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Identifying a Financial Issue in Nursing
The problem of inpatient palliative care units creation in US tertiary hospitals has been continuously addressed for almost 20 years, with its impact on healthcare costs being one of the most significant issues. As the total number of both patients requiring palliative care and patients using intensive care units (ICU) in the end of life (EOL) constantly grows, the question of integration of the inpatient palliative care unit (IPCU) into ICU requires a careful analysis to assess its financial feasibility
The healthcare environment as well as a nursing role in contemporary world deserves attention in terms of both understanding clients’ preferences and analyzing the implications of such preferences for quality of services and finance (Elsayem et al.,2004). The research data shows that 50% of US population spending its last days in hospitals\cancer centers, stay in ICU for the last 3 days of life (on the average) and require palliative support (O’Mahony et al., 2010). In such a setting, the absence of proper control over healthcare costs can affect the access to palliative care, decrease the treatment effectiveness and significantly worsen the quality of life (QOL) of terminal patients.
There is a number of US-based studies (Elsayem et al.,2004; Gade et al.,2008; O’Mahony et al.,2010) evaluating pharmaco-economic data related to provision of in-patient palliative care in ICUs. The retrospective analysis of 320 patients cases (1 palliative care center) demonstrated that mean daily charges in the IPCU were significantly (38%) lower than in the rest of the hospital departments, with reimbursement rate of 57% (Elsayem et al., 2004). As the median hospital stay length in this study was even longer than the abovementioned average of 3 days (7 days out of range from 1 to 58 days), such a rate of daily charges for a palliative care unit can be a good argument in favour of IPCU financial viability. This research data is consistent with the results of the study of Penrod et al. (2010) who showed that provision of in-patient palliative care led to the savings of 464$ a day in hospital costs. The limitations of the last trial, in spite of a large number of its participants (n=3321), were its type (observational study) and population (only war veterans with advanced disease). Also, the results of different trials are only relatively comparable, as the more detailed cost-effectiveness analysis demonstrates that lower costs\ better outcomes depend on different variables, such as methods of unit costs estimation, study population characteristics, currency and price adjustments, model of care used, sample size and selection etc. (Smith,Brick, O’Hara & Normand, 2010). Still, evidence from multiple studies shows that inpatient palliative care is less costly than the care for patients not receiving palliative consultation in the last days of life, with the discrepancy in costs being statistically significant. (Smith et al.,2010). The 2010 preliminary report on palliative care integration into ICU (6 months case-control study with 22 patients of intervention group receiving inpatient palliative care compared to 24 patients following a standard route) revealed that, with the exception of the charges for opioids medication, all the costs ( laboratory and imaging tests) (p = 0.004 and 0.027 respectively) were lower for the intervention group (p=0.001).The patients’ satisfaction with care was also higher in patients receiving palliative consultation (Smith et al., 2010). These results are also supported by findings of randomized control trials (Gade et al., 2008).
The operational decision on ICPU integration into ICU will have an impact of nursing role in many aspects, increasing the need for proper staffing models, costs effective approach and impeccable management of pain and other symptoms. The proper opioids administration can reduce this only type of expenses increasing in ICPU; avoiding overstaffing can decrease payroll costs without affecting service level; and monitoring patients’ and carers’ satisfaction will ensure the clinical efficiency of the decision. The interviews with ICU nurses rating the quality of end-of-life care in the ICU illustrate that the nurses’ involvement in the process can also contribute to the effective increase of the advance directive formalization rates.The studies’ results indicate that only 33% of patients place such orders before palliative care consultation, and 83,4% do it afterwards (Smith et al., 2010).
The research evidence shows that costs per patient in IPCU are substantially lower than in ICU and other hospitals’ departments. The integration of IPCUs into ICUs in US tertiary hospitals can lead to improved clinical efficiency of palliative patients’ management supported by better utilization of hospital resources, decreased charges for hospital stays and costs savings at the expense of witholding unnecessary life-prolonging treatments. Demonstrating abilities for careful planning of resources and professional competence in management of pain and other symptoms, nurses can contribute to further decrease of daily charges and overall cost effectiveness of IPCU.
Elsayem A., Swint K., Fisch M.j.,Palmer J.L.,Ressy S., Walker P.,Bruera E.(2004). Palliative Care Inpatient Service in a Comprehensive Cancer Center: Clinical and Financial Outcomes. Journal of Clinical Oncology, 22 (10), 2008:2014.
Gade G, Venohr I., Conner D.,McGrady K.,Beane J.,Richardson R.H.,Della Penna R. (2008). Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med.,11(2):180-90.
O'Mahony S., McHenry J., Blank A.E., Snow D., Eti Karakas S., Santoro G,Kvetan V. (2010). Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med., 24(2):154-65.
Penrod J.D., Partha D., Dellenbaugh C., Burgess J.F., Zhu C.W., Christiansen S.L.,,Morrison R.S.(2010). Hospital-Based Palliative Care Consultation: Effects on Hospital Cost. Journal of Palliative Medicine,13(8).
Smith S., Brick A.,O’Hara S.,& Normand C.(2014). Palliat Med., 28(2):130-150.