JOURNAL OF PALLIATIVE MEDICINE
Volume 8, Number 6, 2005
© Mary Ann Liebert, Inc.
The Growth of Palliative Care Programs
in United States Hospitals
R. SEAN MORRISON, M.D.,1,2CATHERINE MARONEY-GALIN, M.A., M.P.H.,1
PETER D. KRALOVEC,3and DIANE E. MEIER, M.D.1
Background: Palliative care programs are becoming increasingly common in U.S. hospitals.
Objective: To quantify the growth of hospital based palliative care programs from 2000–2003
and identify hospital characteristics associated with the development of a palliative care pro-
Design and measurements: Data were obtained from the 2001–2004 American Hospital As-
sociation Annual Surveys which covered calendar years 2000–2003. We identified all programs
that self-reported the presence of a hospital-owned palliative care program and acute med-
ical and surgical beds. Multivariate logistic regression was used to identify characteristics sig-
nificantly associated with the presence of a palliative care program in the 2003 survey data.
Results: Overall, the number of programs increased linearly from 632 (15% of hospitals) in
2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased
likelihood of having a palliative care program included greater numbers of hospital beds and
critical care beds, geographic region, and being an academic medical center. Compared to not-
for-profit hospitals, VA hospitals were significantly more likely to have a palliative care pro-
gram and city, county or state and for-profit hospitals were significantly less likely to have a
program. Hospitals operated by the Catholic Church, and hospitals that owned their own hos-
pice program were significantly more likely to have a palliative care program than non-
Catholic Church-operated hospitals and hospitals without hospice programs respectively.
Conclusions: Our data suggest that although growth in palliative care programs has occurred
throughout the nation’s hospitals, larger hospitals, academic medical centers, not-for-profit
hospitals, and VA hospitals are significantly more likely to develop a program compared to
spite the rapid growth of the hospice industry in
the United States since 1982 when the Medicare
LTHOUGH SURVEYS of healthy adults suggest
that most would like to die at home,1and de-
Hospice Benefit was enacted, most Americans
still die in hospitals. In 2004, more than 50%2,3of
Americans with serious illness died in an acute
care hospital and more than 90% of Medicare ben-
eficiaries will be hospitalized in the year prior to
death.4In recognition of the importance hospitals
1Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and the Center to Advance Pallia-
tive Care, Mount Sinai School of Medicine New York, New York.
2Geriatric Research, Education, and Clinical Center, Bronx VA Medical Center, Bronx, New York.
3Health Care Data Center of the American Hospital Association, Chicago, Illinois.
play in the care of persons with serious and
advanced illness, a number of initiatives have
focused on promoting the development of pal-
liative care programs and practitioners in U.S.
hospitals. In 2001, we published the first report
of the prevalence of hospital-based palliative care
programs in the United States.5In this study, we
update this report by examining the growth of
hospital based palliative care programs from
2000–2003 and expand upon it by identifying hos-
pital characteristics that predict both the presence
and development of a palliative care program.
TABLE 1.CHARACTERISTICS OF HOSPITALS HAVING A PALLIATIVE CARE PROGRAM
n ? 4156
n ? 4064
n ? 4163
n ? 4221
East North Central
East South Central
West North Central
West South Central
Other associated area
Region size (persons)
Number of hospital beds
500 and over
Critical care beds
15 or more
Not for profit
State, city, county
ACS cancer program
No ACS cancer program
ACGME residency program
No ACGME residency program
AAMC Council teaching hospital
Not an AAMC council teaching hospital
Affiliated with a hospice
Not affiliated with a hospice
VA, Veterans Administration; ACS, American College of Surgeons; ACGME, American Council of Graduate Med-
ical Education; AAMC, American Association of Medical Colleges.
MORRISON ET AL.1128
GROWTH OF PALLIATIVE CARE IN U.S. HOSPITALS
This study was undertaken to examine the de-
velopment of hospital-based palliative care pro-
grams across the United States from 2000–2003
using data obtained from the American Hospi-
tal Association (AHA) Annual Survey. The AHA
surveys all hospitals, both AHA member and
nonmember hospitals, in the United States and
its associated areas (American Samoa, Guam,
the Marshall Islands, Puerto Rico, and the Vir-
gin Islands) on an annual basis. Data included
in the survey are: organizational structure and
source of control of the hospitals (not-for-profit,
church-operated, for-profit, government–fed-
eral, and government–nonfederal); clinical facil-
ities or services offered by the hospitals (e.g.,
general medical–surgical care, pediatrics care,
various types of intensive care units, physical
rehabilitation, psychiatric services, cardiac
programs, acquired immune deficiency syn-
drome [AIDS] care, etc.); beds and utilization,
Medicare/Medicaid utilization; revenues; ex-
penses; uncompensated care; and professional
staffing levels (e.g., physicians, dentists, resi-
dents, nurses). For the facilities and services, the
survey also requests information on the manner
in which a service is provided (e.g., hospital-
owned, provided by the hospital’s health system
or network, and/or provided through a formal
contract between the hospital and another pro-
vider). Survey response rates over the past 5
years have averaged 86%.
In 2001, the AHA Annual Survey began sur-
veying hospitals as to the presence of a palliative
care program. In the questionnaire, a palliative
care program is defined as, “an organized pro-
gram providing specialized medical care, drugs
or therapies for the management of acute or
chronic pain and/or the control of symptoms ad-
ministered by specially trained physicians and
other clinicians; and supportive care services,
such as counseling on advanced directives, spir-
itual care, and social services, to patients with ad-
vanced disease and their families.” Hospitals are
also surveyed as to whether they operate a com-
munity hospice program.
For the years 2000–2003, we identified all pro-
grams that self-reported the presence of a hospi-
tal-owned palliative care program. Adult hospi-
tals included general medical–surgical hospitals,
specialized cancer hospitals, and specialized car-
diac hospitals. We excluded rehabilitation hospi-
tals, psychiatric hospitals, hospitals that only pro-
vided obstetric services, subacute and chronic
care facilities, and eye, ear, nose, and throat hos-
pitals. For pediatric programs, we included hos-
pitals that limited admission to children and pro-
vided acute medical and surgical services. We
used multivariate logistic regression to identify
hospital characteristics significantly associated
with the presence of an adult palliative care pro-
gram in the 2003 survey data. Covariates entered
into the model were those that reached border-
line significance (p ? 0.15) in univariate and bi-
variate analyses or had construct validity. A sim-
ilar series of analyses were performed to explore
the growth of palliative care programs in pedi-
Characteristics of hospitals having an adult
palliative care program are in Table 1. Figure 1A
displays the growth of adult palliative care pro-
grams in the United States. Figure 2 displays the
geographic locations of hospitals reporting an
adult palliative care program in 2000 and 2003.
Overall, the number of programs increased lin-
early from 632 (15% of hospitals) in 2000 to 1027
(25% of hospitals) in 2003. Table 2 details hospi-
tal and region characteristics that were signifi-
cantly associated with the presence of a hospital-
based palliative care program. Of note, hospitals
located in New England were significantly more
likely to have a palliative care program than
hospitals in all other regions of the country
except for the Mountain Region after controlling
for other variables. Greater numbers of hospital
beds (Table 2) and critical care beds (odds ratio ?
1.02; 95% confidence interval [CI], 1.01–1.03;
p ? ?0.001) increased the likelihood of having
a palliative care program as did being a member
of the American Association of Medical Colleges
Council of Teaching Hospitals (odds ratio ? 1.95;
95% CI, 1.35–2.81; p ? 0.001), and an American
College of Surgery (ACS)-approved cancer
hospital (odds ratio ? 1.48; 95% CI, 1.19–1.85;
p ? 0.001). Compared to not-for profit hospitals,
VA hospitals were significantly more likely to
have a palliative care program (odds ratio ? 8.01;
95% CI, 4.36–14.74; p ? 0.001) and city, county,
or state and for-profit hospitals were signifi-
cantly less likely to have a palliative care
program (odds ratio ? 0.69; 95% CI, 0.54–0.88;
p ? 0.003 and odds ratio ? 0.44; 95% CI, 0.31–
0.63; p ? ?0.001, respectively). Finally, hospitals
that reported being operated by the Catholic
Church were significantly more likely to have a
palliative care program than non-Catholic
Church-operated hospitals and hospitals that
owned their own hospice program were more
also likely to report a palliative care program.
MORRISON ET AL.
Growth of palliative care programs in adult and pediatric hospitals from 2000 to 2003.
GROWTH OF PALLIATIVE CARE IN U.S. HOSPITALS
Figure 1B displays the growth of palliative care
program in pediatric hospitals. Pediatric pallia-
tive care programs increased from 15 programs
in 2000 (15% of all pediatric hospitals) to 24 pro-
grams in 2003 (23% of all pediatric hospitals). The
only significant predictor of a hospital-based pe-
diatric palliative care program in multi-variate
modeling was the presence of a hospital owned
The 67% growth in hospital palliative care pro-
grams demonstrated by these data between 2000
and 2003 reflects and is supported by an associ-
ated growth in the numbers of certified palliative
medicine physicians (1892 as of July 2005),6and
nurses (over 5500 as of March 2005)7; increases in
postgraduate palliative medicine fellowships
(from 17 in 20008to 53 in 20059)and other train-
ing programs; and an increase in scholarly jour-
nals,10publications11, and research funding fo-
cused on this field.
Reasons advanced12,13to account for this
growth in palliative care providers and clinical
and educational programs may include the in-
creases in numbers and costs of chronically ill
Medicare patients turning to the healthcare sys-
tem for care14–17; the recognition based both on
research18–22and repeated media and personal
complaints23,24that the quality of care delivered
to the seriously and chronically ill is suboptimal,
specifically with respect to treatment of pain and
other symptoms, communication about the goals
of medical care and decisions that should follow,
and continuity of healthcare across treatment set-
tings),12,25,26and, not least, the hundreds of mil-
lions of dollars invested in the growth of the field
by The Robert Wood Johnson Foundation, the
Geographic location of palliative care programs in U.S. Hospitals in 2000 (top) and 2003 (bottom).
Open Society Institute’s Project on Death in
America, and others.27
The growth of hospital-based palliative pro-
grams may also be in response to the increasing
body of evidence supporting the beneficial effects
of these programs on a range of important out-
comes. Hospital palliative care programs have
been associated in preliminary studies with
demonstrable improvements in both care quality
and health care costs. Systematic reviews and
meta-analysis32–35of hospital palliative care pro-
grams demonstrated improvement in pain, non-
pain symptoms, patient and family satisfaction,
as well as reduced hospital length of stay and in-
hospital death rates. Others36have reported a
high rate of implementation of interventions rec-
ommended by palliative care consultants, in-
cluding symptom management, goal setting, ad-
vance care planning, and discharge planning.
Finally, several single-center studies of palliative
care37,38and multicenter studies of ethics consul-
tation39,40have suggested substantial reductions
in direct and indirect costs associated with hos-
pital palliative care compared to conventional
care, an observation that has thus far been con-
sistent across a range of hospital settings, patient
populations, and clinical service delivery models.
Our data suggest that although growth in pal-
liative care programs has occurred throughout the
nation’s hospitals, larger hospitals, academic med-
ical centers, not-for-profit hospitals, and VA hos-
pitals were significantly more likely to develop a
program compared to other hospitals. Possible
reasons for the patterns of growth that we ob-
served include VA policy that mandates palliative
care programs28; the growth in palliative care re-
search and fellowship training programs within
academic medical centers9,29; philanthropic foun-
dation investment in large academic programs27;
and the disproportionate impact of the increases
in numbers and costs of chronically ill Medicare
patients on larger hospitals.26,30,31
Despite these preliminary data suggesting im-
provements both in health care quality and in
costs as a result of hospital palliative care inter-
ventions, research is needed41to assure that these
MORRISON ET AL.
TABLE 2.PREDICTORS OF HAVING A HOSPITAL-BASED PALLIATIVE CARE PROGRAM IN 2003
Odds ratio (95% CI)
Census region (reference is New England)
East North Central
East South Central
West North Central
West South Central
Bed size (reference is less than 25 beds)
500 or more beds
Number of critical care beds
Ownership (reference is not-for-profit)
State, municipal, county
American College of Surgeons-approved cancer program
ACGME residence training program
AAMC Council of teaching hospitals member
Operated by the Catholic Church
Hospital owns a hospice program
0.54 (0.35, 0.83)
0.61 (0.40, 0.94)
0.55 (0.30, 0.68)
0.26 (0.16, 0.44)
0.57 (0.37, 0.88)
0.38 (0.24, 0.60)
0.90 (0.56, 1.50)
0.54 (0.35, 0.83)
1.59 (0.90, 2.83)
1.79 (1.01, 3.16)
2.59 (1.46, 4.58)
3.30 (1.91, 6.00)
4.04 (2.13, 7.67)
5.05 (2.47, 10.30)
5.41 (2.60, 11.2)
1.03 (1.02, 1.04)
0.69 (0.54, 0.88)
0.45 (0.32, 0.64)
0.88 (0.26, 3.06)
8.01 (4.26, 15.51)
1.54 (1.23, 1.91)
0.99 (0.74, 1.26)
1.87 (1.29, 2.70)
1.90 (1.50, 2.39)
4.52 (3.78, 5.40)
CI, confidence interval; VA, Veterans Administration; ACGME, American Council of Graduate Medical Education;
AAMC, American Association of Medical Colleges.
GROWTH OF PALLIATIVE CARE IN U.S. HOSPITALS
new palliative care programs are supported in the
delivery of evidence-based quality and efficient
care, and to confirm and explore the early reports
of their benefits. Specifically, studies are neces-
sary to define replicable and standardized inter-
ventions for the core components of palliative
care (symptom management, doctor–patient
communication, and coordination of care across
settings); to determine what components of pal-
liative care team interventions are associated with
improved outcomes (and which are not); as well
as to determine which clinical models are opti-
mal for specific care settings (hospital, long term
care, home, capitation versus fee for service) and
patient populations.11,20Additional strategies are
required to stimulate growth in smaller commu-
nity based hospitals, perhaps with alternate pro-
gram structures. The future of palliative care as
a specialty and the evolution of accessible clini-
cal palliative care programs of reliable quality
depends critically upon the availability of such
This project was supported by a grant from The
Robert Wood Johnson Foundation, Princeton,
New Jersey. Dr. Morrison is the recipient of a
Mid-career investigator award in patient oriented
research from the National Institute on Aging
(K24 AG022345). Dr. Meier is the recipient of an
Academic Career Leadership Award from the
National Institute on Aging (K07 AG00903). Dr.
Morrison had full access to all of the data in the
study and takes responsibility for the integrity of
the data and the accuracy of the data analysis.
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Address reprint requests to:
R. Sean Morrison, M.D.
Department of Geriatrics
Mount Sinai School of Medicine
New York, NY 10029
MORRISON ET AL.