Ambulatory identification of patients with high-risk gynecological cancers Increased conversations about goals of care in a timely manner

Researchers prospectively analyzed the effect of implementing systemic outpatient identification on initiating conversations about goals of care for high-risk patients with gynecological cancers.

According to the results of a prospective study published in Gynecological oncology.

A sustained increase over time was observed in the timely documentation of goal of care discussions in patients with high-risk gynecological cancers, with documentation increasing from 30.2% prior to the implementation of systemic identification 88.7% of patients after implementation (P <.001>

“Timely goal-of-care discussions are an essential component in providing high-quality, goal-compliant cancer care at the end of life,” the researchers wrote. “Our study demonstrates the feasibility, acceptability and effectiveness of an intervention designed to increase the conduct and documentation of these conversations. Further work is needed to address other high-quality measures of end-of-life cancer care.

The research emphasized 4 important intervention components, which included training clinicians in goal-consistent cancer care; build consensus for a goals of care documentation model; identify high-risk patients; and notification of the ambulatory clinician.

Two cohorts of patients were compared in this research, including a pre-pilot cohort of consecutive outpatients from January 2016 to December 2016 who were considered high risk. The pilot cohort consisted of consecutive outpatients from August 2017 to May 2018 who were prospectively identified prior to the index encounter.

The research team defined the inclusion criteria for high risk of death as having recurrent or progressive platinum-resistant ovarian cancer or any other recurrent or metastatic gynecological cancer with evidence of disease.

The primary objective of the research focused on improving timely goals of care conversation rates. Primary secondary endpoints included palliative care acceptance, death within 30 days of admission, and intensive care unit admissions.

A total of 220 patients met the study inclusion criteria, including 96 pre-implantation patients and 124 post-implantation patients. The mean age at diagnosis of recurrent cancer was 64.9 years. The majority of patients were white (62.7%) and black (27.3%), and almost all patients were neither Hispanic nor Latino (95.9%). In addition, 47.3% of patients had platinum-resistant ovarian cancer.

Time from conversation about first goals of care to death increased in patients after implementation (283 days versus 128 days; P <.001 no significant differences were observed before and after implementation among the primary secondary endpoints.>

Seventy-five percent of gynecologic oncology providers returned completed questionnaires (9 of 12 providers) during the pilot period. Notably, 67% agreed that “notification accurately identified patients who needed a goal of care conversation” and 88% agreed that notification improved delivery of patient care, was valuable for clinical care and was not a burden for daily work.

The study had some limitations, including the ratio of 2 different analytical methods. Additionally, the researchers suggest that additional communication interventions were used during the study period, which may have impacted the increased rates of goal of care discussions during the post-implementation period. implemented.

“Physicians are often hesitant to discuss prognosis with patients for a variety of reasons,” the researchers explained. “By clearly defining a priori the clinical eligibility criteria for [goals of care] conversations in every type of cancer, our initiative overcame the challenge of prognosis, one of the most common reasons doctors cite when they [goals of care] discussions are not carried out.

Reference

Davidson BA, Puechl AM, Watson CH, et al. Promote timely conversations about goals of care between gynecologic cancer patients at high risk of death and their providers. Gynecol Oncol. 2021;S0090-8258(21)01635-8. doi:10.1016/j.ygyno.2021.12.009

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