Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care

Abstract

Background: Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence.

Materials and methods: Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral.

Results: Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites.

Conclusions: Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care.

Implications for practice: Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

Keywords: Cancer; Early medical intervention; Health care quality, access and evaluation; Health services accessibility; Health services research; Outcome assessment, healthcare; Outpatient clinics, hospital; Palliative care.

Conflict of interest statement

Disclosures of potential conflicts of interest may be found at the end of this article.

© 2020 AlphaMed Press.

Figures

Figure 1

Difference in referral timing according to characteristics of referring oncologist and tumor site. aOther tumor sites included skin, sarcoma, endocrine, and unknown primary. bOther referring services included psychosocial oncology, internal medicine, anesthesia, and gastroenterology; numbers were too small to compare (n = 4 pre‐evidence and 6 post‐evidence).Abbreviations: Pre‐evid., pre‐evidence; Post‐evid, post‐evidence.

Figure 2

Symptom severity among patients in the pre‐evidence and post‐evidence groups. Bars represent mean symptom severity scores. The number of patients for whom individual Edmonton Symptom Assessment System symptoms were available ranged from 227 to 232 pre‐evidence and from 395 to 402 post‐evidence. The Holm‐Bonferroni method was used to correct for multiple testing, with the following levels of significance: pain (p = .83), tiredness (p = .001), nausea (p = .4), depression (p = .4), anxiety (p = .4), drowsiness (p = .24), appetite (p = .08), wellbeing (p = .21), and shortness of breath (p = .4).