Teamwork Improves End-of-Life Care, Saves Cost

Phoebe Starr

January 2016, Vol 6, No 1 - End-of-Life Care


An innovative care model program for end-of-life care for patients with cancer improved symptom management, reduced hospitalizations and in-hospital deaths, and increased the use of hospice care. Moreover, the model saved approximately $7000 per patient in the cost of care. An interim analysis of the first few years of this model also showed that rapid palliative radiation therapy with shorter, higher doses of radiotherapy (hypofractionation) led to pain relief from bone metastases within 1 week for a substantial proportion of patients. Lead investigator Paul W. Read, MD, PhD, Professor of Radiation Oncology at the University of Virginia Health System, presented the interim data at the 2015 Annual Meeting of the American Society for Radiation Oncology. The model, which was introduced in 2012, has 3 components—CARE Track, a data-driven palliative care team that meets weekly and develops coordinated care plans; MY COURSE—a patient-reported outcomes program integrated into electronic health records that triggers e-mail alerts to the CARE Track team for patients with declining health; and STAT RAD—a same-day conformal palliative radiation program with the goal of treating painful bone metastases within 3 to 4 hours. “This shows that if we listen to our patients carefully, talk to them about their changing medical and emotional needs, and develop rapid and coordinated treatment plans based on their feedback, we can improve their quality of life and reduce the need for hospitalization and symptom management at the end of life,” said Dr Read. The program was based on the recognized need for earlier integration of palliative care into management of patients with advanced-stage cancer. “There is a shortage of palliative care specialists in the United States, so we needed to innovate and collaborate,” he explained. “Our solution is collaborative care with 3 programs to target patients with the highest symptom burdens.”

The CARE Track Program

The CARE Track program enrolled 646 patients with cancer. The interim results were based on a comparison of end-of-life care for 368 CARE Track patients versus 198 control patients. Enrollment in the CARE Track program led to significantly fewer end-of-life hospitalizations compared with the control group. In the final 90 days of life, 48.3% of patients in the program were hospitalized compared with 64% of the control patients (P = .004). Hospice care was delivered to more CARE Track patients (69.6% vs 47% of the controls), leading to fewer hospital deaths for CARE Track patients (8.4% vs 38.5%, respectively; P <.001 for both). Moreover, enrollment in CARE Track reduced the total cost of care per patient during the last 90 days of life by $7317 compared with the controls (P = .012).

STAT RAD

STAT RAD was developed to improve the time to response for initiating pain control in patients with bone metastases. The goal of this workflow effort was to transform a 2- to 3-week treatment program into a 1-day treatment procedure with highly focused radiation treatment to reduce treatment-related toxicity. A pilot STAT RAD trial enrolled 28 patients with 1 to 3 painful bone metastases (37 target lesions) who were treated with radiotherapy of 5 Gy to 10 Gy per fraction, for between 2 and 5 fractions (mean, 21.6 Gy in 3.1 fractions). Using International Bone Metastases Consensus Working Party criteria to assess pain response at 3 weeks, partial or complete pain relief was achieved in 80% to 90% of patients. Using the Functional Assessment of Cancer Therapy–Bone Pain scale, quality of life was significantly improved from 1 week after treatment through 26 weeks after the completion of STAT RAD. A second clinical trial is planned to evaluate a more condensed schedule of radiation so it can be completed in a single 3- to 4-hour procedure. Dr Read said that all the components of this model are readily available across the country. “Therefore, these programs can all be adopted into clinical practice at most health systems with minimal cost, training, or education,” Dr Read stated.