Many patients do not receive recommended palliative care, or they receive it so late in the course of disease that they are not able to fully experience its benefits. While the main goal of palliative care is to improve quality of life, a secondary effect may be to avert unnecessary or unwanted medical services that yield little to no health benefit, an indicator of low-value care. ASCO and NCCN recommend oncologists consider value in their treatment decisions. However, it is not clear how oncologists feel about modifying their practices to include value in point-of-care treatment decision making.
For cancer patients, physician-level factors associated with value and palliative care may be highly influential, as oncologists are often the gatekeepers to palliative care and largely guide purchasing of care for their patients. There is currently a paucity of evidence regarding U.S. oncologists' attitudes towards palliative care and the appropriate use of value in making treatment decisions.
In this study, we evaluated: 1) oncologists' views towards the role of primary and secondary palliative care in treating patients with advanced cancer; and 2) oncologists' views regarding the definition, measurement and merit of value in informing treatment decisions for cancer patients.
Our first aim was to elicit oncologists' attitudes towards a) the role of palliative care for any patient with a metastatic solid tumor; and b) the role of value in making treatment decisions for patients with metastatic solid tumors at the end of life. Our second aim was to design a survey based on findings from semi-structured interviews.
We conducted in-depth telephone interviews with 31 U.S. oncologists practicing in Veterans Health Administration, academic medical centers, and the community. Snowball sampling and oncology professional email lists were used to purposefully sample oncologists. All questions were vetted by a panel of oncologists, clinicians, and qualitative experts before inclusion in the study. Interviews were recorded and transcribed verbatim by a professional transcription service. Transcripts were analyzed using matrix and thematic analysis.
There was uniform agreement that cancer is high cost. Oncologists had varying opinions about whether costs should be discussed with patients and who should discuss costs (oncologists versus financial counselors). Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, i.e., cost relative to health outcomes. Others defined value as providing care that is congruent with patient values or preferences. Many did not include cost in their definition of value. Those using the traditional health economic definition differed as to whether value should be assessed at an individual or societal level and which party should be responsible for determining a threshold for high- and low-value care. Oncologists agreed that cost was an important issue in cancer care, but they disagreed about the definition and role of value in guiding treatment.
Oncologists perceived palliative care as appropriate throughout the disease trajectory, yet reported that patients were largely provided palliative care at end of life. Much of this was due to triaging of patients due to under-availability of palliative care physicians. Palliative care specialists were sometimes viewed as a "team of outsiders," and poor communication created tension between the two disciplines. Oncologists varied on the level of palliative care they provided versus referred to specialists. Oncologists reported the focus of care in palliative care is too narrow, and Academic Medical Center-based palliative care evidence is not generalizable to community practices. Oncologists expressed interest in greater availability of outpatient palliative care. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of non-physician palliative team members.
Miscommunication around patient prognosis, lack of care coordination, and the setting of palliative care negatively impact the delivery of palliative care. A key area for future research will be evaluating and developing ways to improve the delivery/interface of palliative care between oncology and palliative care teams. Interventions aimed at improving palliative care should address these provider-elicited barriers.
Oncologists agreed that cost was an important issue in cancer care, but disagreed about the definition and role of value in guiding treatment. Better clarity on the appropriate way to measure value will enhance efforts to improve value in cancer care. Therefore, results from this study will be used to inform a large national survey further exploring attitudes towards value and its measurement to inform VA, academic medical center, and community care.
- Patel MI, Periyakoil VS, Moore D, Nevedal A, Coker TR. Delivering End-of-Life Cancer Care: Perspectives of Providers. The American journal of hospice & palliative care. 2018 Mar 1; 35(3):497-504.