VA Hospice and Palliative Care:  Identifying Veterans at High Risk of Mortality

Ann Hendricks PhD, Lynn Wolfsfeld MPP  

Health Care Financing & Economics (HCFE)

 Boston VA Healthcare System, HSR&D

April 23, 2008

Email: Ann.Hendricks@va.gov  Lynn.Wolfsfeld@va.gov 

Topics
        - Background on VA Hospice and Palliative Care
        - Overview of RRP
        - Analysis of Inpatients (Methods, Results, Conclusions)
        - Next Steps

VA HPC Initiatives
        - Establishment of National VA Office of Hospice and Palliative Care (2004)
        - Fellowship programs
        - Hospice-veteran partnership programs
        - Directive to establish palliative care consult teams at all VAMCs (2003)

There was an 11% national increase in the number of palliative care consults reported in FY07 (23,240) as compared to FY06 (20,943) for the 127 and 126 facilities reporting respectively. 

From: Hospice and Palliative Care Fiscal Year 2007 Status Report

Number of Palliative Care Consults Vary Across VISNs, FY2006-2007

Proportion of Inpatients Who Died who had Palliative Care Consults,

FY2006-2007

For VA overall, the percentage of inpatient deaths with an associated palliative care consult increased from 42 to 47 percent for FY07. The average number of days between palliative care consult and death also increased from 45 to 47 days (with the median increasing from 34 to 37) from FY06 to FY07. The growth in these areas indicates greater and earlier involvement of palliative care teams with veterans approaching death while the variability among VISNs reflects the varying degrees of palliative care integration.  

From: Hospice and Palliative Care Fiscal Year 2007 Status Report 

FY05 Strategic Initiative*
        - Improving access to hospice and palliative care in inpatient and outpatient settings
        - Exploration of automated case-finding techniques
        - 81% of facilities had no automated case finding method to identify veterans appropriate for HPC

*From HPC FY 2005 Status Report

Project Objectives
        - To work with an expert panel to identify diagnoses and/or events in inpatient, outpatient and long term care settings that could indicated a referral to the hospice and palliative care team
        - To create computer algorithms for the indicators using data elements available in the various national VA databases
        - To determine the prevalence of the indicators
        - To test the final indicators agreed on by the expert panel by merging patients identified with the indicators with mortality data to see how predictive the indicators are

Expert Panel
        - National Director – Hospice and Palliative Care
        - Hospital Administrators (2)
        - Hospice and Palliative Care Specialists

	(2 VA – 1 non-VA)
        - National Chief – Hematology/Oncology
        - ICU Intensivist (1)

Mission Statement

“To develop a practical tool which identifies veterans at substantial risk for needing specialized end-of-life care, often including palliative care and/or hospice services.”

Criteria for Inclusion in Case Finding Metric

Low-hanging fruit

Predicted probability of 50% or more of dying within a year

Cancers with poor prognoses

Multifaceted approach

Across settings and conditions (Inpatient, outpatient, nursing homes)

Patients close to death (days, months+)

ICU Events and Conditions

Chronic conditions

In-depth analysis of conditions meeting first criteria for inclusion  

Low-hanging fruit

Predicted probability of 50% or more of dying within a year

Cancers with poor prognoses

Methods
        - VA NPCD Data FY 2001-2005
        - VA Vital Statistics File (Mortality through March 2006)
        - Population – inpatients with cancer diagnoses
        - Index Date – first appearance of diagnosis (in VA)  after 12 months with no care for that diagnosis (in VA)

Specifications (Populations)

      CANCERS				ICD-9 CODES
        - Head/neck				141-148
        - Trachea/bronchus/lung		162
        - Prostate				185
        - Colon				183 
        - Liver 				155
        - Pancreatic 				157
        - Esophageal				150		
        - Lymphomas				200-202
        - Leukemias (acute)			204.0, 205.0, 206.0, 207.2, 					207.7, 208.0
        - Melanoma 				172
        - CNS					191
        - All other cancers			All remaining  ICD-9 						codes140-239

Regression (SAS – LifeReg)
        - Parametric Accelerated Failure Time Model 
        - Allows for right censoring
        - Dependent Variable
        - Number of months survived
        - Independent Variables
        - Age
        - Gender
        - Advanced Disease
        - Separate model for each condition

Indications of Advanced Disease
        - ICD-9 196 = Secondary and unspecified malignant neoplasm of lymph nodes
        - ICD-9 197 = Secondary malignant neoplasm of respiratory and digestive systems
        - ICD-9 198 = Secondary malignant neoplasm of other specified sites for example (kidney, brain, skin, bone...)

ILLUSTRATIVE SURVIVAL CURVES AND MEDIANS
| Predicted Survival for Inpatients with X Diagnosis without indication of advanced disease |
|-------------------------------------------------------------------------------------------|

ILLUSTRATIVE SURVIVAL CURVES AND MEDIANS
| Predicted Survival for Inpatients with X Diagnosis with indication of advanced disease |
|----------------------------------------------------------------------------------------|

THRESHOLD FOR INCLUSION IN CASE FINDING METRIC
        - Predicted probability of 50% or more of dying within 12 months
        - Equivalent to median predicted months survived <= 12

MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), HOSPITAL INPATIENTS

* ICD-9 196 = Secondary and unspecified malignant neoplasm of lymph nodes;  ICD-9 197 = Secondary malignant neoplasm of respiratory and digestive systems;   ICD-9 198 = Secondary malignant neoplasm of other specified sites for example (kidney, brain, skin, bone...)
| Condition/ Disease          | IdentifyingICD-9 code(s)  or other specification | Indication of advanced disease(ICD-9 codes*) | Inpatient w/ indication of advanced disease(n) | Inpatient without indication of advanced disease(n) |
|-----------------------------|--------------------------------------------------|----------------------------------------------|------------------------------------------------|-----------------------------------------------------|
| Head, neck                  | 141-148                                          | 196,197, or 198                              | 30.1(122)                                      | 22.1(1,696)                                         |
| Trachea, Bronchus, and Lung | 162                                              | 197 or 198                                   | 3.1(867)                                       | 11.0(16,718)                                        |
| Prostate                    | 185                                              | 197 or 198                                   | 22.7(108)                                      | 29.6(5,973)                                         |
| Colon                       | 153                                              | 197 or 198                                   | 11.7(168)                                      | 29.5(5,610)                                         |
| Liver                       | 155                                              | 196, 197 or 198                              | 4.3(59)                                        | 7.3(2,870)                                          |
| Pancreatic                  | 157                                              | 196, 197 or 198                              | 6.2(84)                                        | 6.8(2,410)                                          |
| Esophageal                  | 150                                              | 196, 197 or 198                              | 1.61(59)                                       | 10.1(1,612)                                         |
| Lymphomas                   | 200-202                                          | 197 or 198                                   | 29.0(28)                                       | 24.1(3,101)                                         |
| Leukemias                   | 204.0, 205.0, 206.0, 207.2, 207.8, 208.0         | 8.4(1,425)                                   |
| Melanoma                    | 172                                              | 196, 197 or 198                              | 15.0(21)                                       | 28.8(387)                                           |
| CNS                         | 191                                              | 12.9(1,275)                                  |
| All other cancers           | Remaining cancer  ICD-9 codes (140-239)          | 197 or 198                                   | 6.2(2,363)                                     | 23.3(49,959)                                        |

MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), WITHOUT INDICATION OF

 ADVANCED DISEASE, HOSPITAL INPATIENTS, BY AGE
| <=50                     | 51-60          | 61-70          | 71-75          | 76-80          | 81-85          | >85         |
|-----------------------------|----------------|----------------|----------------|----------------|----------------|----------------|
| Condition/Disease           | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) |
| Head, neck                  | 29.3(129)      | 25.6(576)      | 21.4(457)      | 17.7(223)      | 15.4(175)      | 13.6(107)      | 11.3(29) |
| Trachea, Bronchus, and Lung | 18.0(579)      | 15.4(3,457)    | 12.0(4,835)    | 9.7(2,943)     | 8.0(2,946)     | 6.6(1,525)     | 5.0(433) |
| Prostate                    | 61.7(77)       | 50.7(646)      | 40.7(1,144)    | 32.9(963)      | 27.4(1,298)    | 21.8(1,169)    | 16.3(676) |
| Colon                       | 44.0(175)      | 38.2(998)      | 33.0(1,331)    | 28.9(917)      | 26.0(1,048)    | 23.1(810)      | 20.2(331) |
| Liver                       | 11.2(301)      | 9.4(940)       | 6.6(674)       | 4.8(358)       | 3.5(349)       | 2.4(198)       | 0.9(50) |
| Pancreatic                  | 13.3(122)      | 10.8(551)      | 7.9(577)       | 5.9(389)       | 4.5(390)       | 3.3(273)       | 1.9(108) |
| Esophageal                  | 13.3(69)       | 11.9(444)      | 10.4(441)      | 9.0(253)       | 8.2(229)       | 7.3(142)       | 6.5(34) |
| Lymphomas                   | 40.3(358)      | 32.5(712)      | 26.2(671)      | 20.6(451)      | 17.0(470)      | 13.5(333)      | 10.7(106) |
| Leukemias                   | 24.1(87)       | 17.1(262)      | 11.3(336)      | 7.3(237)       | 4.4(278)       | 2.1(155)       | -1.4(70) |
| Melanoma                    | 39.5(23)       | 35.0(72)       | 31.0(87)       | 27.9(63)       | 25.7(70)       | 24.0(54)       | 21.1(18) |
| CNS                         | 24.3(146)      | 17.8(357)      | 12.4(327)      | 8.0(153)       | 5.3(166)       | 2.6(96)        | -0.1(30) |
| All other cancers           | 36.3(4,091)    | 30.1(11,780)   | 25.0(11,926)   | 20.5(7,013)    | 17.7(7,807)    | 14.9(5,240)    | 12.0(2,102) |

MEDIAN PREDICTED MONTHS OF SURVIVAL (FROM INDEX DATE), WITH INDICATION OF ADVANCED DISEASE, HOSPITAL INPATIENTS, BY AGE
| <=50                     | 51-60          | 61-70          | 71-75          | 76-80          | 81-85          | >85         |
|-----------------------------|----------------|----------------|----------------|----------------|----------------|----------------|
| Condition/Disease           | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) | Median(Number) |
| Head, neck                  | 35.9(13)       | 32.6(47)       | 27.5(40)       | 25.2(6)        | 21.8(12)       | 20.1(3)        | 15.1(1) |
| Trachea, Bronchus, and Lung | 8.8(48)        | 6.1(240)       | 3.1(289)       | 0.4(140)       | -1.3(101)      | -2.7(41)       | -4.7(8) |
| Prostate                    | 51.0(2)        | 42.1(19)       | 33.3(15)       | 23.3(22)       | 17.7(16)       | 14.4(25)       | 7.8(9) |
| Colon                       | 21.9(12)       | 17.5(50)       | 11.7(39)       | 7.7(20)        | 4.8(29)        | 1.9(14)        | -1.6(4) |
| Liver                       | 8.2(6)         | 5.9(17)        | 4.2(20)        | 2.0(11)        | 0.4(4)         | -0.3(1)        |
| Pancreatic                  | 10.9(5)        | 8.4(31)        | 5.7(18)        | 3.5(13)        | 1.8(7)         | 0.9(8)         | -0.2(2) |
| Esophageal                  | 5.2(3)         | 3.3(16)        | 1.7(20)        | 0.3(7)         | -0.4(7)        | -1.4(5)        | -2.3(1) |
| Lymphomas                   | 43.5(1)        | 38.9(4)        | 32.2(9)        | 26.5(7)        | 24.4(3)        | 20.2(3)        | 16.0(1) |
| Leukemias                   |                |
| Melanoma                    | 22.1(2)        | 16.3(11)       | 11.9(2)        | 9.3(2)         | 6.6(3)         | 3.9(1)         |
| CNS                         |                |
| All other cancers           | 15.8(169)      | 11.2(697)      | 6.2(640)       | 1.6(317)       | -1.2(304)      | -3.5(171)      | -6.8(64) |

PRELIMINARY RECOMMENDATIONS FOR CONDITIONS TO INCLUDE IN A CASE FINDING METRIC

FOR CANCER INPATIENTS – ACUTE SETTING
| Condition/Disease           | IdentifyingICD-9 code(s)  or other specification | Indication of advanced disease | Inpatient –Acute w/indication of advanced diseaseAge(n)   | Inpatient – Acute without indication of advanced diseaseAge(n)   |
|-----------------------------|--------------------------------------------------|--------------------------------|-----------------------------------------------------------|------------------------------------------------------------------|
| Head, neck                  | 141-148                                          | 196,197, or 198                | >85(29)                                                |
| Trachea, Bronchus, and Lung | 162                                              | 197 or 198                     | All ages(867)                                             | 61+(12,682)                                                      |
| Prostate                    | 185                                              | 197 or 198                     | >85(9)                                                 |
| Colon                       | 153                                              | 197 or 198                     | 61+(106)                                                  |
| Liver                       | 155                                              | 196, 197 or 198                | All ages(59)                                              | All ages(2,870)                                                  |
| Pancreatic                  | 157                                              | 196, 197 or 198                | All ages(84)                                              | 51+(2,288)                                                       |
| Esophageal                  | 150                                              | 196, 197 or 198                | All ages(59)                                              | 51+(1,543)                                                       |
| Lymphomas                   | 200-202                                          | 197 or 198                     | >85(106)                                               |
| Leukemias                   | 204.0, 205.0, 206.0, 207.2, 207.8, 208.0         | 61+(1,076)                     |
| Melanoma                    | 172                                              | 196, 197 or 198                | 61+(8)                                                    |
| CNS                         | 191                                              | 71+(445)                       |
| All other cancers           | Remaining cancer  ICD-9 codes                    | 197 or 198                     | 51+(2,193)                                                | >85(2,102)                                                    |

Next Steps
        - Assess V66.7 and TS96 codes
        - Refine current analysis - additional look at cancers – outpatients, co-morbidities, LOS
        - Additional analyses – chronic conditions, nursing home patients, outpatients, ICU patients, functional status
        - Implementation