Background: The benefits of palliative care for hospitalized cancer patients are well known and have become a hallmark of high-quality oncologic care. This evolution in cancer treatment has led to a growing demand for palliative care services, and to questions about how to most effectively integrate this specialty into patient care. Furthermore, the field of hospital medicine has seen significant expansion in the role of onco-hospitalists, which specialize in the management of inpatient cancer patients. The primary method for delivering inpatient palliative care within this system is the consultant model. In this study, we describe the outcomes of a novel delivery model where a dedicated palliative care consult team is geographically embedded within the medical oncology service and participates in daily interdisciplinary rounds. Our aim was to measure its impact on resource utilization, intensity of care, and other patient related outcomes.
Methods: This was a retrospective pre- and post-quantitative study looking at patients admitted to the oncology unit at an academic medical center from 6/1/22 – 11/30/22 (pre-implementation) and 1/1/23 – 6/30/23 (post-implementation). Primary outcomes included resource utilization (length of stay (LOS), total hospital charges, 30-day readmissions), intensity of care (ICU utilization) and transition metrics (discharges to hospice). Data were extracted from the electronic health record (Epic). Categorical variables were presented as percentiles. Comparisons were made via chi-square analysis and Wilcoxon rank-sum test with P< 0.05 required for statistical significance.
Results: We included 500 patients in the pre-implementation group and 505 in the post-implementation group. There were no significant changes in median length of stay (LOS) (p = 0.274) or 30-day readmissions (p = 0.103). However, the mean total charges increased from $45,607 to $51,775 (p = 0.013). The number of patients who received a palliative care consult during their admission increased significantly from 157 to 213 (p = < 0.001), while the median days from admission to consult were unchanged at 2 days (p = 0.195). Additionally, the percentage of patients admitted to the ICU between pre-implementation and post-implementation increased from 1% to 3% (p = 0.025). There was no significant difference in the percentage of patients with an order for symptom management in end-of-life care. The number of patients discharged to hospice increased from 51 to 61, however this change was not statistically significant (p = 0.344).
Conclusions: Implementing a geographically embedded palliative care consultant team did not result in any significant reduction in length of stay or 30-day readmissions. This model resulted in a significant increase in the total charges and number of palliative care consults, but the time-to-consult metric remained unchanged. Contrary to our expectations, intensive care utilization significantly increased following the implementation of an embedded palliative care team. Limitations of our study design include difficulty in capturing impact of palliative care services on patient and provider experience, as well as post-hospital palliative care and hospice services. This study highlights the complexity of inpatient oncologic care and provides insights that can inform future interventions. Our study also provides context that many important patient-centered measures are not well captured by the electronic health record.