (25) (24) (27) (33) (31)

286 23 98 102 103 206 199

(15) (49) (29) (29) (30) (35) (34)

8 39 67 135 119 75 63 106

(3) (5) (8) (13) (21) (25) (39) (46)

5 52 84 156 138 98 72 132

(2) (7) (10) (16) (26) (32) (43) (58)

18 62 99 175 166 134 78 147

(7) (8) (11) (18) (31) (42) (50) (65)

16 83 119 217 188 142 90 162

(6) (10) (14) (22) (34) (45) (57) (65)

344 (11) 267 (31)

413 (13) 324 (38)

502 (15) 377 (44)

595 (18) 422 (46)

449 78 26 5 54 355 257 251 361 134 478 131 481 300 311

540 15 34 3 55 423 313 299 437 162 574 158 578 386 413

656 117 37 6 63 504 374 352 526 186 692 202 676 466 413

758 137 47 3 72 561 456 381 636 208 809 232 785 545 595

(19) (7) (5) (11) (65) (30) (9) (36) (11) (46) (12) (24) (13) (10) (29)

(23) (10) (7) (7) (74) (36) (11) (43) (13) (58) (15) (30) (16) (36) (13)

(27) (11) (7) (15) (79) (42) (13) (48) (15) (65) (18) (37) (19) (43) (14)

(30) (14) (8) (10) (84) (46) (15) (52) (18) (68) (21) (41) (22) (49) (18)

VA, Veterans Administration; ACS, American College of Surgeons; ACGME, American Council of Graduate Medical Education; AAMC, American Association of Medical Colleges.

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GROWTH OF PALLIATIVE CARE IN U.S. HOSPITALS

METHODS This study was undertaken to examine the development of hospital-based palliative care programs across the United States from 2000–2003 using data obtained from the American Hospital Association (AHA) Annual Survey. The AHA surveys all hospitals, both AHA member and nonmember hospitals, in the United States and its associated areas (American Samoa, Guam, the Marshall Islands, Puerto Rico, and the Virgin Islands) on an annual basis. Data included in the survey are: organizational structure and source of control of the hospitals (not-for-profit, church-operated, for-profit, government–federal, and government–nonfederal); clinical facilities or services offered by the hospitals (e.g., general medical–surgical care, pediatrics care, various types of intensive care units, physical rehabilitation, psychiatric services, cardiac programs, acquired immune deficiency syndrome [AIDS] care, etc.); beds and utilization, Medicare/Medicaid utilization; revenues; expenses; uncompensated care; and professional staffing levels (e.g., physicians, dentists, residents, nurses). For the facilities and services, the survey also requests information on the manner in which a service is provided (e.g., hospitalowned, provided by the hospital’s health system or network, and/or provided through a formal contract between the hospital and another provider). Survey response rates over the past 5 years have averaged 86%. In 2001, the AHA Annual Survey began surveying hospitals as to the presence of a palliative care program. In the questionnaire, a palliative care program is defined as, “an organized program providing specialized medical care, drugs or therapies for the management of acute or chronic pain and/or the control of symptoms administered by specially trained physicians and other clinicians; and supportive care services, such as counseling on advanced directives, spiritual care, and social services, to patients with advanced disease and their families.” Hospitals are also surveyed as to whether they operate a community hospice program. For the years 2000–2003, we identified all programs that self-reported the presence of a hospital-owned palliative care program. Adult hospitals included general medical–surgical hospitals, specialized cancer hospitals, and specialized cardiac hospitals. We excluded rehabilitation hospi-

tals, psychiatric hospitals, hospitals that only provided obstetric services, subacute and chronic care facilities, and eye, ear, nose, and throat hospitals. For pediatric programs, we included hospitals that limited admission to children and provided acute medical and surgical services. We used multivariate logistic regression to identify hospital characteristics significantly associated with the presence of an adult palliative care program in the 2003 survey data. Covariates entered into the model were those that reached borderline significance (p 0.15) in univariate and bivariate analyses or had construct validity. A similar series of analyses were performed to explore the growth of palliative care programs in pediatric hospitals.

RESULTS Characteristics of hospitals having an adult palliative care program are in Table 1. Figure 1A displays the growth of adult palliative care programs in the United States. Figure 2 displays the geographic locations of hospitals reporting an adult palliative care program in 2000 and 2003. Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Table 2 details hospital and region characteristics that were significantly associated with the presence of a hospitalbased palliative care program. Of note, hospitals located in New England were significantly more likely to have a palliative care program than hospitals in all other regions of the country except for the Mountain Region after controlling for other variables. Greater numbers of hospital beds (Table 2) and critical care beds (odds ratio 1.02; 95% confidence interval [CI], 1.01–1.03; p 0.001) increased the likelihood of having a palliative care program as did being a member of the American Association of Medical Colleges Council of Teaching Hospitals (odds ratio 1.95; 95% CI, 1.35–2.81; p 0.001), and an American College of Surgery (ACS)-approved cancer hospital (odds ratio 1.48; 95% CI, 1.19–1.85; p 0.001). Compared to not-for profit hospitals, VA hospitals were significantly more likely to have a palliative care program (odds ratio 8.01; 95% CI, 4.36–14.74; p 0.001) and city, county, or state and for-profit hospitals were significantly less likely to have a palliative care program (odds ratio 0.69; 95% CI, 0.54–0.88;

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FIG. 1.

Growth of palliative care programs in adult and pediatric hospitals from 2000 to 2003.

p 0.003 and odds ratio 0.44; 95% CI, 0.31– 0.63; p 0.001, respectively). Finally, hospitals that reported being operated by the Catholic Church were significantly more likely to have a

palliative care program than non-Catholic Church-operated hospitals and hospitals that owned their own hospice program were more also likely to report a palliative care program.


FIG. 2.

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Geographic location of palliative care programs in U.S. Hospitals in 2000 (top) and 2003 (bottom).

Figure 1B displays the growth of palliative care program in pediatric hospitals. Pediatric palliative care programs increased from 15 programs in 2000 (15% of all pediatric hospitals) to 24 programs in 2003 (23% of all pediatric hospitals). The only significant predictor of a hospital-based pediatric palliative care program in multi-variate modeling was the presence of a hospital owned hospice.

DISCUSSION The 67% growth in hospital palliative care programs demonstrated by these data between 2000 and 2003 reflects and is supported by an associated growth in the numbers of certified palliative medicine physicians (1892 as of July 2005),6 and nurses (over 5500 as of March 2005)7; increases in postgraduate palliative medicine fellowships

(from 17 in 20008 to 53 in 20059)and other training programs; and an increase in scholarly journals,10 publications11, and research funding focused on this field. Reasons advanced12,13 to account for this growth in palliative care providers and clinical and educational programs may include the increases in numbers and costs of chronically ill Medicare patients turning to the healthcare system for care14–17; the recognition based both on research18–22 and repeated media and personal complaints23,24 that the quality of care delivered to the seriously and chronically ill is suboptimal, specifically with respect to treatment of pain and other symptoms, communication about the goals of medical care and decisions that should follow, and continuity of healthcare across treatment settings),12,25,26 and, not least, the hundreds of millions of dollars invested in the growth of the field by The Robert Wood Johnson Foundation, the

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MORRISON ET AL. TABLE 2.

PREDICTORS

OF

HAVING

A

HOSPITAL-BASED PALLIATIVE CARE PROGRAM Odds ratio (95% CI)

Census region (reference is New England) Middle Atlantic South Atlantic East North Central East South Central West North Central West South Central Mountain Pacific Bed size (reference is less than 25 beds) 25–49 beds 50–99 beds 100–199 beds 200–299 beds 300–399 beds 400–499 beds 500 or more beds Number of critical care beds Ownership (reference is not-for-profit) State, municipal, county for profit Federal-non-VA VA American College of Surgeons-approved cancer program ACGME residence training program AAMC Council of teaching hospitals member Operated by the Catholic Church Hospital owns a hospice program

IN

2003 p

0.54 0.61 0.55 0.26 0.57 0.38 0.90 0.54

(0.35, (0.40, (0.30, (0.16, (0.37, (0.24, (0.56, (0.35,

0.83) 0.94) 0.68) 0.44) 0.88) 0.60) 1.50) 0.83)

0.01 0.02 0.001 0.001 0.01 0.001 0.8 0.005

1.59 1.79 2.59 3.30 4.04 5.05 5.41 1.03

(0.90, (1.01, (1.46, (1.91, (2.13, (2.47, (2.60, (1.02,

2.83) 3.16) 4.58) 6.00) 7.67) 10.30) 11.2) 1.04)

0.10 0.046 0.001 0.001 0.001 0.001

0.69 0.45 0.88 8.01 1.54 0.99 1.87 1.90 4.52

(0.54, (0.32, (0.26, (4.26, (1.23, (0.74, (1.29, (1.50, (3.78,

0.88) 0.64) 3.06) 15.51) 1.91) 1.26) 2.70) 2.39) 5.40)

0.003 0.001 0.9 0.001 0.001 0.8 0.001 0.001 0.001

0.001

CI, confidence interval; VA, Veterans Administration; ACGME, American Council of Graduate Medical Education; AAMC, American Association of Medical Colleges.

Open Society Institute’s Project on Death in America, and others.27 The growth of hospital-based palliative programs may also be in response to the increasing body of evidence supporting the beneficial effects of these programs on a range of important outcomes. Hospital palliative care programs have been associated in preliminary studies with demonstrable improvements in both care quality and health care costs. Systematic reviews and meta-analysis32–35 of hospital palliative care programs demonstrated improvement in pain, nonpain symptoms, patient and family satisfaction, as well as reduced hospital length of stay and inhospital death rates. Others36 have reported a high rate of implementation of interventions recommended by palliative care consultants, including symptom management, goal setting, advance care planning, and discharge planning. Finally, several single-center studies of palliative care37,38 and multicenter studies of ethics consultation39,40 have suggested substantial reductions in direct and indirect costs associated with hos-

pital palliative care compared to conventional care, an observation that has thus far been consistent across a range of hospital settings, patient populations, and clinical service delivery models. Our data suggest that although growth in palliative care programs has occurred throughout the nation’s hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals were significantly more likely to develop a program compared to other hospitals. Possible reasons for the patterns of growth that we observed include VA policy that mandates palliative care programs28; the growth in palliative care research and fellowship training programs within academic medical centers9,29; philanthropic foundation investment in large academic programs27; and the disproportionate impact of the increases in numbers and costs of chronically ill Medicare patients on larger hospitals.26,30,31 Despite these preliminary data suggesting improvements both in health care quality and in costs as a result of hospital palliative care interventions, research is needed41 to assure that these


new palliative care programs are supported in the delivery of evidence-based quality and efficient care, and to confirm and explore the early reports of their benefits. Specifically, studies are necessary to define replicable and standardized interventions for the core components of palliative care (symptom management, doctor–patient communication, and coordination of care across settings); to determine what components of palliative care team interventions are associated with improved outcomes (and which are not); as well as to determine which clinical models are optimal for specific care settings (hospital, long term care, home, capitation versus fee for service) and patient populations.11,20 Additional strategies are required to stimulate growth in smaller community based hospitals, perhaps with alternate program structures. The future of palliative care as a specialty and the evolution of accessible clinical palliative care programs of reliable quality depends critically upon the availability of such data.

ACKNOWLEDGMENTS This project was supported by a grant from The Robert Wood Johnson Foundation, Princeton, New Jersey. Dr. Morrison is the recipient of a Mid-career investigator award in patient oriented research from the National Institute on Aging (K24 AG022345). Dr. Meier is the recipient of an Academic Career Leadership Award from the National Institute on Aging (K07 AG00903). Dr. Morrison had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Address reprint requests to: R. Sean Morrison, M.D. Department of Geriatrics Box 1070 Mount Sinai School of Medicine New York, NY 10029 E-mail: [email protected]