Advance care planning is a measurably good move

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. Can advance care planning aid in bending these metrics in a favorable direction? We would argue in the affirmative.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study following more than 600 incurable cancer patients looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Baseline end-of-life discussions were documented with a single question: "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, not only did costs turn out to be lower by over 35% but quality of care was rated by family members to be higher and people were more likely to spend their final days at home rather than in the hospital (53.8% vs. 37.8%).

This is particularly impressive against the backdrop, demonstrated in many studies, that, when these conversations do occur they last for only a few minutes, the patients don’t have an opportunity to adequately express themselves, caregivers are left wanting more information, and details on specific elements of choices for care are scant.

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

Translation? When using the Dartmouth Atlas Study data from 2007 to compare the number of days spent in the hospital and cost of care over the last 2 years of life, the Gunderson numbers are far more attractive. Their patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000 during the same period of time.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.