Automatic Palliative Care Consultations for Advanced Cancer Can Increase Value of Cancer Care

Kerin Adelson, MD

Kerin Adelson, MD

A recent study found that the use of standardized criteria or “triggers” for palliative care (PC) consultation in patients with advanced cancer is not only associated with an improvement in the quality of oncology care, but also a reduction in downstream healthcare utilization.

When the automatic consult was triggered by specific criteria, 30-day readmission rates and use of chemotherapy after discharge declined, whereas hospice referrals and uptake of support services post-discharge increased.

“Patients with advanced cancer admitted to an acute care hospital often have short life expectancies and high morbidity,” said Kerin Adelson, MD, in a statement. “For these patients, the integration of palliative care has improved symptom burden, reduced patient and caregiver distress, increased referral to hospice, and improved outcomes.” Adelson is an assistant professor of medical oncology at Yale Cancer Center and deputy chief medical officer for Smilow Cancer Hospital at Yale-New Haven.

For this prospective cohort study conducted from August 2012 to January 2013, inpatients with solid tumors meeting any of the following 4 criteria received an automatic palliative care consultation (the intervention group):

• Advanced cancer (stage IV solid tumor or stage III lung or pancreatic cancer)
• Prior hospitalization within 30 days
• Hospitalization >7 days
• Any active symptoms including pain, nausea and/or vomiting, dyspnea, delirium, and psychological distress.

Six weeks prior to implementing the intervention, the researchers observed the inpatient solid tumor census daily using manual chart review. This preintervention cohort (n = 48) served as the control group, and results were compared with patients (n = 65) during the 12-week intervention period when the PC consultations were mandated.

As part of the preparation for the intervention, oncology teams were assured that the palliative care practitioners would, “act as partners, help with time-consuming family meetings, and not take over primary care of the patient unless all parties agreed.” Laminated cards were provided to oncology teams listing the 4 criteria for triggering a PC consult, and they were instructed to place an order for the PC consult in the electronic health record of any patient meeting 1 or more of the criteria.

Overall, 39% of patients in the usual care preintervention group received a PC consultation, whereas 80% of the intervention group had a PC consult after the automatic triggers were implemented.

Comparing the preintervention group to the intervention group, readmission rates decreased from 35% to 18%, hospice referrals increased from 14% to 26%, and receipt of chemotherapy after discharge decreased from 44% to 18%. Intensive care unit use did decline, but it was not statistically significant. Length of stay was not affected.

By implementing eligibility criteria for PC consults, the subjective identification was removed and allowed for a more objective assessment of the patient’s and their family’s needs, the researchers noted.

The Centers for Medicare & Medicaid Services recently launched the value-based payment program, the Oncology Care Model, which encourages value-based care through incentives. In 2016, ASCO called for incorporation of palliative care into oncologic care for all patients with metastatic cancer. This study emphasizes the importance of this charge, and reiterates that patients with advanced cancer should receive dedicated palliative care services, early in their diagnosis, along with their treatment plan.

Researchers concluded that, “Expansion of this model to other hospitals and health systems should improve the value of cancer care,” and stressed that although, “this intervention was highly successful at improving multiple quality measures in hospitalized patients with advanced cancer, integration of PC needs to begin in the ambulatory setting. This will facilitate goals-of-care discussions earlier in the disease process and may have greater impact on the overall care received throughout the disease trajectory.”

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Adelson K, Paris J, Horton JR, et al. Standardized criteria for palliative care consultation on a solid tumor oncology service reduces downstream health care use. J Oncol Pract. 2017;13(5):e431-e440.