A Resting Place

Training Opportunities

Resources available to hospitalists interested in integrating palliative care into their programs:

The American Academy of Hospice and Palliative Medicine (AAHPM), a 4,000-member professional society based in Glenview, Ill., offers annual educational meetings (the next is Feb. 16-19 in Vancouver), a self-study course, summaries of medical literature, and a Clinical Scholars Program with 40 hours of mentorship at one of eight AAHPM training sites. The website (www.aahpm.org) is home to the Hospice and Palliative Medicine (HPM) Fellowship Program Directory, which lists 74 active programs that offer 181 fellowships. The fellowships generally are for one year and include 27 research slots.

Starting in 2014, physicians who want to become board-certified in HPM must complete an American College of Graduate Medical Education-accredited HPM fellowship (www.aahpm.org/certification/abms.html). Sitting for the boards based on work experience is still an option for the 2010 and 2012 exams. Palliative care leaders encourage interested working hospitalists to take advantage of this window of opportunity and join the more than 2,000 physicians who already are HPM certified.

The Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City offers a variety of resources focused on palliative-care program development, including nine regional palliative care leadership centers, annual national training sessions, and financial models. For more info, visit www.capc.org.

Twice a year, Harvard Medical School offers the Program in Palliative Care Education and Practice (www.hms.harvard.edu/cdi/pallcare/pcep.htm) for physician and nurse educators who want to become experts in comprehensive, interdisciplinary palliative care.—LB

What Can Palliative Care Do to Hospitals’ Mortality Rates?

By Larry Beresford

Severity-adjusted hospital mortality rates are the cornerstone of a proliferating number of public and private hospital quality initiatives—and thus a quality focus for hospitalists. Yet some hospital-connected deaths are unavoidable, predictable, and even appropriate when palliative support focused on maximizing comfort and quality of life replaces medical efforts to stave off death.

Where hospice and palliative care fit in hospital mortality rates, how they are defined and counted, and how predictable deaths are either included or excluded from hospitals’ risk-adjusted mortality tallies vary between the reporting programs, according to J. Brian Cassel, PhD, senior analyst at Virginia Commonwealth University. He presented on mortality rates at the National Hospice and Palliative Care Organization’s Management and Leadership Conference in Washington, D.C. in April 2009.

“How hospital mortality rates are determined can be quite complex,” with varied data sources and various methods of adjusting for severity and balancing mortality with other quality metrics, says J. Brian Cassel, PhD, senior analyst at Virginia Commonwealth University who presented on mortality rates at the 2009 National Hospice and Palliative Care Organization’s Management and Leadership Conference in Washington, D.C.

Typically, the risk-adjusted mortality rate is for selected diagnoses but counts deaths from all causes, either during the index hospitalization or within 30 days of that admission, Cassel says. He reviewed three quality programs that use mortality data: the Centers for Medicare and Medicaid Services’ Hospital Compare, which publicly reports data on patient satisfaction and hospital processes and outcomes, including mortality; U.S. News & World Report’s “Best Hospitals”; and HealthGrades (www.healthgrades.com), a Golden, Colo.-based company that ranks hospitals and other health providers. He started studying the subject because of concerns that an acute palliative-care unit at VCU might be hurting the medical center’s overall mortality scores; it turned out not to be the case.

An ICD-9 (International Classifications of Disease) billing code, V66.7 for “palliative care encounter,” can flag the involvement of palliative- care consultants on a hospital case, although this code often goes unused and needs to be among the top nine listed diagnoses in order to turn up in most quality calculations. Palliative care consultants can help promote the use and higher positioning of this code in hospital billing, along with more complete documentation of co-morbidities and symptoms. It is also possible that involving hospice and palliative care teams with seriously ill patients earlier in their disease progression could help manage their care in community settings, avoiding hospitalizations when death is likely in the next few months.

Some hospitals might choose to refer patients known to be close to death to contracted hospice programs—although this should be based on the best interests of the patient, not on improving the facility’s mortality rates. Cassel’s advice for hospice and palliative care advocates trying to stake their claim in hospital quality measurement: provide the best possible care to patients and families, but meanwhile, know which quality measurement systems the hospital’s leadership follows, and what these look for.