Is it important to provide high quality palliative and supportive care in patients with serious illness? Does it matter if we treat pain in patients with metastatic cancer? Does it matter if we listen to patients and provide care consistent with their goals?
I'm sure most health system leaders would answer an emphatic yes! to these questions. But do they really mean it? Will their actions match their words? Unfortunately, the answer to that question will usually be no. If you are serious about improving a care process, you need to measure that process, and use those measurements to improve. Performance measurement has led to many process improvements in health care such as increasing the use of Beta Blockers after MI and the use of screening eye exams to prevent vision loss from diabetic retinopathy. Shouldn't we also be using performance measurement to improve the quality of palliative and supportive care in the seriously ill?
This is what makes a study recently published in JAMA Internal Medicine a crucial leap forward in efforts to improve palliative and supportive care in seriously ill patients with advanced cancer. A team led by first author Anne Walling (@DrAnneMWalling) and senior author Karl Lorenz of UCLA and the Greater LA VA Health System developed measures to assess the quality of palliative care in the Veterans Affairs Health System for patients with advanced cancer (metastatic colon, lung, or pancreatic cancer).
The quality indicators, which focus on pain, non-pain symptoms, and communication, are common sense measures of good and necessary care for seriously ill patients. Each quality indicator takes the form of an IF, THEN statement outlining a clinical scenario and appropriate action. For example:
- If a patient with cancer pain is started on long-term opiod treatment THEN the patient should be offered a prescription or non-prescription bowel regimen within 24 hours or there should be a documented contraindication (52% compliance rate)
- If a patient with cancer undergoes chemotherapy THEN prior to chemotherapy he or she should be informed about the risks and benefits of treatment, including likely benefits and adverse effects and whether treatment intent is curative or palliative--16% compliance rate---:(
In a wonderful accompanying commentary, Melissa Aldridge and Diane Meier (@DianeEMeier) from the Mount Sinai Department of Geriatrics and Palliative Medicine laud this study for proving that the quality of palliative care can be measured. They applaud the VA Health System for supporting this large scale proof of concept effort to measure and improve palliative and supportive care.
The study has good news and bad news for the VA health system. As Aldridge notes, 86% of these patients received palliative care at some point in their illness reflecting the deep penetration of palliative care in the VA. On the other hand, Veterans received only 49.5% of indicated care processes--So only a coin flip chance of getting the right thing done. Clearly the VA has a long long way to go to improve the quality of palliative care for persons with advanced illness. Since the VA has invested far far more in palliative care than the other US health systems, these numbers would certainly be far worse for the typical US patient with advanced cancer.
If we care about improving palliative and supportive care, we have to start by measuring it. Hopefully this study will galvanize national efforts to improve the quality of life and well being for persons dealing with serious advanced illness.
by: Ken Covinsky @Geri_Doc