A pilot initiative conducted at Mount Sinai Hospital offers compelling evidence that establishing standardized criteria for calling a palliative care consultation improves the quality of care for patients hospitalized with advanced cancer. The investigators saw improvements in the use of hospice services, inpatient mortality, and hospital readmissions among patients offered the intervention.
Palliative care is the medical specialty that focuses on improving quality of life for patients and their families in the setting of a serious illness. Palliative care teams provide an added layer of support to patients, caregivers, and doctors by addressing unremitting symptoms, helping with decision making, and coordinating care. The American Society of Clinical Oncology (ASCO) selected a total of four high-impact abstracts, including this one, to feature in an official press briefing for its upcoming 2013 Quality Care Symposium. More than 270 abstracts will be presented at the conference, which will be held in San Diego on November 1-2.
In 2012, ASCO recommended offering palliative care alongside standard oncologic care to all patients with metastatic cancer and uncontrolled symptoms. The recommendation was based on findings from seven randomized clinical studies, which showed that integrating palliative care into oncology services led to improvements in symptoms, quality of life, and patient satisfaction, and reduced caregiver burden. Involving palliative care also led to more appropriate use of hospice and intensive care.
According to Kerin Adelson, MD, Assistant Professor of Medicine, Hematology, and Medical Oncology at the Icahn School of Medicine at Mount Sinai, and lead investigator on the initiative, palliative care services are often underutilized for cancer patients, even at hospitals such as Mount Sinai that have well-established palliative care programs. "Oncologists often equate palliative care with end-of-life care; to many, calling in a palliative care specialist is an admission of defeat," said Dr. Adelson. "However, failure to identify patients who could most benefit from palliative care often results in inadequate pain control, emotional distress for patients and caregivers, and overuse of aggressive medical interventions. By increasing access to palliative care services, we hoped to help patients clarify their own treatment goals and, in turn, align our clinical goals with those of our patients."
In the initiative, all patients hospitalized with late-stage, metastatic solid tumors and uncontrolled symptoms were offered a palliative care consultation. Palliative care consultations increased to 82 percent of patients in the study group, compared with 41 percent of similar patients in the six weeks before the intervention was offered routinely. Readmission to the hospital within 30 days of discharge during the study decreased to 17 percent from 36 percent, and use of hospice services rose to 25 percent from 14 percent after the study began. In addition, the mortality index (expected over actual deaths) in the oncology service dropped dramatically, to 0.59 in the study group from 1.35 in similar patients during the year prior to the study. Length of stay in the hospital was essentially unchanged.
"This demonstrates that making palliative care a routine part of cancer care results in improved outcomes and more patient-centered care," said Dr. Adelson. Numerous studies have demonstrated the benefits of palliative care to patients, families, clinicians, and health systems, according to R. Sean Morrison, MD, Director of the Hertzberg Palliative Care Institute at Mount Sinai. Yet, despite the fact that more than 90 percent of hospitals like Mount Sinai have palliative care teams, most patients who could benefit from palliative care do not receive it or receive it too late. "Findings like Dr. Adelson's provide a strong case for making palliative care consultation a core component of cancer treatment from the time of diagnosis," said Dr. Morrison. "Our goal is to use the results of this project to develop interventions within our hospital to ensure that all people with a serious illness, not just cancer patients, are actively screened for palliative care needs and have those needs addressed -- either by the primary treatment team or through the extra layer of support of the palliative care service."
Based on the success of the pilot, Mount Sinai has expanded its palliative care service so that all cancer patients who meet the criteria used in the study will get the services they need.
"The pilot intervention has become our standard of care," said Dr. Adelson. "Widespread adoption of similar interventions could lead to national improvements in patient care for people with late-stage cancer."
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