outcomes emerging UK evidence Dr Fliss Murtagh Cicely Saunders - PowerPoint PPT Presentation

WHO Collaborating Centre Complexity, case-mix and outcomes – emerging UK evidence Dr Fliss Murtagh Cicely Saunders Institute

What will you hear over next 30 mins? • What are the challenges? • Potential solutions (this and other talks) • Progress on two UK-based projects: – C-CHANGE & OACC • About some early UK findings: – Complexity – how we can measure it? – Case-mix – how might it work? – Outcomes – where do they fit in? – How to implement outcomes? Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Palliative care works… Consistent and comprehensive evidence for better outcomes following palliative care: • Better symptom control • Improved communication • Better emotional well-being, less depression (both patients and families) • More satisfaction with care (patients and families) • Higher quality of life (patients and families) (Higginson 2003, Abernethy 2008, Garcia-Perez 2009, Temel 2010, Murtagh 2014) Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Defining the challenges … • Palliative care is, on the whole, doing a good job, but: – Is it consistently doing a good job? We don’t know – Can we demonstrate the difference it makes? No – Are those with the most complex needs and problems the ones who get most input? No – Do we understand the variations in the difference it makes? – because of the differences between people No – because of the differences between services No (both are needed!) Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Who gets what care at present? MOST COMPLEX NEEDS Primary care plus SPC teams & hospice inpatient uncertainty over time changes INTERMEDIATE NEEDS Primary care with some SPC support LESS COMPLEX NEEDS Primary care team Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Models of care are important… • (Specialist) Palliative care teams deliver holistic care to those with life-limiting progressive disease – as their core daily work – using specialist skills and expertise – in multidisciplinary teams • explicitly provide care to both patients and families • deliver both: – direct care to patients and families – indirect care by supporting other professionals to deliver direct care Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

C-CHANGE – what is it? • A research programme funded by the National Institute for Health Research (Programme Grants for Applied Research funding stream) • Purpose: to discover the best ways to ensure patient- level funding matches individual patient and family needs and achieves optimal outcomes • Will achieve this through a 5 year programme to develop/test case-mix classification in UK and understand best models of care and outcomes • 1 year into the programme – testing and validation of measures – preliminary data - to be presented … Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

What we think Use predictors to Which indicators are Understand the group people with determines the best predictors of outcomes achieved for similar levels of need patient need? patients and families patient need and link to resources Domain 1A: Highest Better symptom Age? Background information complexity control Domain 1B: Patient preferences Improved and priorities Symptoms? High complexity quality of life Phase of Domain 2: illness? Physical well-being Patient and Intermediate family Domain 3: complexity Family? satisfaction Social and occupational well-being Preferences met Worries Low complexity Domain 4: or when feasible Psychological well- anxiety? being Advance care Lowest Domain 5: At peace? planning to Spiritual well-being and complexity anticipate needs life goals

Defining the language… • Case-mix criteria • Combined into classes • ‘Currency’≠ money ! • ‘Currency’ = case -mix classes • Episode of care = spell of care Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Why describe complexity? • Why try to describe complexity of palliative care needs? – So we can compare ‘like’ with ‘like’ (understand and adjust for patient variation) – Clinical, quality improvement, commissioning communication – Delivering “right care at the right time in the right place” (Five Year Forward View, Oct 2014) – Matching resources to needs • How can we describe complexity? Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

What is complexity? • The number, severity and interaction of different domains of need • Can we measure it using measures such as: – phase of illness – functional status/dependency – problem severity: – pain – other physical problems – psychological problems – family distress/needs Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Phase of illness reported among patients seen by a UK hospital palliative care team (N=232 spells of care, 512 phases) 40.0% 37.5% 35.0% 30.0% Proportion of phases 26.0% 25.0% 19.3% 20.0% 15.0% 11.9% 10.0% 5.1% 5.0% 0.2% 0.0% Stable Unstable Deteriorating Dying Not known Patient not seen Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Comparison of phase distribution among inpatients; UK and Australia 40.0% 37.5% 35.0% 30.1% 30.0% 26.0% 24.8% % of phases 25.0% 23.3% 19.3% 20.0% 18.5% 15.0% 11.9% 10.0% 5.0% 0.0% Stable Unstable Deteriorating Dying UK Australia *From: Palliative Care Outcomes Collaboration, Report Jan-Jun 2014 Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Admission phase of illness reported among patients seen by a UK hospital advisory palliative care team (N=232 spells of care, 512 phases) 60.0% 50.0% 47.8% 40.0% % of phases 30.0% 19.4% 20.0% 16.8% 11.2% 10.0% 4.7% 0.0% Stable Unstable Deteriorating Dying Not known Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Functional status at admission (N=200 phases, 32 unknown removed) 50 47 45 40 37 35 Number of phases 35 31 30 30 25 20 16 15 10 4 5 0 10% - Comatose or 20% - Totally bedfast 30% - Almost 40% In bed more 50% - Requires 60% - Occasional 70% - care for self, barely arousable and requiring completely bedfast than 50% of the considerable assistance but is unable to carry on nursing care by time assistance and able to care for most normal activity or to professionals and/or frequent medical of own needs do active work family activity Functional status Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Distribution of problem severity score (0-12) at admission (N=149 phases, 83 unknown removed) 30 25 25 23 Number of phases 20 19 20 16 15 13 9 10 8 7 5 5 2 1 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Combined problem severity score Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Functional status distribution by phase (N= 457 phases, 28 unknown removed) 60 50 Number of phases 40 30 Deteriorating Dying 20 Stable 10 Unstable 0 0% - Dead 10% - 20% - Totally 30% - Almost 40% In bed 50% - Requires 60% - 70% - care for Comatose or bedfast and completely more than 50% considerable Occasional self, unable to barely requiring bedfast of the time assistance and assistance but carry on arousable nursing care by frequent is able to care normal activity professionals medical for most of or to do active and/or family activity own needs work Functional status Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Dependency distribution by phase (N=233 phases, 252 unknown removed) 30 25 20 No of phases Deteriorating 15 Dying Stable Unstable 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Dependency score Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

For each phase, proportion by duration among patients seen by a UK hospital advisory PC team (N=442 phases of illness) 40.00% 35.00% 30.00% % of each phase 25.00% Deteriorating 20.00% Dying Stable 15.00% Unstable 10.00% 5.00% 0.00% 1 2 3 4 5 6 7 8 9 10 11 12 Duration of phase (days) Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Combined problem severity score distribution (N=232 phases, 253 unknown removed) 120% 100% 80% Deteriorating Cumulative phases 60% (%) Dying Stable Unstable 40% 20% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 Combined problem severity score Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Dependency distribution (N=233 phases, 252 unknown removed) 120% 100% 80% Cumulative Deteriorating phases 60% Dying (%) Stable Unstable 40% 20% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Dependency score Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Total phase costs (direct, indirect, corporate) Stable Unstable Deteriorating Dying Mean total cost £184.30 £319.80 £221.02 £211.83 (SD) (£157.71) (£313.06) (£245.60) (£190.34) Max £909.65 £2,354.63 £1,818.83 £1,160.36 Follow us on twitter @csi_kcl www.csi.kcl.ac.uk

Mean total phase costs among patients seen by a UK hospital advisory palliative care team (N=489 phases) £350.00 £319.80 £300.00 £250.00 £221.02 £211.83 £200.00 £184.30 £150.00 £100.00 £50.00 £0.00 Stable Unstable Deteriorating Dying Follow us on twitter @csi_kcl www.csi.kcl.ac.uk