Impact of intervention aimed at improving the integration of oncology units and local palliative care services: results of the multicentre prospective sequential MIRTO study

Abstract

BackgroundChemotherapy (CT) in patients with advanced cancer (ACP) near the end of life is an increasing practice of oncology units. A closer integration with palliative care (PC) services could reduce the use of potentially harmful CT. This prospective study is aimed at assessing whether a more integrated care model could reduce CT use near the end of life and increase local PC service utilisation.MethodsThe study enrolled sequentially two cohorts of ACP with an estimated life expectancy of ≤6 months. In the first cohort, the usual oncologist’s practice to prescribe CT and to activate local PC services were recorded. In cohort 2, the oncologist’s decision was taken after an in-hospital consultation with the local PC teams. After patient death, a follow-back survey was carried out.ResultsThe two cohorts included 109 and 125 evaluable patients, respectively. The oncologist’s decision to prescribe CT occurred in 51.4% and 60%, respectively: the percentages of patients receiving the final CT administration in the last 30 days of life did not differ in the two cohorts (33.9% and 29.3%, respectively,p=0.83). Conversely, an increase in home PC service utilisation (from 56.9% to 82.4%, p=0.00), at home deaths (from 40.4% to 56.8%, p=0.01) and in-hospice deaths (from 8.3% to 19.2%, p=0.00) occurred in cohort 2.ConclusionThe implementation of an initial in-hospital consultation of oncologists and experienced home PC teams has not reduced the use of CT near the end of life but increased PC service utilisation and reduced in-hospital deaths.

Implementation and Impact of Choosing Wisely Recommendations in Oncology

“…The most commonly reported barriers to improving uptake of CW recommendations were preconceived views and routines of providers and reluctance to adopt new practices (Fig 1). 22,35,36,38,[40][41][42] Additional barriers included lack of awareness of the CW recommendations, 22 lack of validated tools or standardized processes to support practice change, 39 and lack of resources 37 to support change. Reports also cited providers' fear of longer clinic visits stemming from additional patient counseling regarding low-value practices 34 and that fee for service structures do not motivate the reduction of low-value service provision.…”

“…46,53 Therefore, when the identified facilitators and barriers are used as implementation strategies in an environment where compensation rewards value, programs focus on cost-savings, and there is easy access to data needed to provide continuous audit and feedback to providers, a comprehensive multipronged approach arises that can lead to sustainable change in practice (Table 2). 22,35,36,38,[40][41][42] Lack of knowledge about Choosing Wisely recommendations 54 Reluctance to modify existing routines and adopt new practices because of comfort and time required to change practice 22,35,36,38,[40][41][42] Fear that counseling will lead to longer visits 34 Fear that decreasing use of low-value evaluations will lead to missed disease progression/diagnoses 37 Patient request/insist on undertaking additional follow-up investigations and procedures 22 Lack of validated tools to support decision making 39 Lack of standardized processes in clinical settings 39 Lack of resources to support successful implementation in clinical settings 55 Use technology to facilitate change: order sets and forced functions Disseminate information/materials in convenient, easily accessible formats to stakeholders Make available tools for physician champions (handouts, pamphlets, and presentations) to educate other providers in their practice and promote change in clinical settings Abbreviations: CMS, Centers for Medicare and Medicaid Services; CW, Choosing Wisely.…”

Relationship Dynamics Underlying Cancer Overtreatment in Advanced Cancer Patients From an Oncologist Point of View

“…Despite the crucial contribution of integrating early palliative care in cancer management (Temel et al, 2010 ; Bandieri et al, 2020 ), no definitive change in the overtreatment of cancer patients with advanced disease, particularly those at the end of life, has been seen yet (Martoni et al, 2017 ; Zhang et al, 2021 ). Hospitalization in advanced-stage disease, given its poor prognosis, can itself be considered a form of overtreatment (El-Jawahri et al, 2020 ).…”