When a recent class of oncology fellows at Johns Hopkins’ Sidney Kimmel Comprehensive Care Center gathered to discuss how they might improve day-to-day practice, there was consensus that palliative care should be a prime focus area. Specifically, the fellows considered the American Society of Clinical Oncology’s (ASCO) palliative care guideline recommendation (also reflected in American Academy of Hospice and Palliative Medicine’s Choosing Wisely recommendations) that patients with advanced or metastatic cancer should receive early palliative care (PC).
“Patients were often not referred early, despite evidence they’d benefit from extra support,” said Ramy Sedhom, MD, who led the project during his fellowship and is now a palliative care fellow at Memorial Sloan Kettering Cancer Center. “But we recognized that the referral process itself had problems.” Barriers included an EMR system that made it difficult to order PC visits, multiple referral pathways, and long delays in scheduling those that were requested.
To better understand these barriers and develop potential solutions, the project leaders convened an interdisciplinary focus group that included attending physicians from PC and oncology, oncology fellows, PC team members, IT analysts and clinic schedulers. They decided to focus on first-year fellows, whose referral rates were particularly low (only 11.5 percent of their patients who met eligibility criteria had PC visits between July-December 2018) and who were considered to be more receptive to change.
The project team implemented changes to the EMR to create a standardized referral process with a single order set, and identified a single scheduler to speed up visits that were ordered. They also provided reminders for fellows at weekly QI sessions about low rates of palliative care utilization and devoted two educational sessions to the topic. Over the course of the intervention, the team collected data and provided feedback and comments to the fellows about utilization. Dr. Sedhom said the team also asked PC team members to provide positive reinforcement by letting the referring physicians know when their patients had beneficial PC visits. In the post-intervention period, 48.4 percent of patients who met eligibility criteria saw a PC specialist.
“I think the program succeeded because we identified a systems issue and took an evidence-based approach,” said Arjun Gupta, MD, a medical oncology fellow at Johns Hopkins who helped lead the project. “Everyone knows Choosing Wisely and wants to do the right thing for their patients; when presented with data, it creates an internal dialogue – ‘What are we doing when there’s such good evidence?’”
Dr. Sedhom said the project was part of a larger curriculum for the fellows on providing high-value care, which embedded a mix of educational components (e.g., Choosing Wisely ASCO recommendations, behavioral economics, implementation science, etc.). He said the fellows also heard from oncologists from other systems about the importance of PC to their practices. “When fellows considered what future skills they would need, they realized PC was more important than they thought,” he said.
Drs. Sedhom and Gupta have continued to focus on this topic. Both received Young Investigator awards from ASCO to study palliative care and symptom management. Dr. Sedhom’s project investigates how to optimize hospice utilization using behavioral economics and qualitative interviews. These ideas and opportunities developed thanks to mentorship from key leaders in ASCO, and in particular due to skills developed through ASCO’s Quality Training Program. While their fellowship work focused on whether patients received PC, they are now focused on the quality of PC. “The next step is: What exactly is good palliative care and how do we deliver it?” Dr. Sedhom said. “How do we set up structures so that everyone has appropriate access, especially with a workforce shortage in palliative care?”
Both physicians saw palliative care as essential to any effort to provide high-value care. “Palliative care is simply patient-centered care to improve quality of life by reducing suffering for patients and caregivers,” Dr. Gupta said. “This can include symptom control, advance care planning, spiritual support—whatever the patient and caregivers need. Secondarily, most palliative care interventions are low cost compared to $20,000 per month oncology drugs. Good quality palliative care is the highest-value intervention I can think of.”
Readers can learn more about the Johns Hopkins project here.