Palliative Care Services and Outcomes Improve Using a Standardized Approach


Key Points

  • Applied to 68 patients meeting the criteria, the program led to greater utilization of palliative care consultations, reduced rates of readmission, greater use of hospice, and a more favorable mortality index.
  • Mount Sinai’s oncology service improved from worse than average to better than average after implementation of the standardized palliative care program, according to the authors.

Standardized criteria for initiating palliative care consultations can substantially improve the care of patients with advanced solid tumors, according to research from Mount Sinai School of Medicine, New York, led by Kerin Adelson, MD, Coordinator for Ambulatory Oncology Quality for the Tisch Cancer Institute (Abstract 37)

“Formalizing criteria for a palliative care consult was easy to implement, highly effective, and led to improvements in multiple quality measures,” Dr. Adelson said.

At a press briefing in advance of the 2013 ASCO Quality Care Symposium, to be held November 1 to 2, 2013, in San Diego, Dr. Adelson described the 3-month pilot program, which evaluated whether the use of standardized criteria could improve palliative care services and outcomes. Prior to the study, no guidelines were available for identifying which patients with advanced solid tumors most warranted palliative care consultation, she said.

“Despite a top-rated palliative care division at Mount Sinai, our solid tumor division utilized palliative care and hospice less than other medical centers. Our inpatient solid tumor service consistently demonstrated poor-quality metrics,” said Dr. Adelson.

For example, data from Mount Sinai’s University Health System Consortium (UHC), which measures quality performance among 118 academic medical centers, had logged the following statistics for the solid tumor service in the year prior to the intervention: mortality index 1.35 (target < 1.0); 30-day readmission rate 21.7% (target < 10.3%); and length of stay index, 1.23 (target < 1.0).

“We hypothesized that implementing standardized criteria for palliative care consultation would improve these metrics,” she said.

Criteria Developed From Literature and Guidelines

Dr. Adelson and her team developed criteria based on extensive literature review and discussions with oncologists and palliative care specialists. The criteria stipulate that palliative care consultation is warranted for patients with any of the following: stage IV solid tumor, stage III pancreatic or lung cancer, hospitalization within the prior 30 days, prolonged hospitalization (> 7 days), and uncontrolled symptoms, including pain, nausea, shortness of breath, delirium, and psychological distress.

Over 3 months, 68 patients met the criteria for consultation, and their outcomes were compared to 51 similar patients seen within 6 weeks of the program’s initiation (preintervention group).

Standardization Leads to Multiple Improvements

“Mandating palliative care consults for patients at the highest risk for in-hospital death and readmission improved hospice utilization, 30-day readmissions, and the oncology service,” Dr. Adelson reported.

Comparing the pilot group’s outcomes to the aggregate UHC data from the previous year, the researchers showed that standardization reduced 30-day readmission rates from 21.7% to 13.5%, and improved the mortality index from 1.35 to 0.59. In short, Mount Sinai’s oncology service improved from worse than average to better than average, the researchers noted.

“Making palliative care a routine part of cancer care results in improved quality,” Dr. Adelson maintained. “This has become our standard of care. We have expanded our palliative care service so that all cancer patients who meet the criteria will get the services they need.”

Olatoyosi Odenike, MD, of the University of Chicago, who moderated the press briefing, commented, “ASCO has identified the provision of palliative care as an important initiative, especially in patients with metastatic cancer or a high symptom burden. This study is an excellent example of how implementation of a few simple criteria to identify individuals most likely to benefit can lead to significant improvements in terms of utilization of services and improvements in quality measures.”

Dr. Odenike would like to see subsequent larger studies validate this approach, followed by wider adoption.

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®.