Over the past two decades, the past five years in particular, a national discussion has emerged concerning the increased cost of health care. Perhaps of greater importance, increased health care costs have not always led to improved outcomes. In fact, overdiagnosis, overuse of treatments and a “try everything” approach have contributed to rising costs with little discernible improvement in health.
The American Hospital Association, with guidance from its Committee on Clinical Leadership, examined the issue and developed the white paper "Appropriate Use of Medical Resources," which identifies the drivers and recommends ways to move forward to reduce nonbeneficial services. Among its efforts, the AHA developed a Top Five list of hospital-based procedures or interventions that should be reviewed and discussed by a patient and physician prior to proceeding:
· Appropriate blood management in inpatient services
· Appropriate antimicrobial stewardship
· Reducing inpatient admissions for ambulatory-sensitive conditions (e.g., low back pain, asthma, uncomplicated pneumonia)
· Appropriate use of elective percutaneous coronary intervention
· Appropriate use of the intensive care unit for imminently terminal illness (including encouraging early intervention and discussion about priorities for medical care in the context of progressive disease)
To further support hospitals’ efforts, the AHA’s Physician Leadership Forum has produced toolkits on each of the five areas. In September, the Physician Leadership Forum released the most recent one that addresses aligning treatment with patient priorities in the context of progressive disease for use of the ICU.
Aligning ICU Care with Patient Priorities
About one-third of adults have advance directives; yet, as many as 75 percent of physicians are unaware of whether their patients have directives in place, according to the Centers for Disease Control and Prevention. Numerous studies have shown the impact advance care planning can have on patients. A 2010 study in The British Medical Journal found that if properly carried out, advance care planning improves end-of-life care and the satisfaction of patients and families. For the surviving relatives, it can also reduce anxiety, stress and depression.
It’s imperative that the health care system encourage early intervention and discussion about priorities for medical care in the context of progressive disease, as well as foster robust communication between patients and their providers to understand the patients’ goals. These discussions should address the likelihood of acceptable (to the patient) recovery, the risk of long-term impairment, the options for palliative care co-management at the same time as disease-directed treatment, and the benefits of hospice care in the framework of the patient’s priorities.
To bring more awareness to this issue, the Physician Leadership Forum collaborated with the Center to Advance Palliative Care, Coalition to Transform Advanced Care, Education in Palliative and End-of-life Care, National Hospice and Palliative Care Organization, and the Society of Critical Care Medicine to bring hospitals and health systems resources and tools to help in their quest for safe, high-quality care. The toolkit is broken into three sections:
· Hospital and health system resources: Includes assessment guides, PowerPoint presentations, key statistics and findings, position statements and resources supporting the appropriate use of the ICU for imminently terminal illness
· Clinician resources: Includes fact sheets, a palliative care screen, tip sheets, communication guides, articles, a webcast, and recommendations regarding end-of-life care in the ICU
· Patient resources: Includes resources regarding palliative care, advance care directives and ICU/treatment-specific concerns for patients, their families and caregivers
Highlights include an assessment guide from NHPCO that helps organizations to determine strengths and gaps of services in providing a seamless continuum of care for patients with life-limiting illness, and a National Academy of Medicine report about how to improve quality and honor the preferences of patients toward the end of their lives. In addition, CAPC, with the support of the National Institutes of Health, has created IPAL-ICU, a central venue where clinicians can share expertise, evidence and tools, and link with colleagues.
Also included in the toolkit is a conversation starter kit from the Conversation Project and Institute for Healthcare Improvement that families can use to begin a discussion on priorities and goals for care near the end of life. Finally, the toolkit includes links to a wealth of resources for patients and families on what to expect when a loved one is in intensive care.
As the end of life approaches, clinicians need to do their best to honor the wishes of their patients. With discussion and planning, a happy medium can be found between the priorities of the patient and the context of their progressive disease. By reducing the utilization of nonbeneficial care — care that increases costs without a concomitant increase in value — health care can move closer toward achieving the Triple Aim of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing per capita costs of health care.
John R. Combes, M.D., is the chief medical officer and a senior vice president of the American Hospital Association. He is also president of the Center for Healthcare Governance, an AHA affiliate, and is a member of Speakers Express.