Encouraging early palliative consultations for patients with stage IV lung and pancreatic cancers: A retrospective chart review of a quality improvement initiative

Encouraging early palliative consultations for patients with stage IV lung and pancreatic cancers: A retrospective chart review of a quality improvement initiative

Dr. Sharon Buehner, MDCM, CCFP (EM) & Megan Gray, BScN, RN

 

Correspondence concerning this article should be addressed to:

Dr. Sharon Buehner

Algoma District Cancer Program, Sault Area Hospital

750 Great Northern Road

Sault Ste. Marie, Ontario P6B 0A8

buehnersharon@hotmail.com

705-759-1234, (Fax) 705-759-7460

 

Megan Gray

Clinical Trials Department, Sault Area Hospital

750 Great Northern Road

Sault Ste. Marie, Ontario P6B 0A8

grayme@sah.on.ca

Abstract

Background: Evidence shows that early palliative care referrals improve the quality of life for patients with advanced cancer. The complex needs of patients with incurable, stage IV cancer generally arise several months before the patient’s death, yet many palliative care referrals happen in the last two months of life, or not at all. In December of 2013 the Algoma District Cancer Program (ADCP) implemented an initiative to encourage early palliative referrals for patients with newly diagnosed incurable lung or pancreatic cancer.

Objectives: The purpose of this study was (1) to investigate the effectiveness of encouraging early palliative referrals and (2) to determine whether this initiative reduced ER visits or hospital admissions.

Methods: A retrospective chart review was performed on patients diagnosed with incurable lung and pancreatic cancer at Sault Area Hospital for a 12 month period before and after implementing an initiative to encourage palliative referrals from the onset of diagnosis. Data including demographics, timing of oncology and palliative consultations, and number and timing of ER visits and hospital admissions was captured.

Results: Overall, we found no meaningful difference in numbers of early palliative consultations after our initiative compared to pre-initiative. Of the pre-initiative group, 48% had an early palliative consultation which we defined as within 42 days of their initial visit to the oncologist, while of the post-initiative group, 53% had an early palliative consultation. Of the entire cohort of patients, 89% had at least one palliative care consult before death. Comparing the groups of deceased patients before and after our initiative, we found no meaningful difference in number of ER visits or hospital admissions in the last two weeks of life.

Keywords: Palliative care, early palliative consultation, advanced cancer, emergency room visit, hospital admission

Introduction

Receiving a diagnosis of cancer often engenders significant concerns, fears, and life-altering treatment plans that greatly impact the quality of life of both the patient and their family members. Patients diagnosed with Stage IV cancer typically have a poor prognosis, but some are living for longer periods of time and undergo difficult treatments throughout their course of illness. These patients experience a reduced quality of life, which often further declines as they approach end of life (Zimmermann et al., 2014).

Evidence suggests that early palliative care referrals have been shown to improve the quality of life of patients with advanced cancer (Hannon et al., 2014; Temel et al., 2010; Yoong et al., 2013; Zimmermann et al., 2014). The palliative care team facilitates improved end of life care, promotes symptom management, and emphasizes psychosocial components of care such as coping, allowing medical oncologists to focus on the treatment itself, and manage complications (Yoong et al., 2013). Palliative care ultimately improves the quality of life for this patient population and facilitates a comforting, seamless transition as end of life approaches.

The complex needs of patients with incurable cancer often begin several months before the patient’s death, however, it has been determined that the majority of palliative care referrals happen in the last two months of life, or not at all (Zimmermann et al., 2014). This study was proposed (1) to investigate the effectiveness of an initiative to encourage early palliative referrals for all incurable lung and pancreatic cancers at the time of the patients’ initial oncology consult and (2) to determine whether this initiative reduced emergency room (ER) visits or hospital admissions.

Studies have been conducted to determine the effects of early palliative care for patients with advanced cancer on their quality of life (Hui et al., 2014; Jang et al., 2014; Temel et al., 2010; Zimmermann et al., 2014), however, except for a study by Hui et al. (2014), there is limited research to our knowledge examining the correlation between early palliative consultations and the number of patient visits to the ER and hospital admissions towards end of life. Within the final weeks of life, medical interventions including ER visits and hospital admission may indicate poor-quality care (DiMartino et al., 2014; Hui et al., 2014; Jang et al., 2014).

Our initiative to encourage early palliative referrals was implemented in December of 2013 at the Algoma District Cancer Program (ADCP) in Sault Ste. Marie, ON, for patients with newly diagnosed incurable lung or pancreatic cancer, as these patients typically experience a high burden of symptoms(Barbera et al., 2010; Jang et al., 2014).The initiative involved the oncologist’s primary care nurse placing a palliative referral form on the front of the patient’s chart at the time of their initial oncology consultation as a reminder for the oncologist to initiate an early palliative care referral.This retrospective cohort study was proposed to show the value of early palliative consultations. We hypothesized that earlier palliative care referrals would be associated with less ER visits and hospital admissions, especially in the last two weeks of life.

Materials and Methods

A single-site, retrospective chart review was performed on patients diagnosed with incurable lung and pancreatic cancer who had their initial oncology consultation in the ADCP either before the initiative (Nov, 2012 through Oct, 2013) or after the initiative began (Feb, 2014 through Jan, 2015).  Follow up data was obtained on all patients up to Apr, 2016. These dates capture one year prior and one year after the beginning of the early palliative consultation initiative, so that for the pre-initiative group, discussion of early palliative referrals was absent and bias could be avoided.  An application was submitted to the Joint Group Health Centre/Sault Area Hospital Research Ethics Board and approval was granted.

Using the oncology new consultation record kept in the Clinical Trials department of the ADCP, the electronic health records of patients with a diagnosis of lung or pancreatic cancer were pre-screened to confirm staging at the time of consult and to identify those meeting the chart review criteria. Patients were included on the basis of the following criteria: 1) new diagnosis of advanced lung cancer (Stage IIIB or IV) or pancreatic cancer (unresectable or Stage IV) cancer and (2) had an oncology consultation through the ADCP (inpatient or outpatient). There were a total of 231 patients identified from the new consultation record with newly diagnosed lung or pancreatic cancer; after the initial review there were 101 patients who met the inclusion criteria and 130 patients who were excluded from the study. Patients were excluded if (1) they did not meet the staging criteria, (2) we did not have access to their medical record or (3) the patient relocated to another city, preventing the reliable capturing of ER visits or hospital admissions in their last two weeks of life. There were a total of 52 ‘pre-intervention’ patients before the initiative and 49 ‘post-intervention’ included in the study.

For the patients included in the study, additional information was collected from their paper and electronic health records, including demographic data, date of initial oncology consultation, date and location of initial palliative consultation, number and timing of emergency room (ER) visits and hospital admissions, and date and location of death. All data was recorded without identifiers to maintain patient confidentiality.

Descriptive statistics were used for the summary of the variables of interest, specifically the number of patients who received early palliative consultations pre and post-initiative, which we defined as within 42 days of the patient’s initial visit to the oncologist. Descriptive statistics were also used to analyze visits to the ER and hospital admissions in the final two weeks of life, as well as patient’s location of death pre and post-initiative.

Results

Overall, we found no meaningful difference in numbers of early palliative consultations after our initiative compared to pre-initiative (Table 1). Of the pre-initiative group, 48% had an early palliative consultation which we defined as within 42 days of their initial visit to the oncologist, while of the post-initiative group, 53% had an early palliative consultation. Of the entire group of 101 patients (pre and post-initiative), 88 were deceased by the end of the follow up period.  Of these deceased patients, 89% had at least one palliative care consult before death with 50% having an early palliative consultation.

Comparing the groups of deceased patients before and after our initiative we found no difference in number of ER visits or hospital admissions in the last two weeks of life and no difference in location of death (Table 2).Overall, 35% of patients at our centre had at least one visit to ER in their last two weeks of life and 53% had at least one ER visit or admission to hospital in their last two weeks of life. 33% of the patients died in hospital, 49% died in the residential hospice and 17% died in their own home (Table 2).

Discussion

Although our initiative to encourage early palliative referrals did not seem to make a meaningful difference in increasing the number of early palliative consultations, our data did reveal some encouraging aspects of palliative care consultation patterns in our community and identified areas upon which we can improve.

Overall, including both pre- and post-initiative groups, the majority of patients (89%) with newly diagnosed advanced lung or pancreatic cancer had a palliative consultation before death. This is impressive as there may have been even more patients who never received a palliative consultation but were instead followed regularly by their family physician for their palliative care.

Not surprisingly, almost 40% of our patients died within 60 days of diagnosis of advanced disease.  In a subgroup analysis when we excluded these patients who did poorly, there was a trend toward more outpatient consultations and more early palliative care consults post-initiative (35% pre-initiative versus 53% post-initiative) (Table 1).  Those patients living longer than 60 days are typically going through difficult medical treatments and procedures throughout their course of illness for a longer period of time and could be the ones that could most benefit from early palliative care. Many of these patients however received no palliative consultation. For example, in the post-initiative group, there were 9 of 12 patients, still living, who had not received a palliative consultation. This group of patients have had 25 ER visits and nine admissions over their 15-26 months since diagnosis. We need to do better at offering early palliative care for these ‘longer term palliative’ patients. Perhaps in our community we could also benefit from more standardized palliative education for caregivers at our community cancer clinic.

We could also look for other opportunities to encourage earlier palliative consultations at pivotal stages when patients are in crisis such as at the time of an ER visit, a hospital admission, or when patients make unscheduled visits to the oncology clinic for symptom management.

We compared our results to Cancer System Quality Index (CSQI) data, data on all cancer types published by the Cancer Quality Council of Ontario. Although not a direct comparison, our patients had fewer ER visits in the last two weeks of life, 35% versus 42.8% in CSQI data (Cancer Quality Council of Ontario, [CQCO], 2015). This is encouraging considering that patients with advanced lung and pancreatic cancer are often high users of the emergency department and hospital compared to patients with other cancer types (Barbera et al., 2010; Jang et al., 2014). In addition, we also noted that we have fewer patients dying in hospital, 33% versus 51%, and more patients dying at home, 17% versus 9% (CQCO, 2015). Our community is fortunate to have a 10-bed residential hospice for a population of 79,800(Statistics Canada, 2011).  This gives patients an option other than hospital for end of life care, which could explain why our hospital deaths are lower than average.

Although our initiative did not reduce the number of ER visits or hospital admissions in the last two weeks of life, these findings are supported by a systematic review of the literature by DiMartino et al., (2014), which found that there is no significant evidence to date proving early palliative care interventions are associated with reduced ER visits. In addition, our results may be explained by the fact that those who require palliative care often experience a greater burden of symptoms that may require acute care services. Our study revealed that in the post-initiative group, of the deceased patients, only 32% survived longer than 90 days from their initial oncology consultation, compared to 63% in the pre-initiative group. This could have had a profound impact on our results, as it is possible that patients in the post-initiative group had a greater number of ER visits and hospital admissions because they were more ill as a group. In a study by Hui et al. (2014), those who had an early palliative consultation referral did experience fewer emergency room visits and hospital admissions within the last 30 days of life. However, they defined an early consultation as within more than three months before death. This longer time period would allow for more time to make a difference in the quality of life for the patients towards end of life.

The limitations of this study include the small sample size and the fact that the data was collected at only one site, limiting the generalization of the results. It also involved only two cancer types and did not account for patients with other types of cancer. A future study could restrict the inclusion criteria to perhaps include only patients who lived longer than 60 days post diagnosis for example, as it would be expected that the most significant effect of early palliative care interventions would be on those patients who live long enough to benefit.

To conclude, our study revealed encouraging results about our community’s palliative care program as 89% of patients diagnosed with advanced lung or pancreatic cancer received a palliative consultation. In addition, even though our initiative did not greatly improve the numbers of patients getting an early palliative consult, 53% received an early palliative consult, which we defined as within 42 days of initial diagnosis. This study adds to the current body of knowledge by demonstrating that further research is needed to study the correlation between early palliative care referrals and reduced ER visits and hospital admissions toward end of life.  Lastly, this study identifies opportunities for improvement at our community cancer clinic so we can continue to better improve the quality of life and end of life care for our patients with advanced cancer.

Acknowledgements

Many thanks to Natalie Kovacevich for her research work, encouragement and advice.

 

References

Barbera, L., Taylor, C., and Dudgeon, D. 2010. Why do patients with cancer visit the emergency department near the end of life. CMAJ. 182(6): 563–568. doi: 10.1503/cmaj.091187

Cancer Quality Council of Ontario. 2015. End of life care measures: From cancer system quality index. Available from www.csqi.on.ca

DiMartino, L., Weiner, B., Mayer, D., Jackson G., and Biddle, A. 2014. Do palliative care  interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med. 17(12): 1384-99. doi: 10.1089/jpm.2014.0092.

Hannon, B., Swami, N., Pope, A., Rodin, G., Dougherty E., Mak, E., . . . Zimmermann, C. 2014. The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Supportive Care in Cancer. 23: 1073-1080. doi: 10.1007/s00520-014-2460-4

Hui, D., Kim, S., Roquemore, J., Dev, R., Chisholm, G., and Bruera, E. 2014. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients.    Wiley Online Library: Cancer. 120(11): 1743-1749. Available from http://onlinelibrary.wiley.com/doi/10.1002/cncr.28628/pdf

Jang R.W., Krzyzanowska, M.K., Zimmermann, C., Taback, N., and Alibhai, S. 2014.  Palliative care and the aggressiveness of end-of-life care in patients with advanced pancreatic cancer. J Natl Cancer Inst. 107(3): 1-8. doi 10.1093/jnci/dju424

Statistics Canada. 2011. Census agglomeration of Sault Ste. Marie, Ontario. Available from https://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-cma-   eng.cfm?LANG=Eng&GK=CMA&GC=590

Temel, J., Greer, J., Muzikansky, A., Gallagher, E., Admane, S., Jackson, V., . . . Lynch, T. 2010. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 363: 733-42.

Yoong J., Park E., Greer, J., Jackson, V., Gallagher, E., Pirl, W., . . . Temel, J. 2013. Early palliative care in advanced lung cancer. JAMA Intern Med. 173(4): 283-290. Available from http://archinte.jamanetwork.com/article.aspx?articleID=1566605

Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A., . . . Lo, C. 2014. Early palliative care for patients with advanced cancer: A cluster-randomized controlled trial. Lancet. 383: 1721-1730.

 

Tables

 

Table 1: Palliative Consultations Pre and Post Initiative

  Pre-Initiative52 Post-Initiative49
Early Palliative Consult (PC) (<42 days after diagnosis)       25 (48%) 26 (53%)
Still alive 1 (no PC) 12 (75% no PC)
Deceased      51 (98%) 37 (76%)
Any Palliative Consult before death 45 (88%) 33 (89%)
Subgroup Analysis:
Patients who died > 60 days after diagnosis   37 19
Any Palliative Consult 33 (89%) 18 (95%)
Outpatient consult 17 (52%) 14 (78%)
Early Palliative Consult 13 (35%) 11 (58%)

 

Table 2: Quality Indicators of Care

    ALL Patients (pts)101    PRE-All 52   POST-All 49   POST-Early PC<42 days   POST-Late orNo PC Cancer System Quality Index DataOntario 2011
Deceased  88 51 37 26 11  
Pts dying in Hospital 29 (33%) 14 (27%) 15 (41%) 8 (31%) 7 (64%) 51%
Pts dying in Hospice 43 (49%) 27 (53%) 16 (43%) 13 (50%) 3 (27%)  
Pts dying at Home 15 (17%) 10 (20%) 5 (14%) 5 (19%) 0 (0%) 9%
Emergency Room (ER) Visit in last 2 weeks of life 31 (35%) 16 (31%) 15 (41%) 9 (35%) 6 (55%) 42.8%
ER or Admission in last 2 weeks of life 47 (53%) 25 (49%) 22 (59%) 15 (58%) 7 (64%)  

 

 

Filed in: Research

You might like:

Encouraging early palliative consultations for patients with stage IV lung and pancreatic cancers: A retrospective chart review of a quality improvement initiative Encouraging early palliative consultations for patients with stage IV lung and pancreatic cancers: A retrospective chart review of a quality improvement initiative
Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer
HSN research team receives funding for smoking vaccine HSN research team receives funding for smoking vaccine
Kapuskasing moves to improve access to primary care Kapuskasing moves to improve access to primary care

Leave a Reply

Submit Comment
© 2017 Northern Ontario Business. All rights reserved.
Read previous post:
Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer

Examination of Current Algoma District Cancer Program Practices and Local Referral Processes for Patients with Prostate Cancer   Daniella Febbraro*;...

Close