The impact of two triggered palliative care consultation approaches on consult implementation in oncology

Abstract

Background: Studies show palliative care delivered concurrently with cancer treatment improves outcomes, yet palliative care integration with inpatient oncology is underused. This may be, in part, because effective implementation of palliative care consults in oncology is logistically challenging for healthcareorganizations. A promising approach to improve integration is a triggered palliative care consultation (TPCC). This study evaluated the impact of two TPCC approaches on consistency and quality of consult implementation, operationalized as uptake and timeliness, on solid tumor medical and gynecologic oncology services at a large academic hospital.Methods: The study timeframe was January 2010 to June 2016. TPCC in gynecologic oncology began in 2014 and was supported by a single strategy (one-page guideline using clinical criteria to initiate a consult); TPCC in medical oncology began in 2015 and was supported by multiple strategies (e.g.training, chart review to identify cancer patients with metastatic disease and uncontrolled symptoms, clinician prompting). Palliative care consult information was chart abstracted and linked to hospital encounter data. We compared the effect of a single strategy vs. usual care, and multiple strategies vs. a single strategy on implementation (i.e., uptake and timeliness). Difference-in-differences modified Poisson regression models evaluated whether implementation differed after TPCC; we estimated adjusted relative risk (aRR), controlling for patient demographic and clinical characteristics.Findings: Our sample included 5,873 medical oncology and 3,889 gynecologic oncology hospitalizations. Overall, 8.8% of medical oncology and 11.0% of gynecologic oncology inpatient encounters involved palliative care consultation. In regression analyses, TPCC supported by a single strategy in gynecologic oncology was associated with greater uptake vs. usual care (aRR: 1.45, p<.05), and TPCC supported by multiple strategies in medical oncology wasassociated with greater uptake vs. a single strategy (aRR: 2.34,p<.001). Across all comparisons, TPCC did not have a significantimpact on timing of consults.Implications for D&I Research: Our study findings are timely andadd to the growing evidence base indicating TPCC can promotethe use of palliative care for cancer inpatients. Across twoinpatient oncology services, TPCC supported by multiplestrategies had the greatest impact on uptake. How thestrategies affect the sustained use of palliative care consultsremains to be investigated.