CARE Track for Advanced Cancer: Impact and Timing of an Outpatient Palliative Care Clinic

Abstract

Background: Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. Objectives: The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. Design: The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. Setting: Academic medical center. Measurements: We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. Results: Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. Conclusion: Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.

Early Palliative Care Reduces End-of-Life Intensive Care Unit (ICU) Use but Not ICU Course in Patients with Advanced Cancer

“…The CARE Track (Comprehensive Assessment with Rapid Evaluation and Treatment) program is a multiyear study of a phased palliative care intervention implemented by the University of Virginia Emily Couric Clinical Cancer Center that began in 2012. Early results from this same program, not related to ICU admission, have been recently published . The goal of the program is to improve the quality of life of patients with incurable malignancies while reducing costs and decreasing hospitalization at the end of life.…”

“…The benefits of early specialty palliative care in the setting of advanced cancer have been reported in several recent publications. Recipients have higher satisfaction with care and fewer emergency room, hospital, and intensive care unit (ICU) admissions; they have better mood and quality of life, experience less depression, and are more likely to die at home rather than in the hospital . In one prospective study, despite the receipt of less aggressive care with lower cost, a significant survival advantage was shown in patients with metastatic non‐small cell lung cancer who received early palliative care compared with those who did not .…”

Improving patient knowledge of palliative care: A randomized controlled intervention study

“…Palliative care is intended to be complementary to curative treatment and can be offered throughout the course of a serious illness [1–4], in contrast to hospice, a subtype of palliative care that is reserved for the last six months of life, when only comfort care is indicated. Although palliative care programs are increasingly prevalent in America’s health care systems [5,6], many patients who would benefit from palliative care and have access to it never receive palliative care or receive it too late in their illness trajectory to be maximally beneficial [7–9]. As America’s population continues to age, there will be an increased need for palliative care services.…”

“…Furthermore, because hospice is mistakenly and frequently equated with palliative care, patients may be unwilling to accept a referral for palliative care early in their disease trajectory if they are still interested in curative treatments [14]. Indeed, palliative care tends to be introduced late in the illness trajectory [7–9,15] despite recommendations to initiate it at the time of a life-limiting illness diagnosis.…”

Is patient information on palliative care good enough? A literature review and audit

“…In the United States, the average time between a palliative care referral and death is approximately 72.5 days (Blackhall et al, 2016). However, within routine clinical practice in the UK, palliative care clinicians report that many referrals are made in the last weeks and days of life.…”