Purpose: Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood. Methods:This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences.Results: Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care. Conclusion: Most hematologic oncologists view palliative careas end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists.

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111 Background: Concern that patients will react negatively to the idea of palliative care is cited as a barrier to timely referral. Strategies to successfully introduce specialty palliative care to patients have not been well-described. We sought to understand how gynecologic oncologists introduce outpatient specialty palliative care. Methods: We conducted a national qualitative interview study at six geographically diverse academic cancer centers with well-established palliative care clinics between September 2015 and March 2016. Thirty-four gynecologic oncologists participated in semi-structured telephone interviews focusing on attitudes, experiences, and practices related to outpatient palliative care. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework. This analysis focuses on practices for introducing palliative care. Results: Mean participant age was 47 years (± 10). Mean interview length was 25 minutes (± 7). Gynecologic oncologists described three main strategies for introducing outpatient specialty palliative care: first establish a strong primary relationship and trust with patients in order to alleviate fear and increase acceptance of referral; focus initial palliative care referral on symptom control to gain a “foot in the door”, facilitate early relationship-building with palliative care clinicians, and dissociate palliative care from end-of-life; and normalize and explain palliative care referral to decrease patient anxiety and confusion. These strategies aimed to decrease negative patient associations and encourage acceptance of early referral to palliative care specialists. Conclusions: Gynecologic oncologists have developed strategies for introducing palliative care services to alleviate patient concerns. Future research should examine patient perception of these strategies and assess impact on rates of acceptance of outpatient specialty palliative care referral.

109 Background: Rates of early specialty palliative care utilization remain low, despite increasing familiarity and favorable attitudes amongst cancer center oncologists. In this context, understanding organizational barriers to specialty palliative care use becomes critical. Methods: We conducted a qualitative interview study with 74 medical oncologists practicing at 3 U.S. academic cancer centers with well-established specialty palliative care clinics. The in-depth interview guide elicited experiences and views related to outpatient palliative care. For this analysis, we focused on organizational factors influencing palliative care use, defined as the structural arrangements and social patterns that facilitate or impede implementation of best practices in healthcare. The team conducted mixed deductive and inductive coding, using Cabana’s quality improvement framework as a starting point. Key concepts were iteratively refined with interdisciplinary input. Two coders applied the final codebook to all transcripts, with disagreements reviewed and resolved by team consensus. Results: Participating oncologists were 68% male, specialized in solid tumors (61%), hematologic malignancies (32%), or both (7%), and had been practicing oncology for a mean of 17 (SD 12) years. Organizational factors impeding early specialty palliative care utilization included: the perceived burden on patients from spending more time at clinic appointments, which was balanced against the value added from specialty palliative care; social, financial, and disease-related factors interfering with patients’ ability to attend additional specialty visits; the clinic name, with concern that patients equated ‘palliative care’ with death, dying or giving up; an unwieldy referral process without availability of same-day appointments; and inadequate communication between oncologists and palliative care specialists. Conclusions: Even when oncologists are aware of the evidence and agree with recommended practices, organizational factors may impede adherence to oncologic and palliative care guidelines. Addressing these barriers could improve use of outpatient specialty palliative care.