Oncologic outpatient specialty palliative care referral uptake: a single institution quality improvement project

Late-stage and recurrent disease patients with a prognosis of 6-24 months should receive specialty palliative care, yet only 30% of eligible patients are referred. We aimed to characterize outpatient palliative care referral sources, timeliness, and completion rates across our cancer center at The University of Kansas Medical Center.

We conducted a single institution retrospective quality improvement study of patients in oncology subspecialties with the most palliative care referrals from 2019-2022 at our institution. Data collected included demographics, referral sources, and utilization metrics. The primary outcome was referral completion rates, and secondary outcomes included time from referral to first palliative care visit, hospice enrollment, and/or death. We performed descriptive statistics using chi-square and one-way analysis of variance (ANOVA) tests to compare oncologic subspecialty cohorts regarding these outcomes.

There were 1,674 outpatient specialty palliative care referrals. Medical oncologists initiated 57%, whereas surgical oncologists initiated only 14%. Seventy-four percent of patients referred were ultimately seen by outpatient palliative care. Gynecologic and breast cancer patients had the highest rates of being scheduled. The median time from referral to appointment was 20 days, ranging from 19-23 days. The most common reason patients did not utilize palliative care was patient choice (41%). Eighty-five percent of patients were enrolled in hospice at the time of death; gynecologic cancer patients had the highest rate of enrollment. The median time from referral to hospice was 66 days and the median time from palliative care referral to death was 92 days. Gynecologic cancer patients had the longest median times for both metrics.

At our cancer center, most patients referred to outpatient specialty palliative care were seen within 30 days, which represents timely initiation of palliative care after referral placement. However, the uptake of outpatient specialty palliative care and the timing of outpatient specialty palliative care referral relative to end-of-life transitions varied across oncologic subspecialties. Relevant goals for quality improvement interventions include increasing palliative care referrals among surgical oncologists, referring patients earlier in the disease process, and reframing palliative care as a beneficial resource for all patients.