Lung Cancer Provider Education and Referral Criteria for Palliative Care

Abstract

Problem: Individuals diagnosed with advanced lung cancer encounter a life-limiting illness compounded by a high symptom burden and quality of life issues. Despite evidence of complex care needs during many phases of the illness and evidence supporting the contribution of palliative care interventions to relieve symptom burden and psychosocial distress, health care providers typically delay referrals to palliative care until the final days of life. Numerous barriers contribute to limited utilization of palliative care by lung cancer providers including: lack of knowledge about palliative care, uncertainty about criteria for palliative care, timing of referral to palliative care in the disease trajectory, and attitudes about palliative care or the role of specialists. Published data on lung cancer referrals to a palliative care consultation service (PCS) at the researcher’s institution indicated that referrals were made for 8% (n=118) of lung cancer patients admitted over a 3.5-year period. Referrals occurred late in the disease trajectory and late during the hospital stay (6-day median pre-consult length of stay ([LOS]). To improve referral to palliative care, palliative care experts recommend evidence-based education of providers about palliative care and the use of referral criteria to identify eligible patients Objective: 1. To develop and implement a multi-faceted educational intervention including referral criteria for lung cancer providers (physicians and nurse practitioners) caring for hospitalized lung cancer patients. 2. To assess the impact of the interventions on outcome measures indicative of provider referral patterns compared to previously published baseline data. Design: A single group post-test only quasi-experimental design was used to measure outcomes (number of referrals, reasons for referral, pre-consult LOS, performance scores and patient LUNG CANCER PROVIDER EDUCATION AND REFERRAL CRITERIA 2 discharge disposition) following implementation of the educational intervention including referral criteria. Sample: Two inpatient oncology provider teams in an urban teaching hospital with 700 beds. Methods: The intervention consisted of a didactic presentation to key oncologists and nurse practitioners about palliative care needs of lung cancer patients, the role of the palliative care consultation team, and the referral criteria followed by education outreach visits to 4 oncologists and 2 nurse practitioners to reinforce the educational content. The investigator also attended weekly interdisciplinary oncology team meetings to provide written copies of referral criteria. Data Source: Baseline and post-intervention data from the Palliative Care Service database. Results: Data were collected for 2.5 months following the initial didactic education session and introduction of referral criteria. Lung cancer remained the diagnosis most frequently referred to the PCS. Oncology providers referred 21.4% (n=3) of all lung cancer admissions to PCS post intervention, compared to 20.5% (n=32) during the baseline period. Ten patients with cancers other than lung cancer were also referred, and their data aggregated with lung cancer referral data. Patients were mostly female (53%), African American (61.5%), and had a mean age of 58.7 years. The top reasons for referral were end of life issues, goals of care discussion, and advanced care planning in the post-intervention sample, similar to baseline data. Following the intervention, more referrals for pain management (31% versus 18%) were made compared to baseline data and the pre-consult LOS was shorter (median-1 day). Additionally, more patients were discharged alive (100%, n=13 versus 70%, n=83), and more were enrolled in hospice (77%, n=10 versus 41%, n=48). Implications: The study design, a short data collection period, and small number of lung cancer referrals limited interpretation of the impact of this intervention. LUNG CANCER PROVIDER EDUCATION AND REFERRAL CRITERIA 3 The addition of non-lung cancer referrals to the data analysis showed promising trends favoring the intervention but lack of a baseline comparison was a limitation. Dissemination of initial results will be presented to oncology providers and a longer data collection period will ensue.