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Timing of Palliative Care Consults Affects Healthcare Utilization in Elderly Patients with Pancreatic Cancer

TOP - November 2018, Vol 11, No 3 - HOPA
Chase Doyle

A claims analysis of elderly patients with pancreatic cancer has shown that those receiving early palliative care consultations had lower healthcare utilization than patients who received late palliative care. Data presented at ASCO 2018 showed that patients who received palliative care within 4 weeks of diagnosis had fewer visits to the emergency department (2.4 vs 3.0, respectively; P <.001) and lower emergency department–related costs ($3043 vs $4117, respectively; P <.001). According to the study investigators, these findings provide real-world evidence to support oncology societies’ recommendations for the early integration of palliative care.

“We know that palliative care, when provided in parallel with antineoplastic therapy, can lead to improved cancer outcomes, including overall survival and quality of life, and many studies have shown that if offered early in the disease course, palliative care can lead to less aggressive interventions near the end of life,” said Nizar Bhulani, MD, MPH, Postdoctoral Fellow, Harvard Medical School and Brigham and Women’s Hospital, Boston, who presented the study’s results. “However, these studies are frequently performed in single centers and highly controlled environments and are done in cancers other than pancreatic cancer.”

“Because pancreatic cancer patients experience exceptionally high morbidity,” he added, “the role of palliative care for this group of patients is very important.”

According to Dr Bhulani, pancreatic cancer is the ninth most common cause of cancer in the United States, but it is the third most common cause of cancer-related death, with a 5-year survival of only 8.5%. Most patients with pancreatic cancer are diagnosed at a later stage and have significant symptom burden. High symptom burden, said Dr Bhulani, is associated with increased healthcare utilization, which is especially problematic toward the end of life.

ASCO recommends that patients with advanced cancer receive dedicated palliative care concurrent with active treatment within the first 8 weeks of diagnosis, but recent research has shown that 70% of first-time palliative care encounters for patients with pancreatic cancer are occurring in the last 30 days of life. Dr Bhulani and colleagues investigated whether the timing of palliative care intervention affected healthcare utilization. Using the SEER-Medicare–linked database, the researchers identified patients with pancreatic cancer who were diagnosed between 2000 and 2009 and had pal­liative consultations. Early palliative care was defined as having a consultation in the first 4 weeks of diagnosis. Patients aged >66 years with >3 months survival and a known date of death were included in the analysis.

Overall, 54,000 patients met the inclusion criteria. Of these, 3166 (<6%) patients received a palliative care consultation at least once during their disease course. Among those who received palliative care, 28% had an early palliative care consultation and 72% had a first palliative care encounter >4 weeks from their diagnosis. Patients with early palliative care were older, and were more likely to be female and have stage IV disease, but no racial differences were observed between the 2 groups.

An adjusted analysis showed that patients with early palliative care had fewer emergency department visits, lower emergency department charges, fewer intensive care unit (ICU) stays, and lower ICU costs, with no difference in the median ICU days. After propensity score adjustments, however, only the differences in emergency department visits remained significant. An analysis of healthcare utilization in the last 30 days of life showed no difference in the early versus late palliative care groups.

“Most palliative care consults were offered close to death, which did not give palliative care the ability to modify those measures,” Dr Bhulani noted.

Regarding the lack of difference in ICU-related visits, ICU charges, or days in the ICU, the researchers noted that there are multiple factors that lead to ICU care.

“We know that the most common cause for ED [emergency department] visits in our pancreatic cancer patients is uncontrolled symptoms, so early palliative care improved symptom control, which reduced ED use,” said Dr Bhulani. “Unlike ED visits, however, many of the factors that lead to somebody requiring ICU care cannot be modified by palliative care.”

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Last modified: November 21, 2018