Patients admitted to the hospital with advanced cancers who were referred early to palliative care had decreased health-care utilization and increased use of support services following discharge, according to a new study led by researchers at the Icahn School of Medicine at Mount Sinai. Published by Adelson et al in the Journal of Oncology Practice, the study also determined that a systemized process of referrals resulted in significant improvements in 30-day readmission rates, hospice referral, and receipt of chemotherapy after discharge in patients with advanced cancers. This is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, standardized use of triggers for palliative care consultation is associated with substantial improvement on multiple quality measures.
Patients with advanced cancers often have significant symptoms that affect their emotional status, quality of life, and functional ability. The integration of palliative care improves symptom control and decreases unwanted health-care use, yet many patients are never offered these services.
“As cancer progresses, patients are often at high risk for physical pain and emotional distress,” said Cardinale B. Smith, MD, MSCR, Associate Professor of Medicine (Hematology and Medical Oncology) and of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. “Health-care utilization is extremely high once cancer progresses, with hospital readmission rates as high as 40% and death in the acute care setting ranging from 30% to 50%—both measures of poor-quality cancer care.”
To improve the quality of care, researchers at the Icahn School of Medicine developed standardized criteria for palliative care consultation for patients admitted to the cancer unit at The Mount Sinai Hospital. Patients were eligible for this prospective cohort study if they met one or more eligibility criteria: advanced solid tumor cancer, prior hospitalization within 30 days, hospitalization for more than 7 days, or active symptoms.
“Care for patients with advanced cancer is often characterized by time spent on acute care hospital wards and intensive care units, or receiving invasive procedures, chemotherapy infusions, and radiographic imaging. Such interventions drive escalating costs and are often directly in conflict with patients’ prior stated wishes,” said Dr. Smith.
Consultation with the palliative care team included establishment of goals of care, advance care plans using standardized communication protocols, transition planning, and symptom assessment and treatment using the Edmonton Symptom Assessment Scale (ESAS). The palliative team was composed of one board-certified primary care physician, one nurse practitioner, one social worker, a chaplain, and one to two trainees.
When researchers compared patients in the intervention group with control subjects, there were increases in palliative care consultations (19 [39%] of 48 to 52 [80%] of 65; P ≤ .001) and hospice referrals (7 [14%] of 48 to 17 [26%] of 65; P = .03).
There were declines in 30-day readmission rates (17 [35%] of 48 to 13 [18%] of 65; P = .04) and receipt of chemotherapy after discharge (21 [44%] of 48 to 12 [18%] of 65; P = .03). There was an overall increase in support measures following discharge (P = .004). Length of stay was unaffected.
“Our results highlight the need to adopt this practice at acute care hospitals across the nation,” said Dr. Smith. “Palliative care involvement helps patients understand their prognosis, establish goals of care, and formulate discharge plans in line with those goals, and this study is the first to confirm the impact of using standardized criteria and automatic palliative care consultation on quality of cancer care.”
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.