More affirmation of the benefits of ambulatory palliative care in terminal cancer
Most end-stage cancer patients did not receive outpatient palliative care, despite their association with reduced hospitalizations and increased use of palliative care, a retrospective analysis showed.
Overall, 50% of 522 patients received palliative care, which was linked to greater use of palliative care, do not resuscitate (DNR) designation, and advanced planning, at some point before the death. However, only one in five patients has been exposed to outpatient palliative care.
Palliative inpatient care was associated with increased length of hospital stay. In contrast, outpatient palliative care dramatically reduced hospitalizations and end-of-life intensive care (EOL) and dramatically increased the length of hospice stay, reported Jonathan C. Yeh, MD, of Beth Israel Deaconess Medical Center and from Harvard Medical School in Boston, and co-authors in JCO oncology practice.
âOur results suggest that palliative care is associated with better quality end-of-life care, but inpatient and outpatient palliative care have different effects,â the authors concluded. âPatients with advanced cancer should receive outpatient palliative care early, along with cancer treatment. The expansion and strong support of ambulatory palliative care should be a priority for hospitals. “
The study added to a “robust” evidence base supporting the benefits of ambulatory palliative care for cancer patients, said Neha Kayastha, MD, and Thomas W. LeBlanc, MD, of the Duke Cancer Institute in Durham. , in North Carolina, in a accompanying editorial. Over the past decade, nearly a dozen randomized clinical trials have demonstrated the benefits of ambulatory palliative care, and several systematic reviews and meta-analyzes have confirmed the benefits.
âHowever, despite this clear evidence, we have failed to implement large-scale palliative care outside of trials,â they wrote.
Kayastha and LeBlanc cited multiple barriers to integrating palliative oncology care. Lack of clinician awareness of available services, lack of patient awareness of the potential benefits of hospice care, and lack of resources for hospice clinics all contribute to the problem.
âThe current model of integrating palliative care relies on oncologists to recognize unmet needs and then refer patients and is therefore doomed to failure due to an incomplete understanding of palliative care and its benefits,â said noted Kayastha and LeBlanc. “A better system would trigger referrals based on standard criteria through objective assessments of unmet needs.”
“It is tragic that despite more than a decade of evidence and recommendations from society, we still fail to deliver what we know to be a meaningful service to patients and families. We need to do better,” they concluded.
When planning the scan, Yeh and his colleagues assumed that palliative care improves outcomes in advanced cancer. Noting that most palliative care takes place in hospital settings, they sought to quantify exposure to inpatient and outpatient palliative care and to describe associations between palliative care and end-of-life quality measures.
The analysis included 522 patients who were admitted to an inpatient oncology unit from October 1, 2017 to September 30, 2018. Follow-up continued until October 1, 2020, when all patients had died. . The study population had a median age of 69 years at the time of death, males accounted for 53% of the total, 25% of patients identified as racial or ethnic minorities, and 82% had advanced or metastatic solid tumors.
Medical records showed that 259 patients (50%) had some exposure to palliative care, including 111 patients who had been exposed to outpatient palliative care (42% of all palliative care and 21% of the total study population ). Patients who received inpatient palliative care had a median of five visits, the first occurring a median of 45 days before death. Patients exposed to outpatient palliative care had a median of two visits, the first occurring a median of 223 days before death.
In all patients, the most common reasons for hospitalization were complications from the cancer or treatment, such as infection, uncontrolled symptoms, or factors associated with disease progression. Patients who received palliative care were younger (66 vs 71; PP= 0.03).
Overall, palliative care was associated with longer hospital stay (8.4 versus 7.2 days; P= 0.03), but the subgroup analysis showed that the difference was due to a longer length of stay in patients who received only inpatient palliative care. Patients who were exposed to outpatient palliative care spent an average of 6.3 days in hospital compared to 8.2 days for patients who had no palliative care visits (PP= 0.003).
Patients exposed to palliative care were more likely to enroll in palliative care (78% vs. 44%; PP= 0.002).
Palliative care had a significant association with documentation of advanced care planning in electronic health records (53% vs. 31%; PPP= 0.046).
Yeh has revealed a relationship with Takeda.
LeBlanc disclosed relationships with AbbVie, Astellas Pharma, Seattle Genetics, Pfizer, Genentech, AstraZeneca, Daiichi Sankyo, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Agios and Jazz Pharmaceuticals, as well as patent / royalty / intellectual property interests.