Opportunity lost: End‐of‐life discussions in cancer patients who die in the hospital

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98330/1/jhm1989.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98330/2/jhm1989-sup-0001-SuppInfo.pd

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness.

OBJECTIVES: To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. DESIGN AND SETTING: Decision analysis using literature estimates and inpatient administrative data from Premier. PATIENTS: Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions\u27 efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. CONCLUSIONS: In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions.

BACKGROUND: Terminal intensive care unit (ICU) stays represent an important target to increase value of care. OBJECTIVE: To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. DESIGN: Secondary analysis of an intervention study to improve quality of care for critically ill patients. SETTING/PATIENTS: 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. METHODS: Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. MAIN RESULTS: Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics. CONCLUSIONS: Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models

Observation of Velocity-Tuned Multiphoton Doppleron Resonances in Laser-Cooled Atoms

An atomic beam of Li was transversely cooled using an intense standing-wave radiation field. A dramatic change in the transverse velocity distribution was observed. Structure in the resulting velocity distribution was found to be due to velocity-tuned multiphoton Doppleron resonances. The force due to seven-photon resonances is clearly resolved in the data. The data are in good agreement with theoretical predictions

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective.

Purpose of report: Understanding the impact of palliative care interventions on intensive care unit (ICU) costs and utilization is critical for demonstrating the value of palliative care. Performing these economic assessments, however, can be challenging. The purpose of this special report is to highlight and discuss important considerations when assessing ICU utilization and costs from the hospital perspective, with the goal of providing recommendations on methods to consider for future analyses. FINDINGS: ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies. SUMMARY: ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions

Observation of Velocity-Tuned Multiphoton Doppleron Resonances in Laser-Cooled Atoms

An atomic beam of Li was transversely cooled using an intense standing-wave radiation field. A dramatic change in the transverse velocity distribution was observed. Structure in the resulting velocity distribution was found to be due to velocity-tuned multiphoton Doppleron resonances. The force due to seven-photon resonances is clearly resolved in the data. The data are in good agreement with theoretical predictions

Conceptual Process Description for the Manufacture of Low-Enriched Uranium-Molybdenum Fuel

The National Nuclear Security Agency Global Threat Reduction Initiative (GTRI) is tasked with minimizing the use of high-enriched uranium (HEU) worldwide. A key component of that effort is the conversion of research reactors from HEU to low-enriched uranium (LEU) fuels. The GTRI Convert Fuel Development program, previously known as the Reduced Enrichment for Research and Test Reactors program was initiated in 1978 by the United States Department of Energy to develop the nuclear fuels necessary to enable these conversions. The program cooperates with the research reactors’ operators to achieve this goal of HEU to LEU conversion without reduction in reactor performance. The programmatic mandate is to complete the conversion of all civilian domestic research reactors by 2014. These reactors include the five domestic high-performance research reactors (HPRR), namely: the High Flux Isotope Reactor at the Oak Ridge National Laboratory, the Advanced Test Reactor at the Idaho National Laboratory, the National Bureau of Standards Reactor at the National Institute of Standards and Technology, the Missouri University Research Reactor at the University of Missouri–Columbia, and the MIT Reactor-II at the Massachusetts Institute of Technology. Characteristics for each of the HPRRs are given in Appendix A. The GTRI Convert Fuel Development program is currently engaged in the development of a novel nuclear fuel that will enable these conversions. The fuel design is based on a monolithic fuel meat (made from a uranium-molybdenum alloy) clad in Al-6061 that has shown excellent performance in irradiation testing. The unique aspects of the fuel design, however, necessitate the development and implementation of new fabrication techniques and, thus, establishment of the infrastructure to ensure adequate fuel fabrication capability. A conceptual fabrication process description and rough estimates of the total facility throughput are described in this document as a basis for establishing preconceptual fabrication facility designs