According to new research, a program that used standardized criteria to trigger palliative care consultations for patients with advanced cancer was associated with lower use of chemotherapy, fewer readmissions, and increased utilization of home-based support services after discharge.
The study, published in the Journal of Oncology Practice, examined the impact of an intervention introduced within an inpatient oncology service. Researchers gathered data on length of stay (LOS), hospice referral rates, readmission rates, discharge services, and chemotherapy receipt after discharge for patients before and after the intervention was implemented, and compared the outcomes for the preintervention and intervention groups.
The pilot intervention aimed to identify hospitalized cancer patients who might benefit from palliative care as indicated by their symptom burden or distress. A consultation for palliative care was triggered when an oncologist, resident, nurse practitioner, social worker, or care coordinator at the hospital noted that a patient met 1 of the eligibility criteria and placed an order in the electronic health record for the consult. The criteria were:
- Advanced solid tumor (stage IV solid tumor or stage III lung or pancreatic cancer)
- Prior hospitalization within 30 days
- Hospitalization longer than 7 days
- Active symptoms including pain, nausea and/or vomiting, dyspnea, delirium, and psychological distress.
The researchers found that the proportion of eligible patients receiving a palliative care consultation more than doubled when the intervention was introduced, from 39% in the preintervention group to 80% of the intervention group. Receipt of chemotherapy post-discharge and 30-day readmission rates decreased significantly from the preintervention to intervention patients, while hospice referral rates increased. There was no significant difference in the LOS or intensive care unit use between the groups.
Using a composite measure of home service use, home hospice, inpatient hospice, and discharge to a site other than subacute rehabilitation, the researchers found that discharge support was improved among the patients in the intervention group. They were more likely to go home upon discharge, as opposed to a rehabilitation facility, and were more likely to use home-based resources like visiting nurses or hospice services.
According to the study authors, these findings indicate that “the standardized use of triggers for [palliative care] consultation is associated with a substantial impact on multiple quality measures.” This could have important implications for both cost savings, as lowering readmissions and utilizations would result in less spending, and quality of life, as patients could avoid needless interventions and unwanted outcomes like dying in the hospital.
They emphasized that a major factor in the intervention’s success was its strong support from both oncologists and the palliative care team. Before the intervention was introduced, the researchers explained the quality benefits of palliative care to the oncologists and assured them that the palliative care teams would not add to their workload or control primary care decisions, which led to smoother implementation and better staff buy-in.
Finally, the study authors mentioned an anecdote that supported the feasibility of such an intervention to prompt palliative care consultations. The setting of the study, Mount Sinai, has now permanently expanded their palliative care capabilities to ensure that every patient on the oncology service will automatically receive a consult upon meeting these criteria.