The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Report: Integrated Outpatient Palliative Care in Oncology

More than 500,000 Americans, including 40,000 Veterans, are diagnosed with advanced cancer annually in the United States. Often provided concurrently with oncology care, palliative care improves quality of life by managing patients' physical symptoms, as well as psychosocial and spiritual distress. Palliative care occurs across a continuum, ideally beginning at the time when a serious illness has been diagnosed and continuing until the end of life. Integration of palliative care and oncology care is now considered standard of care for patients with advanced cancer; however, the most effective approach to integrating care among multiple providers or across health systems has not been identified. Therefore, this evidence report was commissioned to answer the following key questions:

1. In patients with symptomatic or advanced cancer, what are the benefits and harms of integrated outpatient palliative and oncology care compared with usual oncology care?
2. Which features of integrated palliative and oncology care are associated with greater benefit to patients with symptomatic or advanced cancer?
3. What are the most common and important barriers to implementing integrated palliative and oncology care in VA settings?

Investigators with VA's Evidence-based Synthesis Program site located in Durham, NC aimed to provide actionable information to VA healthcare providers, leaders, and policymakers regarding the potential benefits of palliative care integration among the diverse population of Veterans with cancer. Searching multiple data sources (MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials) through November 21, 2016 to help answer questions #1 and #2, and through January 19, 2017 to answer question #3, investigators identified 1,988 articles for review. After applying exclusion and inclusion criteria, they used 24 articles -- including 13 primary papers and 11 companion papers (i.e., secondary publications and related papers) -- in their analyses.

Summary of Findings
There is small but growing literature about integrated palliative and oncology care interventions for patients with symptomatic or advanced cancer. Overall, investigators identified a diverse set of interventions that showed moderate levels of integration. These interventions demonstrated a pattern of small-to-moderate, positive short-term effects on mortality and on outcomes that are important to patients. Specific findings include the following.

Key Question #1

• In 9 trials, integrated palliative care was delivered by multidisciplinary teams in outpatient settings, but the intensity of interventions varied considerably.
• Most studies enrolled a majority of white men and women with multiple types of advanced cancer at a median of 8 to 12 weeks following diagnosis or recurrence.
• Integrated palliative care improved short-term, but not longer-term patient quality-of-life.
• Integrated palliative care decreased overall mortality. These effects were consistent across the 4 studies reporting this outcome.
• When excluding an outlier study, overall symptom burden improved modestly, but there was no effect when evaluating all studies. Psychological symptoms did not improve with palliative care, but were reported in only a subset of studies.

Key Question #2

• Published trials of palliative care do not routinely describe elements of integration with oncology care. Classifying integration required author queries for additional data.
• Of 9 trials, 2 were classified as having basic collaboration onsite and 4 as having close collaboration onsite with some systems integration. Three studies could not be classified due to missing information.
• Investigators did not identify an association between integration level and overall intervention effects or effects on short-term quality of life. However, these analyses were limited by the small number of studies and the limited range of integration levels.

Key Question #3

• Few studies directly addressed common and important barriers to implementing integrated palliative and oncological care in the VA.
• Common barriers to implementation included low participation rates to shared appointments, perceptions that palliative care is meant to be used later in the disease trajectory, and poor communication and coordination among providers and patients.
• Facilitators to implementation included greater collaboration among local leaders within a healthcare system, improved patient and family support, coping, and self-care skills, and patient-provider education about roles and responsibilities of care both in oncology and palliative care services.

Future Research
Although it would be possible to generate an extensive list of gaps in evidence, investigators restricted this list to the areas judged to be highest priority, given the current state of evidence. First, research is needed with ethnically, racially, and socioeconomically diverse groups of people. Trials should report more clearly the intervention elements, dose, and integration elements. A study comparing inpatient palliative care to integrated palliative and oncology care in outpatient settings could provide invaluable comparative effectiveness data. Studies also are needed in community settings. Outcome measures should be standardized and include input on barriers and facilitators to implementation as well as the outcomes most valued by patients.

As it pertains to the VA, a key component of the Quality Enhancement Research Initiative (QUERI) program is to advance implementation science and identify effective strategies for implementing effective interventions. However, palliative care does not appear to be a particularly good fit into any of the 15 existing QUERI programs, so to pursue this, it is likely a new QUERI program would need to be formed that focuses on this issue.

Reference
Fulton J, LeBlanc T, Porter-Starr K, Kamal A, Ramos K, Cutson T, Freiermuth C, McDuffie J, Adam S, Kosinski A, von Isenburg M, Van Noord M, Williams JW Jr. Integrated Outpatient Palliative Care in Oncology. VA ESP Project #09-009; 2017.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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