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Access to Palliative Care Improving, But Major Geographic Gaps Remain

Eastman, Peggy

doi: 10.1097/01.COT.0000473582.34781.64


WASHINGTON—A new report released on Capitol Hill here shows there has been a marked growth in hospital palliative care teams since 2011, but that major gaps in access to palliative care occur across the nation, especially in southern states.

The report—“America's Care of Serious Illness: 2015 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals”—and a related study—“The Growth of Palliative Care in U.S. Hospitals: A Status Report,” published in the Journal of Palliative Medicine (doi:10.1089/jpm.2015.0351)—were led by R. Sean Morrison, MD, Director of the National Palliative Care Research Center (NPCRC), and Diane E. Meier, MD, Director of the Center to Advance Palliative Care (CAPC). NPCRC and CAPC are part of the Icahn School of Medicine at Mount Sinai Health System in New York City. Other researchers were Tamara Dumanovsky, PhD (who was first author of the journal study); and Maggie Rogers, MPH, both of CAPC.

Overall, the new report gives the United States a B for access to palliative care in hospitals—access that depends on hospital size, geographic location, and tax status. The report follows previous similar report cards in 2008 and 2011; the B grade is unchanged from 2011. Data for the 2015 report card are drawn from the American Hospital Association's Annual Survey Database from fiscal years 2012 and 2013 and the National Palliate Care Registry.

Key findings are as follows:

  • A major sign of progress is that 17 states received a grade of A (up from just three in the 2008 report and seven in the 2011 report): The states receiving an A are: Connecticut, Maryland, Massachusetts Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Jersey, Ohio, Oregon, Rhode Island, South Dakota, Utah, Vermont, Washington, and Wisconsin;
  • 67 percent of U.S. hospitals with 50 or more beds report having palliative care teams—up from 63 percent in 2011 and 53 percent in 2008—but this means that one-third of U.S. hospitals with 50 or more beds report no palliative care services;
  • Southern states received a grade of C, reflecting the fact that 60 percent or fewer hospitals have palliative care teams, as compared with As and Bs (60 percent or more hospitals with palliative care teams) for all other regions;
  • The states receiving a D grade (having no more than 40 percent hospitals with palliative care teams) were Alabama, Arkansas, Mississippi, New Mexico, Oklahoma, and Wyoming; and
  • For the first time, no state received an F (defined as fewer than 20 percent of a state's hospitals reporting a palliative care program).
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What Would It Take to Have an A for the Country Overall?

Asked by OT what it would take for the nation to receive an A overall, Morrison said: “To ensure universal access to palliative care and bring the nation to an A, we need to promote regulatory and accreditation requirements that mandate the inclusion of palliative care in U.S. hospitals. Additionally, we need payment linked to value and quality measures that truly address the needs of the seriously ill and their families. These steps are critical to redress inconsistencies in access and quality of palliative care services associated with geographic location and ownership, among other factors.”



The report recommends that as the Centers for Medicare & Medicaid Innovation (CCMI) of the Centers for Medicare & Medicaid Services (CMS) pilots new care models, it should ensure that palliative care is a component of care, quality measurement, and payment for those with serious illness.

“I think we are past the point where we can rely on hospital administrators to start programs on their own initiative,” he continued. “We now need to actively address the barriers that are preventing universal access to high-quality palliative care.”

Good palliative services should be available in all hospitals and are a basic quality-of-care issue: “Whereas most Americans would not think about going to a hospital without an ICU in the setting of a serious illness, many Americans are still admitted to hospitals without a palliative care team—especially if they live in the south and their hospital is a for-profit hospital.”

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Key Differentiator: Hospital Ownership

Indeed, the new report card found that hospital ownership is an important factor in whether the hospital has a palliative care team. Specifically, the data show that only 23 percent of for-profit hospitals offer their patients palliative care; in contrast, not-for-profit hospitals are seven times more likely to have a palliative care team than for-profits are.

The report also found that:

  • 90 percent of hospitals operated by the Catholic Church have palliative care;
  • 90 percent of hospitals with 300 or more beds have palliative care;
  • 78 percent of Medicare patients died near a hospital that had a palliative care team, suggesting that access to palliative care services is improving for this older population; and
  • 96 percent of teaching hospitals now have palliative care teams—increasing the likelihood that the next generation of clinicians will receive training in palliative care.

Morrison said that in addition to issues of hospital size, location, and ownership, the specific barriers need to be addressed to ensure that all Americans with serious illnesses have access to high-quality palliative care.

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Workforce Demand

The first is workforce demand: “To address the workforce demand, we need to establish palliative care centers that would develop and disseminate curricula relating to palliative care, support the training and retraining of clinicians in palliative care skills, support continuing education, and provide students with clinical training in appropriate sites of care.”

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Knowledge Gaps

A second barrier to universal access to palliative care is knowledge gaps in this relatively new but fast-growing medical specialty, Morrison continued: “To address the knowledge gaps, we need to support research by the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and the Agency for Healthcare Research & Quality—research that focuses on symptom relief, communication with those with serious illness, and developing and evaluating models of care delivery. We also need to support the development of innovative palliative care delivery models.”

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Figure. Di

Meier and others have emphasized that palliative care can be provided at the same time as treatment to cure the disease. In fact, patients should have access to palliative care at any age and at any stage of a serious illness. Meier pointed to the well-known groundbreaking study by Jennifer Temel, MD, et al published several years ago in the New England Journal of Medicine (2010;363:733-742), which found that patients newly diagnosed with metastatic lung cancer lived nearly three months longer than similar patients receiving the best cancer care but who did not receive palliative care. Those receiving palliative care also felt better and were less depressed, that team reported.

In 2009 the American Society of Clinical Oncology released an updated policy statement recommending the integration of palliative care into treatment as part of comprehensive cancer care for patients with metastatic disease and/or a high symptom burden. And at this year's Palliative Care in Oncology Symposium (, ASCO released a joint guidance statement with the American Academy of Hospice and Palliative Medicine, which recommends primary palliative care services for medical oncology practices.

The statement is the first formal consensus-based set of recommendations on the types of palliative care services that constitute high-quality primary palliative care in oncology.

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Still, despite the remaining gaps and barriers, the new report on U.S. palliative care takes an optimistic view of the future for increased access to palliative care services, stating: “The timing, demand, and opportunity to expand access to palliative care are unprecedented. The public and private heath care markets are under pressure to provide higher-quality care for the growing number of aging Americans who face serious and chronic disease.”

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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