Integrating Palliative and Oncology Care for Patients with Advanced Cancer: A Quality Improvement Intervention

Background: Practice guidelines recommend palliative care for patients with advanced cancer, but gaps in access and quality of care persist. Objective: To increase goals-of-care (GOC) communication for hospitalized patients with Stage IV cancer. Methods: An interdisciplinary team designed a quality improvement intervention to enhance oncology palliative care, including training in communication skills and triggers for palliative care consults. Setting/Subjects: All adult inpatients with Stage IV cancer and unplanned admission at an 804-bed hospital affiliated with a National Cancer Institute (NCI) Comprehensive Cancer Center. Measurements: The primary quality measure was the percentage of patients with Stage IV cancer who had a GOC discussion during hospitalization; secondary measures included screening for pain, dyspnea, spiritual needs, and outcomes of intensive care, hospice, and 30-day readmission. Results: In the 11-month study period, n=330, Stage IV cancer patients were hospitalized. Comparing the first three months with the final three months, rates of GOC discussion increased from 29% to 48% (p=0.013), and specialty palliative care consultation increased from 18% to 33%, (p=0.026). Rates of symptom screening, intensive care unit transfer, hospice, and 30-day re-admission did not change overall. However, patients with specialty palliative care more frequently had pain screening (91% vs. 81%, p=0.020), spiritual assessment (48% vs. 10%, p<0.001), and hospice referral (39% vs. 9%, p<0.001), and they were less likely to be re-admitted within 30 days (12% vs. 21%, p=0.059). Discussion: Interdisciplinary quality improvement was effective to increase GOC discussions and palliative care consults for patients with Stage IV cancer.