Use of Palliative Care Among Commercially Insured Patients With Metastatic Cancer Between 2001 and 2016

PURPOSE: Early palliative care, concomitant with disease-directed treatments, is recommended for all patients with advanced cancer. This study assesses population-level trends in palliative care use among a large cohort of commercially insured patients with metastatic cancer, applying an expanded definition of palliative care services based on claims data. METHODS: Using nationally representative commercial insurance claims data, we identified patients with metastatic breast, colorectal, lung, bronchus, trachea, ovarian, esophageal, pancreatic, and liver cancers and melanoma between 2001 and 2016. We assessed the annual proportions of these patients who received services specified as, or indicative of, palliative care. Using Cox proportional hazard models, we assessed whether the time from diagnosis of metastatic cancer to first encounter of palliative care differed by demographic characteristics, socioeconomic factors, or region. RESULTS: In 2016, 36% of patients with very poor prognosis cancers received a service specified as, or indicative of, palliative care versus 18% of those with poor prognosis cancers. Being diagnosed in more recent years (2009-2016 v 2001-2008: hazard ratio [HR], 1.8; P < .001); a diagnosis of metastatic esophagus, liver, lung, or pancreatic cancer, or melanoma ( v breast cancer, eg, esophagus HR, 1.89; P < .001); a greater number of comorbidities (American Hospital Formulary Service classes > 10 v 0: HR, 1.71; P < .001); and living in the Northeast (HR, 1.43; P < .001) or Midwest ( v South: HR, 1.39; P < .001) were the strongest predictors of shorter time from diagnosis to palliative care. CONCLUSION: Use of palliative care among commercially insured patients with advanced cancers has increased since 2001. However, even with an expanded definition of services specified as, or indicative of, palliative care, < 40% of patients with advanced cancers received palliative care in 2016.

Download Full-text

In-hospital cancer care: Are we missing an opportunity for end of life care?

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.9039 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 9039-9039

Author(s):

Gabrielle Betty Rocque ◽

Anne Elizabeth Barnett ◽

Lisa Illig ◽

Howard Harry Bailey ◽

Toby Christopher Campbell ◽

...

Keyword(s):

Palliative Care ◽

Overall Survival ◽

Hospital Admission ◽

End Of Life ◽

Poor Prognosis ◽

Metastatic Cancer ◽

Academic Medical Center ◽

Imaging Studies ◽

Improvement Project ◽

Palliative Care Consultation

9039 Background: Little data exists on the estimated survival of patients with metastatic cancer after hospitalization. As part of a prospective quality improvement project, we characterized the population of patients admitted to an inpatient oncology service in an academic medical center with emphasis on the disposition at discharge and overall survival. Methods: We collected data over a 4 month period (9/1/10-12/23/10) representing 149 admissions of 119 unique patients. We measured patient characteristics, disease evaluation, procedures, consults, imaging studies performed, disposition, length of stay, and overall survival. These data were compared to a similar study conducted in our center in 2000. Results: Uncontrolled symptoms were the most common reason for admission (pain 28%, dyspnea 9%, nausea 9%). Imaging studies were more common than in 2000 (415 vs. 196 total procedures). Eighty-five percent of patients had progressive disease. Seventy percent of patients were discharged home without additional services such as home health or hospice. The overall median survival was poor in 2000 and in 2010, 100 days and 60 days from discharge, respectively. Despite an overall poor prognosis, palliative care consultation was obtained only 13 times (8% of admissions) and 18% of patients were enrolled in hospice at discharge. Conclusions: An unscheduled hospital admission portends a poor prognosis. Cancer patients in the hospital are nearing the end-of-life with a median life expectancy of approximately 3 months and could be considered hospice-eligible and appropriate for a palliative care consult. We believe that hospital admission represents a missed opportunity to provide palliative care services and end-of-life counseling to this patient population.

Download Full-text

Cluster-randomized trial of early palliative care for patients with metastatic cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.9003 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 9003-9003 ◽

Cited By ~ 4

Author(s):

Camilla Zimmermann ◽

Nadia Swami ◽

Gary Rodin ◽

Ian Tannock ◽

Monika K. Krzyzanowska ◽

...

Keyword(s):

Palliative Care ◽

Randomized Trial ◽

Symptom Severity ◽

Metastatic Cancer ◽

Symptom Control ◽

Cluster Randomized Trial ◽

Satisfaction With Care ◽

Early Palliative Care ◽

Cluster Randomized

9003 Background: Patients with metastatic cancer have compromised quality of life (QOL), which tends to worsen towards the end of life. We conducted a cluster-randomized trial of early versus routine palliative care in patients with metastatic cancer, to assess impact on QOL, symptom control and satisfaction with care. Methods: Twenty-four medical oncology clinics were randomized, stratified by tumour site (4 lung clinics, 8 gastrointestinal, 4 genito-urinary, 6 breast, 2 gynecological), to intervention and follow-up (at least monthly) by a palliative care team, or to routine cancer care. Eligible patients had ECOG performance status 0-2 and a clinical prognosis of 6 months to 2 years. Patients completed measures of QOL (FACIT-Sp, including physical, social, emotional, functional and spiritual well-being; range 0-156, with higher scores indicating better QOL), symptom severity (Edmonton Symptom Assessment System; range 0-90, with higher scores indicating worse symptom severity), and satisfaction with care (FAMCARE-P16; score range 16-80) at baseline and monthly for 4 months. The primary outcome was the change in FACIT-Sp at 3 months. The planned sample size was 225 patients per arm, assuming 80% power and a 2-sided significance level of 0.05. Results: From December 2006 to September 2010, 461 patients completed baseline measures (228 intervention, 233 control); 442 patients completed at least one follow-up assessment (mean patients/cluster 18.8±11.6 control, 18.1±12.6 intervention). At 3 months, patients in the intervention group had marginally improved QOL (mean change in intervention vs. control, 1.6±14.5 vs. -2.0±13.6, p=0.07) but not symptom severity (0.1±16.9 vs. 2.1±13.9, p=0.34). At 4 months the change in QOL was more marked (2.5±15.5 vs. -4.0±14.2, p=0.008) and symptom severity was marginally better (-1.3±16.0 vs. 3.2±13.9, p=0.05). Improvement in satisfaction with care was evident at one month (p=0.001) and remained significant at both 3 months (2.3±9.1 vs.-1.8±8.2, p=0.001) and 4 months (3.7±8.6 vs. -2.4±8.3, p<0.001). Conclusions: In patients with metastatic cancer, early palliative care intervention immediately improved satisfaction with care, while QOL and symptom control improved later.

Download Full-text

Palliative Cancer Care: An Epidemiologic Study

Journal of Clinical Oncology ◽

10.1200/jco.2010.29.2599 ◽

2011 ◽

Vol 29 (6) ◽

pp. 646-650 ◽

Cited By ~ 29

Author(s):

Gerhild Becker ◽

Isaak Hatami ◽

Carola Xander ◽

Bettina Dworschak-Flach ◽

Manfred Olschewski ◽

...

Keyword(s):

Palliative Care ◽

Cancer Care ◽

Medical Center ◽

Metastatic Cancer ◽

Epidemiologic Study ◽

Care Needs ◽

Patients With Cancer ◽

Discharge Management ◽

Hospital Patients ◽

Definition Of

Purpose To analyze the need for palliative care in hospital patients who have cancer. Palliative care is an essential component of comprehensive cancer care and identification of palliative care needs (PCNs) of patients with cancer is a topic that has not been thoroughly studied. Patients and Methods Data were collected prospectively from inpatients of University Medical Center Freiburg in Freiburg, Germany, with 982 hospital beds included in the study. During the observation period of 17 months, each patient discharged from a hospital ward was screened by surveying the treating physician who was responsible for dismissal about patients' PCNs based on the WHO 1990 definition of palliative care. To complete obligatory electronic discharge management, a modified dismissal form asking to classify the patient as having PCN “yes/no” had to be filled out for each patient discharged. Results The response rate was 96% with data for 39,849 patients that could be analyzed. A total of 6.9% of all hospital patients and 9.1% of patients older than age 65 years were considered to have PCNs. Of the 2,757 patients with PCNs, 67% (n = 1,836) had cancer. Among the 11,584 patients with cancer, 15.8% were classified as having PCNs. PCNs were particularly high in patients with head and neck cancer (28.3%), malignant melanoma (26.0%), and brain tumors (18.2%). Suffering from cancer increases the probability of developing PCNs by a factor of 3.63 (95% CI, 3.27 to 4.04). For patients with metastatic cancer, the risk of developing PCNs is increased 12-fold (odds ratio, 12.27; 95% CI, 11.07 to 13.60). Conclusion Structures to provide palliative care for patients with cancer are needed.

Download Full-text

The practice of early palliative care: A qualitative study of patient-clinician encounters.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.2 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 2-2 ◽

Cited By ~ 1

Author(s):

Christopher Taekyu Lim ◽

Avia Tadmor ◽

Daisuke Fujisawa ◽

James John MacDonald ◽

Emily R. Gallagher ◽

...

Keyword(s):

Palliative Care ◽

Massachusetts General Hospital ◽

Metastatic Cancer ◽

Treatment Decision ◽

Clinic Visit ◽

Ambulatory Setting ◽

Inpatient Setting ◽

Early Integration ◽

Early Palliative Care ◽

The Relationship

2 Background: Studies have shown that palliative care (PC) integrated early in the course of metastatic cancer, shortly after diagnosis, leads to improved patient outcomes. Unlike PC in the inpatient setting, PC initiated early, in the ambulatory setting, had not been well studied. Our aim was to elucidate the practice of early PC through analysis of PC clinic visit transcripts. Methods: As part of an ongoing study of early PC in patients with advanced lung and gastrointestinal cancers at the Massachusetts General Hospital, we are audio-recording patients’ outpatient PC clinic visits. To capture the range of PC content, we randomly selected five patients and analyzed three clinic transcripts per patient: early, midway, and late in each patient’s clinical course. We performed thematic analysis on these clinic transcripts using NVivo 10. Results: Our analysis suggests that the elements of early PC that occur most frequently across the disease course are managing symptoms, facilitating coping, and developing the relationship with patients and their family caregivers. Elements that tend to occur during clinical transitions include advising treatment decision-making, facilitating medical understanding, and advance care planning. Our analysis also identifies four broad approaches to PC that are applied longitudinally, over the course of the patient-clinician relationship: 1) eliciting versus commenting on patients’ perspectives, 2) alluding to and preparing for the future, 3) transitioning between managing symptoms and facilitating coping, and 4) transitioning between developing the relationship and facilitating coping. Lastly, we observe three specific techniques applied by PC clinicians: 1) coordinating with oncologists, 2) providing referrals, and 3) addressing family dynamics. Conclusions: Our study identifies the predominant elements, four longitudinal approaches, and three specific techniques of early PC. These novel insights can be applied to care delivered by both PC and non-PC clinicians, well before patients approach the end of life. The longitudinal approaches in particular may help explain the significance of early integration of PC into cancer care.

Download Full-text

African American perceptions of early palliative care in oncology.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.31_suppl.104 ◽

2017 ◽

Vol 35 (31_suppl) ◽

pp. 104-104

Author(s):

William F. Pirl ◽

Estefany Saez-Flores ◽

Neysari Arana ◽

Joseph Greer ◽

Areej El-Jawahri ◽

...

Keyword(s):

Palliative Care ◽

Focus Groups ◽

Cancer Diagnosis ◽

Metastatic Cancer ◽

Major Theme ◽

Course Of Illness ◽

Early Palliative Care ◽

Early Introduction ◽

Knowledge And Beliefs ◽

After Cancer

104 Background: While ASCO guidelines recommend early palliative care (PC) for patients with metastatic cancer, few African Americans (AA) have participated in PC trials and little data exist on the acceptability and effect of early PC in this population. Using the ADAPT-ITT framework for culturally tailoring evidence-based interventions, we assessed perceptions of PC and its early introduction in oncology in AAs. Methods: We conducted four focus groups with AAs from community centers in Miami. We enrolled adults without a history of cancer to approximate the knowledge and beliefs of someone with newly diagnosed cancer. Focus groups explored knowledge of PC, value of different components of early PC, and perceptions about introducing PC early after cancer diagnosis. We recorded and transcribed the focus groups, performing thematic analysis with NVivo. Results: Thirty-seven AAs participated. Over half were female (24/37), and median age was 54 years old (range 35-71). Participants had little to no knowledge of PC. Lack of familiarity was attributed to AAs receiving sub-standard care and the belief that PC has been kept from AAs. Rather than being concerned that it might result in less cancer treatment, they reported that PC was actually part of doing everything possible for cancer, and it is the “best care.” PC was viewed as a solution to a major theme of doctors not providing adequate information for patients and families to prepare for negative outcomes such as death. However, some objected to discussing specific survival estimates for fear of speaking them into existence. Distinctions were drawn between what doctors manage (treatments) and what God manages (life/death). Participants could not understand why PC would be reserved for later in the course of illness instead of immediately after cancer diagnosis (“Don’t wait until I’m dying; give it to me now!”). PC was described as “supervising your needs and making sure they are addressed.” Conclusions: AAs were enthusiastic about early PC in oncology, but did not support providing specific estimates of survival. End-of-life planning was considered by some to be spiritual and not medical.

Download Full-text

Identifying early-phase clinical trial (EP-CT) participants at risk for poor outcomes.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.301 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 301-301

Author(s):

Debra Lundquist ◽

Rachel Jimenez ◽

Megan Healy ◽

Andrew Johnson ◽

Sienna Durbin ◽

...

Keyword(s):

At Risk ◽

Palliative Care ◽

Social Work ◽

Supportive Care ◽

Clinical Outcomes ◽

Poor Prognosis ◽

Metastatic Cancer ◽

Care Services ◽

Poor Outcomes ◽

Prognosis Score

301 Background: EP-CTs investigate novel treatment options, with recent advances in personalized therapy leading to increased response rates, decreased toxicity, and improved survival. Identifying EP-CT participants at risk for poor outcomes could help identify those who may benefit most from targeted supportive care efforts. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs from 2017-2019 to obtain baseline characteristics (demographics and clinical factors), clinical outcomes (survival, time on trial, completion of dose-limiting toxicity [DLT] period, emergency room [ER] visits, hospitalizations, and hospice use), and receipt of supportive care services before/during trial (palliative care, social work, physical therapy [PT], and nutrition). We calculated the validated Royal Marsden Hospital (RMH) prognosis score using data at the time of EP-CT enrollment based on patients’ lactate dehydrogenase, serum albumin, and number of sites of metastasis. RMH scores range from 0-3, with scores of 2+ indicating a poor prognosis. We examined differences in patient characteristics, clinical outcomes, and receipt of supportive care services based on the RMH prognosis score. Results: Among 350 patients (median age = 63.2 years [range 23.0-84.3]; 57.1% female, 98.0% metastatic cancer), the most common cancer types were lung (23.4%), gastrointestinal (20.3%), and breast (12.0%). Nearly one-third (31.7%) had an RMH score indicating a poor prognosis. Patients with a poor prognosis RMH score had a worse performance status (ECOG ≥1: 80.2% vs 58.1%, p <.001) and more prior treatment (3+ prior lines: 48.6% vs 34.7%, p =.001) than those with a better prognosis score. Those with a poor prognosis RMH score had worse survival (median: 147 vs 402 days, p <.001) and shorter time on trial (median: 49 vs 84 days, HR = 1.53, p <.001), as well as a lower likelihood of completing the DLT period (72.1% vs 80.8%, p =.015). Patients with a poor prognosis score had a higher risk for ER visits (HR 1.66; p =.037) and hospitalizations (HR 1.69; p =.016) while on trial, with earlier hospice enrollment (HR 2.22; p =.006) following the trial. Patients with a poor prognosis score were significantly more likely to receive palliative care before/during trial (46.8% vs 27.6% p =.001), but not social work (41.4% vs 41.4% p = 1.00), PT (44.1% vs 34.7%; p =.098), or nutrition (40.5% vs 37.2%; p =.557). Conclusions: EP-CT participants represent a unique population of patients with advanced cancer, and we identified a group at risk for particularly poor outcomes, including worse survival, shorter time on trial, and greater use of healthcare services. Although patients with a poor prognosis score had higher rates of palliative care use, under half received supportive care services, underscoring the need for efforts to prospectively target these patients with interventions that address their supportive care needs.

Download Full-text

Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care

Tumori Journal ◽

10.1177/0300891618792478 ◽

2018 ◽

Vol 105 (2) ◽

pp. 103-112 ◽

Cited By ~ 3

Author(s):

Domenico C. Corsi ◽

Adriana Turriziani ◽

Luigi Cavanna ◽

Piero Morino ◽

Angela S. Ribecco ◽

...

Keyword(s):

Palliative Care ◽

Medical Oncology ◽

Metastatic Cancer ◽

Italian Society ◽

Cancer Prognosis ◽

Early Palliative Care ◽

Cancer Management ◽

Consensus Document ◽

Palliative Care Consultation ◽

Practice Models

A consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology and the Italian Society of Palliative Care to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of those who daily face the problems of advanced stage cancer patients. The simultaneous administration of antineoplastic treatments and early palliative care was shown to be beneficial in metastatic cancer pathway outcomes. Patients who could benefit from early palliative care are those with an advanced cancer at presentation, a compromised PS for cancer, and/or morbidities, and who are too frail to receive treatment. According to the Bruera practice models, in which the combination of cancer management with early palliative care can be offered, three groups of patients needing simultaneous care were identified and three different models of the delivery of palliative care were proposed. In patients with good prognosis and low need of simultaneous care, the solo practice model and the request for consultations were suggested, while in patients with poor prognosis disease with high need of simultaneous care and in conditions with high need of simultaneous care, regardless of cancer prognosis, the integrated care approach should be offered. Palliative care consultation services are seldom accessible in the majority of Italian hospitals; thus the application of various practice models depends on available resources, and a shared care model with the structures of palliative care operating in the area is often required.

Download Full-text

Developing a “toolkit” to measure implementation of concurrent palliative care in rural community cancer centers

Palliative & Supportive Care ◽

10.1017/s1478951517000323 ◽

2017 ◽

Vol 16 (1) ◽

pp. 60-72 ◽

Cited By ~ 4

Author(s):

Lisa Zubkoff ◽

J. Nicholas Dionne-Odom ◽

Maria Pisu ◽

Dilip Babu ◽

Imatullah Akyar ◽

...

Keyword(s):

Palliative Care ◽

Rural Areas ◽

Assessment Tool ◽

Metastatic Cancer ◽

Lessons Learned ◽

Newly Diagnosed ◽

National Guidelines ◽

Cancer Centers ◽

Early Palliative Care ◽

Implementation Costs

ABSTRACTObjective:Despite national guidelines recommending early concurrent palliative care for individuals newly diagnosed with metastatic cancer, few community cancer centers, especially those in underserved rural areas do so. We are implementing an early concurrent palliative care model, ENABLE (Educate, Nurture, Advise, Before Life Ends) in four, rural-serving community cancer centers. Our objective was to develop a “toolkit” to assist community cancer centers that wish to integrate early palliative care for patients with newly diagnosed advanced cancer and their family caregivers.Method:Guided by the RE-AIM (Reach, Effectiveness–Adoption, Implementation, Maintenance) framework, we undertook an instrument-development process based on the literature, expert and site stakeholder review and feedback, and pilot testing during site visits.Results:We developed four instruments to measure ENABLE implementation: (1) the ENABLE RE-AIM Self-Assessment Tool to assess reach, adoption, implementation, and maintenance; (2) the ENABLE General Organizational Index to assess institutional implementation; (3) an Implementation Costs Tool; and (4) an Oncology Clinicians' Perceptions of Early Concurrent Oncology Palliative Care survey.Significance of results:We developed four measures to determine early palliative care implementation. These measures have been pilot-tested, and will be integrated into a comprehensive “toolkit” to assist community cancer centers to measure implementation outcomes. We describe the lessons learned and recommend strategies for promoting long-term program sustainability.

Download Full-text

Integrating the ENABLE early palliative care approach in community cancer centers: Results of an implementation trial.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.34_suppl.114 ◽

2018 ◽

Vol 36 (34_suppl) ◽

pp. 114-114 ◽

Cited By ~ 1

Author(s):

Marie Bakitas ◽

J Nicholas Dionne-Odom ◽

Maria Pisu ◽

Andres Azuero ◽

Dilip Sankar Babu ◽

...

Keyword(s):

Palliative Care ◽

Assessment Tool ◽

Underserved Populations ◽

Metastatic Cancer ◽

Gynecologic Cancer ◽

National Guidelines ◽

Learning Collaborative ◽

Cancer Centers ◽

Early Palliative Care ◽

Implementation Trial

114 Background: Despite national guidelines recommending early palliative care (EPC) for individuals newly-diagnosed with metastatic cancer, it is rarely available in rural community cancer centers serving underserved populations. We conducted the first implementation trial of EPC in rural cancer centers using the evidence-based ENABLE (Educate, Nurture, Advise, Before Life Ends) model of early, concurrent oncology palliative care. Methods: Mixed methods case study of a 4-year American Cancer Society-funded 4-site, implementation trial using a virtual learning collaborative in AL and SC. Guided by the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework, we gathered qualitative and quantitative data via monthly reports and yearly in-person site visits using: 1) a RE-AIM Self-Assessment Tool completed by site staff to measure reach, adoption, implementation, and maintenance; 2) EPC General Organizational Index (GOI) to measure capacity for EPC services and implementation progress; and 3) field notes from site interviews and final reports. Results: Across the 4 sites, 62 patients (range: 4–31; mean: 15) and 46 caregivers (range: 2–22; mean: 12) participated. Baseline patient characteristics included: mean age of 58, 70% female, 17% Black or minority, 57% some college or college, 49% rural dwelling, and 57% non-gynecologic cancer. Sites enrolled at least 58% of the patients they planned to enroll (range: 58%–100%; average: 84%), of which 44% received 100% of ENABLE content and nearly 60% received two-thirds. Reasons for not completing all six sessions included death, unrecorded contacts, or lost to follow up. Longitudinal GOI scores indicated a trend of improved capacity for EPC services at three of the four sites. Qualitative data from site lead interviews revealed administrative (presence or lack of palliative ‘champions’), clinical (having adequate training), and economic (reimbursement) implementation barriers and facilitators. Conclusions: This pilot implementation study demonstrated feasibility and areas to enhance implementation in a larger comparative effectiveness trial to enhance scaling and spreading EPC in community practices.

Download Full-text