Cost Effectiveness of a Palliative Care Program
The authors used a retrospective analysis of financial data with intact groups (palliative care compared to non-palliative care) to investigate cost effectiveness. Demographic and financial data from patients who died during fiscal year 2009 (July 1, 2008- June 30, 2009) were selected for the analysis. The hospital granted permission and a university institutional review board approved the study.
The health care setting for the study of palliative care services was a 145-bed community hospital that served 150,000 residents in four rural counties. The hospital provides general medical, surgical, emergency, obstetric, pediatric, home health, and hospice services. The facility is located 60 miles between two major urban southern cities. Admissions for the fiscal year 2011- 2012 were 7,127. The medical staff comprises over 100 physicians all of whom are board certified in internal medicine, surgery, pediatric, obstetric, or gynecology specialties. All major services are provided except invasive cardiology and neurosurgery. The nursing staff consisted of 80% associate- of-nursing educated staff, 15% bachelor-of-science educated staff, and 5% master-of-science educated including APN staff.
The palliative care program was initiated on December 30, 2007 and was promoted through formal medical staff meetings, articles written for the hospital's in-house publications, and word of mouth from the physician champion. Palliative care team members included the APN, case manager, dietitian, social worker, wound care specialist, physical therapist, and chaplain.
All nursing staff members participated in an in-house palliative care class which emphasized how to access the palliative care service, reviewed the team member's roles, and presented key concepts of the palliative care approach. Additionally, a 2-hour pain management course was offered at three different times for all hospital staff.
An acute care APN with 22 years of nursing experience and an additional 6 years of hospice home care experience was the first line of communication for the referrals to the palliative care service. The APN did not initiate referrals; rather, she wore a beeper, responded to pages and telephone calls within 15 minutes, and evaluated patients within 1 hour of consultation in order to mentor the staff about the urgency and importance of relieving pain and suffering in a timely manner. The APN provided in-hospital coverage Monday through Friday from 0800-1700 and 24-hour phone coverage. The hospital hospice on-call staff provided evening, night, and weekend coverage as needed in consultation with the APN.
In 2007, all medical staff members were educated about the new palliative care program, and palliative care services began in January 2008. Physicians were encouraged to offer palliative care to patients who would benefit from care with emphasis on relieving pain and controlling symptoms. Patients were enrolled into palliative care based on the physician's understanding of palliative care's key concepts and their comfort with the palliative care team members. Additionally, staff nurses encouraged physicians to refer patients in need of pain and symptom management. Although this approach could have introduced bias into the study, as an initial step in service development in a small hospital, it was the preferred method.
After 1.5 years of offering palliative care services, the retrospective analysis commenced. The first 6 months of palliative care services were not included in the study because this was a period of time needed to solidify the procedures of referral and delivery of services. The data collection plan conformed to the recommendations of the Center to Advance Palliative Care (2004).
The APN requested a list of all patients who had died during the study period of July 1, 2008 to June 30, 2009 from the hospital's department of information systems. The APN reviewed the list, excluded the patients who died in the emergency department, and sorted the patients according to whether or not they had received palliative care. Patients were coded as 0 for no palliative care services and 1 for having received palliative care. The patient data set included the patient's name, age, gender, race, marital status, length of stay (LOS), hospital charges, discharge diagnosis, physician, date of death, and thirdparty payer.
The patient data set was then sent to the hospital's financial services department for analysis. Data were extracted for analysis by the financial services staff who utilized the Executive Information System software from Computer Program and Systems, Inc. (2008). The financial analysis included type of third-party payer, LOS, total reimbursement for stay, total cost for stay, and average cost per day.
The final data set including patient and financial data were used for descriptive analysis and to compare costs in non-palliative and palliative care groups using t tests.
Methods
Design
The authors used a retrospective analysis of financial data with intact groups (palliative care compared to non-palliative care) to investigate cost effectiveness. Demographic and financial data from patients who died during fiscal year 2009 (July 1, 2008- June 30, 2009) were selected for the analysis. The hospital granted permission and a university institutional review board approved the study.
Setting
The health care setting for the study of palliative care services was a 145-bed community hospital that served 150,000 residents in four rural counties. The hospital provides general medical, surgical, emergency, obstetric, pediatric, home health, and hospice services. The facility is located 60 miles between two major urban southern cities. Admissions for the fiscal year 2011- 2012 were 7,127. The medical staff comprises over 100 physicians all of whom are board certified in internal medicine, surgery, pediatric, obstetric, or gynecology specialties. All major services are provided except invasive cardiology and neurosurgery. The nursing staff consisted of 80% associate- of-nursing educated staff, 15% bachelor-of-science educated staff, and 5% master-of-science educated including APN staff.
Initiation of Palliative Care Program
The palliative care program was initiated on December 30, 2007 and was promoted through formal medical staff meetings, articles written for the hospital's in-house publications, and word of mouth from the physician champion. Palliative care team members included the APN, case manager, dietitian, social worker, wound care specialist, physical therapist, and chaplain.
All nursing staff members participated in an in-house palliative care class which emphasized how to access the palliative care service, reviewed the team member's roles, and presented key concepts of the palliative care approach. Additionally, a 2-hour pain management course was offered at three different times for all hospital staff.
An acute care APN with 22 years of nursing experience and an additional 6 years of hospice home care experience was the first line of communication for the referrals to the palliative care service. The APN did not initiate referrals; rather, she wore a beeper, responded to pages and telephone calls within 15 minutes, and evaluated patients within 1 hour of consultation in order to mentor the staff about the urgency and importance of relieving pain and suffering in a timely manner. The APN provided in-hospital coverage Monday through Friday from 0800-1700 and 24-hour phone coverage. The hospital hospice on-call staff provided evening, night, and weekend coverage as needed in consultation with the APN.
Procedure for Study
In 2007, all medical staff members were educated about the new palliative care program, and palliative care services began in January 2008. Physicians were encouraged to offer palliative care to patients who would benefit from care with emphasis on relieving pain and controlling symptoms. Patients were enrolled into palliative care based on the physician's understanding of palliative care's key concepts and their comfort with the palliative care team members. Additionally, staff nurses encouraged physicians to refer patients in need of pain and symptom management. Although this approach could have introduced bias into the study, as an initial step in service development in a small hospital, it was the preferred method.
After 1.5 years of offering palliative care services, the retrospective analysis commenced. The first 6 months of palliative care services were not included in the study because this was a period of time needed to solidify the procedures of referral and delivery of services. The data collection plan conformed to the recommendations of the Center to Advance Palliative Care (2004).
The APN requested a list of all patients who had died during the study period of July 1, 2008 to June 30, 2009 from the hospital's department of information systems. The APN reviewed the list, excluded the patients who died in the emergency department, and sorted the patients according to whether or not they had received palliative care. Patients were coded as 0 for no palliative care services and 1 for having received palliative care. The patient data set included the patient's name, age, gender, race, marital status, length of stay (LOS), hospital charges, discharge diagnosis, physician, date of death, and thirdparty payer.
The patient data set was then sent to the hospital's financial services department for analysis. Data were extracted for analysis by the financial services staff who utilized the Executive Information System software from Computer Program and Systems, Inc. (2008). The financial analysis included type of third-party payer, LOS, total reimbursement for stay, total cost for stay, and average cost per day.
The final data set including patient and financial data were used for descriptive analysis and to compare costs in non-palliative and palliative care groups using t tests.