Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For adult chronically-ill patients of low SES who are living in an urban environment, what is the comparative effectiveness of earlier versus later palliative care involvement on quality of life and total health care expenditures over the course of their illness?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Early involvement of palliative care services (starting at time of diagnosis) versus later involvement of palliative care services (at time of hospitalization) for quality of life and total health care expenditures.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Adults (18 years old and older), male and female, serious or life threatening chronic illness (e.g., cancer, CHF, CRF, dementia, liver disease, COPD, DM).

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Low SES, urban dwellers.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Improvement in quality of life for the patient and the family; easier disease management for the health care team; earlier referral to hospice as needed.

Describe any health-related risks, side effects, or harms that you are concerned about.

Earlier involvment of palliative care might scare some people into thinking they are dying sooner than they actually are dying, thus increasing stress. But with education by the team, patients will come to learn that palliative care is symptom management and not solely end-of-life care.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

no

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cancer
• Cardiovascular disease, including stroke and hypertension
• Dementia, including Alzheimer's disease
• Depression and other mental health disorders
• Diabetes mellitus
• Infectious diseases, including HIV/AIDS
• Pulmonary disease/asthma

AHRQ Priority Populations

• Low income groups
• Minority groups
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Outcomes research in palliative care is scant and the studies that exist are very specific to context and disease state. Making the case for palliative care in the era of reduced health care spending must focus on patient outcomes (quality of life) and program outcomes (financial savings). Those most affected will be the disenfranchised populations: the poor, urban American.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

I was motivated to ask this question because there are no clinical guidelines about many of the operational issues of in-patient palliative care services, particularly for poor uban dwellers. What is the optimal census to staff ratio? What constitutes quality of life improvements? What financial data must we show to grow programs?

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Why must we allocate scarce health care dollars to palliative care? Why must palliative care be a priority for policy makers?

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

We will come to understand those components of palliative care that make the most impact on maintaining quality of life for the urban poor and will have more data to make the financial case to policy makers.

Describe the timeframe in which an answer to your question is needed.

The tru answer is as soon as humanly possible. I suspect the project will take about one year.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Urban dwellers of low SES are typically disenfranchised. As such, they frequently do not have access to the best, most appropriate health care. Knowing the components of palliative care that help them to maintain their quality of life and the financial impact would support the need for programs in every urban setting with a similar population as they live their lives with chronic illnesses that are often life threatening.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

We will come to understand those components of palliative care that make the most impact on maintaining quality of life for the urban poor and will have more data to make the financial case to policy makers.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

AHRQ website