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ONLINE EXCLUSIVE: Palliative Care Documentation Key to Core Measures


A growing number of publicly reported hospital quality initiatives include severity-adjusted hospital mortality rates. Although individual hospitalists are unlikely to be rated based on their patients’ mortality, this is an important component of how hospitals are evaluated—and thus a natural target for the hospital’s quality-improvement (QI) efforts and for hospitalists’ participation in them.

The challenge is that some hospital-connected deaths are unavoidable, predictable, and even appropriate when care plans focused on maximizing comfort and quality of life replace medical efforts to stave off death. Referring seriously ill patients to the hospital’s palliative-care service or to a community hospice can influence a hospital’s mortality rate, but not always in the same ways.

Where hospice care 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 (VCU), a presenter at the National Hospice and Palliative Care Organization’s Management and Leadership Conference in April 2010 in Washington, D.C.

“Hospitals are naturally concerned about mortality rates because they want to be seen as quality health providers,” Dr. Cassel says. “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. Dr. Cassel says he began digging into mortality data when concerns were raised that VCU’s acute-palliative-care unit might be causing the medical center’s overall mortality rates to spike. His research found that the unit’s operation was probably neutral relative to VCU’s overall mortality rates.

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, Dr. Cassel says. Three examples of QI programs that use mortality data: CMS’ Hospital Compare, which publicly reports data on patient satisfaction and hospital processes and outcomes, including mortality; U.S. News & World Report’s “Best Hospitals” list, for which one-third of total scores are derived from its mortality index; and HealthGrades, a Golden, Colo.-based company that ranks hospitals and other health providers within a region, one condition or procedure at a time.

An ICD-9 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 should 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 comorbidities and symptoms. It also is 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 thought to be close to death to contracted hospice programs—and some hospice and palliative-care advocates are using the rates as conversation starters with hospital administrators. Dr. Cassel’s advice for those advocates: Know which quality-measurement systems the hospital’s leadership follows, where adjusted mortality rates fit in those systems, and how hospice and palliative care affect them.

Regardless of mortality metrics, Dr. Cassell says, a clinician’s primary responsibility is to provide the best possible care to patients and families, reflecting their values, hopes, and treatment goals.

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