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Palliative care ‘triggers’ reduce downstream health care use among patients with advanced cancer
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Standardized use of triggers for palliative care consultations for patients with advanced cancer admitted to an inpatient oncology service considerably reduced their downstream health care utilization, according to study results published in Journal of Oncology Practice.
The approach also increased patients’ use of support services after discharge.
Prior research showed the integration of palliative care improved symptom control and decreased unwanted health care use among those with advanced cancer, yet many patients are not offered these services. Last year, ASCO called for the incorporation of palliative care into treatment plans for all patients with metastatic cancer.
Cardinale B. Smith, MD, MSCR, associate professor of medicine (hematology and medical oncology), geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, and colleagues developed standardized criteria — or triggers — for palliative care consultations for patients on the inpatient solid tumor service.
Patients met at least one of the following eligibility criteria for the pilot intervention: advanced cancer, defined as stage IV solid tumor, or stage III lung or pancreatic cancer; hospitalization within the prior 30 days, excluding routine chemotherapy; hospitalization for more than 7 days; or any active symptoms, such as pain, nausea or vomiting, dyspnea, delirium or psychological distress.
Smith and colleagues conducted a prospective cohort study to assess the effects of these criteria on patients’ downstream health care use.
The analysis included 48 patients who met eligibility criteria during a 6-week preintervention period. These patients did not receive automatic palliative care consultations but could still have them if members of the primary team requested them.
Researchers compared that group with 65 patients who met eligibility criteria during the 3-month intervention period. Groups were balanced with regard to age, sex, race/ethnicity, cancer type and other characteristics.
Results showed a higher percentage of eligible patients in the intervention group than preintervention group received palliative care consultations (80% vs. 39%; P < .001) and hospice referrals (26% vs. 14%; P = .03). Eligible patients in the intervention group were less likely to be readmitted within 30 days (18% vs. 35%; P = .04), less likely to receive chemotherapy after discharge (18% vs. 44%; P = .03) and more likely to use support services after discharge (P = .004). The intervention had no effect on length of stay.
HemOnc Today spoke with Smith about the study results and their potential implications.
Question: What prompted you to conduct this study?
Answer: Despite having a very strong palliative care program at Mount Sinai, we still had low quality indicators of patient care. We had observed high mortality and readmission rates, and we thought we could do better. Our rates of hospice enrollment were very low, and patients were getting there within 3 days of end of life, when it is unlikely to provide maximum benefit. We hypothesized that increasing utilization of palliative care could help us improve.
Q: Can you describe the methods?
A: We spent six weeks gathering information by tracking patients admitted to our inpatient solid oncology unit. Then our pilot project started, and we continued to track every patient. Previously, patients needed to have a consult; in other words, an attending provider had to approve the patient for palliative care. We tried to take that decision out of the oncologist’s hands and decided that our palliative care team should evaluate all of our patients if they were found to have identifiable needs.
Q: Can you describe your reaction to the results?
A : It was nice to see that we could extend these benefits to patients who are later in the trajectory of their care in the hospital. It was validating to see that good supportive care combined with palliative care can improve quality care measures and ensure that patients get the appropriate care they need.
Q: Did any of the results surprise you?
A: One pleasant surprise was that we decreased the number of patients who received chemotherapy after discharge. Patients with solid tumors who get admitted to the hospital typically have a poor prognosis. They likely have 6 months or less to live, so it was nice to see a decline in usage of treatments that would not be beneficial for someone who is closer to the end of life.
Q: How does this study add to the literature on the potential benefits of palliative care?
A: It supports and adds to our understanding that palliative care is not just good for patient care and satisfaction, but that it also decreases health care utilization. That isn’t just important to patients and families. It is important to hospital systems and payers, as well.
Q: How can the automatic ‘trigger’ approach ensure palliative care is offered to patients who need it most?
A: In the preintervention group, only about 40% of patients received a palliative care consultation. That number is relatively high, as literature shows approximately 20% of patients receive palliative care consultations. That is due to a combination of providers not referring as often as they should, and misconceptions on the part of patients, some of whom still equate palliative care with hospice. The automatic consultation route takes bias and lack of knowledge out of the picture. This is a service that can benefit patients who meet the criteria, and we want to provide that service.
Q: What are some potential future directions for this type of research?
A: The next step is to examine patients with hematologic malignancies. A paper published by researchers at Massachusetts General Hospital looked at standard palliative care consultations for patients with leukemia who underwent bone marrow transplantation. Their results showed improved quality of life and symptom management in that cohort. We are looking to have a similar standard trigger system established for patients with hematologic malignancies to see if we can improve their care. – by Kyle Doherty
References:
Adelson K, et al. J Oncol Pract. 2017;doi:10.1200/JOP.2016.016808.
El-Jawahri A, et al. JAMA. 2016;doi:10.1001/jama.2016.16786.
For more information:
Cardinale B. Smith, MD, MSCR, can be reached at Mount Sinai, 1470 Madison Ave., New York, NY 10029; email: cardinal.smith@mssm.edu.
Disclosure: Smith reports honoraria from Teva. One other researcher reports a consultant or advisory role with Anthem; honoraria, travel, accommodations or other expenses from Genentech; and employment with Lyra Health.