Vol.
-
No.
- -
2014
Journal of Pain and Symptom Management
e1
Letter
Integrating the Biopsychosocial Model Into Quality Measures in Palliative Care: A Case for Improving the Hospice Item Set To the Editor: As palliative medicine grows and matures, an increased focus on quality of care is needed to demonstrate the value of its services. Quality of health care is often evaluated through assessments of care delivery compared against published health-care quality measures. Such quality measures support consistent auditing of current practice at the organizational level, while fostering comparison and benchmarking activities at the regional and national levels. Then, as these data are reported to payers, accreditors, and other stakeholders, the entire health delivery community can ensure that a consistent level of quality care improves the experience of all patients with serious illness and their caregivers. Recently, the Centers for Medicare and Medicaid (CMS) announced on July 1, 2014, implementation of the Hospice Quality Reporting Program (HQRP). Included within the Patient Protection and Affordable Care Act, the HQRP calls for expanded quality measurement within hospice care. This program uses the newly developed hospice item set (HIS) for reporting data on quality to CMS.1 The HIS incorporates seven measures from the National Quality Forum (NQF)-endorsed measure set for palliative care, including those addressing pain, dyspnea, constipation prevention, beliefs and values, and treatment preferences. This change in hospice quality measurement represents the largest evolution in hospice quality monitoring. The HQRP and HIS will now broaden the scope of the Ó 2014 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
previous program, which required reporting of one process and one structural measure, NQF #0209 (Pain Measure) and the Quality Assessment and Performance Improvement Program. Undoubtedly, this is a remarkable leap forward in ensuring that all patients receiving end-of-life care experience consistent assessment and management across areas of distress that matter. Yet, some important areas for optimization of this quality improvement process remain. Despite many of the NQF domains for quality palliative care being addressed by the HIS, a remarkable piece of the biopsychosocial puzzle appears missing. As would be expected, the HIS prioritizes the biological (pain/ dyspnea) and ethical/legal (patient preferences and beliefs) aspects of care, yet seems to miss the other important aspects of the biopsychosocial model of distress. For example, the HIS excludes measures of psychological distress, such as depression, despite the recommendations of the American College of Physicians clinical practice guidelines for regular assessment of this common symptom in palliative care and at the end of life.2 That pain and dyspnea are both exacerbated and alleviated by psychological distress has been well conceptualized in the literature.3,4 Furthermore, clinical experience reminds us that anxiety, depression, personality and behavioral disorders, among others, must often be addressed first before resolution of other physical symptoms can be achieved. Separating physical, biological, and social determinants of distress often is counteractive; an effective and comprehensive palliative care plan accounts for integrative biopsychosocial care.5 Also important, neuropsychiatric illness, apart from its effect on physical symptoms, causes significant burden in the hospice population.6 Research estimates suggest that more 0885-3924/$ - see front matter
e2
than 60% of cancer patients experience psychological distress and that 47%e68% of hospice patients suffer from some form of neuropsychiatric illness including depression, anxiety, and delirium during their course of enrollment.7 Prevalence estimates of depression in terminally ill hospice patients range from 10% to 30%, and anxiety has been reported to affect nearly 16% of veterans enrolled in hospice.8,9 Neuropsychiatric disorders in terminally ill patients also inherently decrease the quality of life of terminally ill patients during their final months, weeks, and days.10 Despite the high burden of neuropsychiatric disorders in seriously ill patients with illnesses frequently cared for under the hospice benefit, quality markers for neuropsychiatric care appear to be glaringly absent from the HIS. We applaud the development and near-term implementation of the HIS. It represents an important step forward for standardized quality monitoring in palliative care. Since the endorsement by the NQF of 14 quality measures for palliative care in early 2012, the field has anxiously awaited the inclusion of these measures into structured quality assessment programs in our field. As we do in our clinical care and research focus, we should continue to appreciate the complex etiologies of distress in those who experience serious illness. Then, we should incorporate our appreciation of these into quality measures that we use to assess the quality of care we deliver. Ultimately, if we are not the stewards for a greater appreciation of the complex nature of psychological distress in serious illness and then incorporate that appreciation into our quality measures, then who will?
Letter
Vol.
-
No.
- -
2014
Duke Cancer Institute Duke Center for Learning Health Care Durham, North Carolina, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.05.002
References 1. Centers for Medicare and Medicaid Services. HIS fact sheet. 2014. Available at: http://www.cms. gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/HospiceItem-Set-HIS.html. Accessed April 22, 2014. 2. Quaseem A, Snow V, Shekelle P, et al. Evidencebased interventions to improve palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148: 141e146. 3. Campbell LC, Clauw DJ, Keefe FJ. Persistent pain and depression: a biopsychosocial perspective. Biol Psychiatry 2003;54:399e409. 4. Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professional: assessment, burdens, and etiologies. J Palliat Med 2011;14:1167e1172. 5. Institute of Medicine (IOM). In: Adler NE, Page NEK, eds. Cancer care for the whole patient: meeting psychosocial health needs. Washington, DC: The National Academies Press, 2008. 6. Novy DM, Aigner AC. The biopsychosocial model in cancer pain. Curr Opin Support Palliat Care 2014;8:117e123. 7. Block SD. Assessing and managing depression in the terminally ill patient. Ann Intern Med 2000; 132:209e218. 8. Irwin SA, Rao S, Bower K, et al. Psychiatric issues in palliative care: recognition of depression in patients enrolled in hospice care. J Palliat Med 2008; 11:158e163.
Jason A. Webb, MD Department of Medicine Duke University Medical Center Durham, North Carolina, USA
9. Raynor L, Price A, Hotopf M, Higginson IJ. The development of evidence-based European guidelines on the management of depression in palliative care. Eur J Cancer 2011;47:702e712.
Arif H. Kamal, MD Department of Medicine Duke University Medical Center Durham, North Carolina, USA
10. Goy ER, Ganzini L. Prevalence and natural history of neuropsychiatric syndromes in veteran hospice patients. J Pain Symptom Manage 2011;41: 394e401.
-
No.
- -
2014
Journal of Pain and Symptom Management
e1
Letter
Integrating the Biopsychosocial Model Into Quality Measures in Palliative Care: A Case for Improving the Hospice Item Set To the Editor: As palliative medicine grows and matures, an increased focus on quality of care is needed to demonstrate the value of its services. Quality of health care is often evaluated through assessments of care delivery compared against published health-care quality measures. Such quality measures support consistent auditing of current practice at the organizational level, while fostering comparison and benchmarking activities at the regional and national levels. Then, as these data are reported to payers, accreditors, and other stakeholders, the entire health delivery community can ensure that a consistent level of quality care improves the experience of all patients with serious illness and their caregivers. Recently, the Centers for Medicare and Medicaid (CMS) announced on July 1, 2014, implementation of the Hospice Quality Reporting Program (HQRP). Included within the Patient Protection and Affordable Care Act, the HQRP calls for expanded quality measurement within hospice care. This program uses the newly developed hospice item set (HIS) for reporting data on quality to CMS.1 The HIS incorporates seven measures from the National Quality Forum (NQF)-endorsed measure set for palliative care, including those addressing pain, dyspnea, constipation prevention, beliefs and values, and treatment preferences. This change in hospice quality measurement represents the largest evolution in hospice quality monitoring. The HQRP and HIS will now broaden the scope of the Ó 2014 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.
previous program, which required reporting of one process and one structural measure, NQF #0209 (Pain Measure) and the Quality Assessment and Performance Improvement Program. Undoubtedly, this is a remarkable leap forward in ensuring that all patients receiving end-of-life care experience consistent assessment and management across areas of distress that matter. Yet, some important areas for optimization of this quality improvement process remain. Despite many of the NQF domains for quality palliative care being addressed by the HIS, a remarkable piece of the biopsychosocial puzzle appears missing. As would be expected, the HIS prioritizes the biological (pain/ dyspnea) and ethical/legal (patient preferences and beliefs) aspects of care, yet seems to miss the other important aspects of the biopsychosocial model of distress. For example, the HIS excludes measures of psychological distress, such as depression, despite the recommendations of the American College of Physicians clinical practice guidelines for regular assessment of this common symptom in palliative care and at the end of life.2 That pain and dyspnea are both exacerbated and alleviated by psychological distress has been well conceptualized in the literature.3,4 Furthermore, clinical experience reminds us that anxiety, depression, personality and behavioral disorders, among others, must often be addressed first before resolution of other physical symptoms can be achieved. Separating physical, biological, and social determinants of distress often is counteractive; an effective and comprehensive palliative care plan accounts for integrative biopsychosocial care.5 Also important, neuropsychiatric illness, apart from its effect on physical symptoms, causes significant burden in the hospice population.6 Research estimates suggest that more 0885-3924/$ - see front matter
e2
than 60% of cancer patients experience psychological distress and that 47%e68% of hospice patients suffer from some form of neuropsychiatric illness including depression, anxiety, and delirium during their course of enrollment.7 Prevalence estimates of depression in terminally ill hospice patients range from 10% to 30%, and anxiety has been reported to affect nearly 16% of veterans enrolled in hospice.8,9 Neuropsychiatric disorders in terminally ill patients also inherently decrease the quality of life of terminally ill patients during their final months, weeks, and days.10 Despite the high burden of neuropsychiatric disorders in seriously ill patients with illnesses frequently cared for under the hospice benefit, quality markers for neuropsychiatric care appear to be glaringly absent from the HIS. We applaud the development and near-term implementation of the HIS. It represents an important step forward for standardized quality monitoring in palliative care. Since the endorsement by the NQF of 14 quality measures for palliative care in early 2012, the field has anxiously awaited the inclusion of these measures into structured quality assessment programs in our field. As we do in our clinical care and research focus, we should continue to appreciate the complex etiologies of distress in those who experience serious illness. Then, we should incorporate our appreciation of these into quality measures that we use to assess the quality of care we deliver. Ultimately, if we are not the stewards for a greater appreciation of the complex nature of psychological distress in serious illness and then incorporate that appreciation into our quality measures, then who will?
Letter
Vol.
-
No.
- -
2014
Duke Cancer Institute Duke Center for Learning Health Care Durham, North Carolina, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.05.002
References 1. Centers for Medicare and Medicaid Services. HIS fact sheet. 2014. Available at: http://www.cms. gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/HospiceItem-Set-HIS.html. Accessed April 22, 2014. 2. Quaseem A, Snow V, Shekelle P, et al. Evidencebased interventions to improve palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148: 141e146. 3. Campbell LC, Clauw DJ, Keefe FJ. Persistent pain and depression: a biopsychosocial perspective. Biol Psychiatry 2003;54:399e409. 4. Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professional: assessment, burdens, and etiologies. J Palliat Med 2011;14:1167e1172. 5. Institute of Medicine (IOM). In: Adler NE, Page NEK, eds. Cancer care for the whole patient: meeting psychosocial health needs. Washington, DC: The National Academies Press, 2008. 6. Novy DM, Aigner AC. The biopsychosocial model in cancer pain. Curr Opin Support Palliat Care 2014;8:117e123. 7. Block SD. Assessing and managing depression in the terminally ill patient. Ann Intern Med 2000; 132:209e218. 8. Irwin SA, Rao S, Bower K, et al. Psychiatric issues in palliative care: recognition of depression in patients enrolled in hospice care. J Palliat Med 2008; 11:158e163.
Jason A. Webb, MD Department of Medicine Duke University Medical Center Durham, North Carolina, USA
9. Raynor L, Price A, Hotopf M, Higginson IJ. The development of evidence-based European guidelines on the management of depression in palliative care. Eur J Cancer 2011;47:702e712.
Arif H. Kamal, MD Department of Medicine Duke University Medical Center Durham, North Carolina, USA
10. Goy ER, Ganzini L. Prevalence and natural history of neuropsychiatric syndromes in veteran hospice patients. J Pain Symptom Manage 2011;41: 394e401.
