From the 2024 HVPA National Conference
Ariel Leong MS (The Johns Hopkins University School of Medicine), Evelien van Gelderen BA,Carolyn Im BS, Razeen Karim BS, Clarissa Ren BS, Ting-Jia Lorigiano MD, MBA, Jamison Kies MHS, Danielle Doberman MD, MPH, HMDC, FAAHPM
Background:
Weekend palliative services may improve patient care quality but may not be financially or logistically viable. We present the first evaluation of palliative weekend coverage feasibility that considers financial and practitioner perspectives.
Objective:
Characterize volume of demand, palliative team perspective, and financial feasibility of weekend palliative services.
Methods:
We extracted day of the week, length of stay (LOS), and palliative care consult description at an academic quaternary medical center in Baltimore, Maryland for one representative month, January 2023. Each consult was assigned to one or more categories: goals of care (GOC), symptom management, hospice transitions, and patient/family support. Category percentage was compared between weekday and weekend consults using a z-test of proportions. Differences in LOS between weekday and weekend consults were compared using Mann-Whitney U tests (Figure 1).
We obtained baseline salary, usual FTE (full-time equivalent) staffing, and wRVU (work relative value units) per day information for physicians, advanced practice providers (APPs), and social workers (SWs). Annual cost, revenue (using the Medicare conversion factor), and gross loss (cost – revenue) was calculated for the current staffing model and four models of weekend coverage: 3 Physicians; 2 Physicians & 1 APP; 1 Physician, 2 APPs, & 1 SW; and 3 APPs & 1 SW. The number of providers was estimated based on an approximate patient panel size of 120. We estimated a 5% increase in weekend RVUs compared to weekday, assuming for each weekend day, visits comprised new consult requests for symptom management alongside follow-up symptom visits for approximately 10% of our existing patient panel.
We individually interviewed 3 palliative physicians and 3 palliative social workers for perspectives on weekend coverage (Figure 2). Manual thematic analysis followed.
Results:
For all consult categories, there was no significant difference in either consult percentage or LOS between weekends and weekdays. Notably, there was a weekend-weekday difference in LOS (27 vs. 19 days) for symptom management.
Per survey respondents, the highest priority weekend need is symptom management (5/6 respondents) requiring coverage by at least one provider (6/6). Adjusting schedules to cover weekends was viewed variably (2/5 positive, 3/5 negative), with one respondent mentioning, “Most of my colleagues do not think that it’s a good idea… [the] biggest reason for that is lifestyle.” No respondents were aware of specific harms caused by lack of weekend coverage.
Compared to our base model, gross losses were 12%, 10%, 11%, and 9% greater for the 3 Physicians; 2 Physicians and 1 APP; 1 Physician, 2 APPs, and 1 SW; and 3 APPs and 1 SW models, respectively.
Conclusions:
Specialty palliative care optimally manages refractory symptoms¹. However, the insignificant differences between weekend and weekday palliative consults in LOS and symptom management consult percentage, lack of team consensus, and substantially increased gross losses suggest that currently, weekend palliative coverage should not be initiated at our institution. Study limitations include a small consult sample size and a possible underestimation of weekend demand if providers currently delay ordering consults until palliative providers are present.
Clinical Implications:
Programs should evaluate symptom management demand, team member buy-in, and costs when considering weekend palliative coverage.
References:
- Quill, T. E., & Abernethy, A. P. (2013). Generalist plus specialist palliative care—creating a more sustainable model. New England Journal of Medicine, 368(13), 1173-1175.