Symptom Burden and Palliative Referral Disparities in an Ambulatory South Texas Cancer Center

Abstract

Background: The American Society of Clinical Oncology's recommendation for “dedicated palliative care services, early in the disease course, concurrent with active treatment” for cancer patients is a challenge for cancer centers to accommodate. Despite demonstrated benefits of concurrent care, disparities among socioeconomic and ethnic groups in access to supportive care services have been described. The aim of this project was to evaluate: (a) how insurance coverage and ethnicity impact patient symptom burden and, (b) how those factors influence palliative access for patients at a South Texas NCI-designated cancer center.Methods: During a 5-month prospective period, 604 patients from five ambulatory oncology clinics completed the 10 question Edmonton Symptom Assessment Scale (ESAS) surveys during their clinic visit. Patient demographics, ESAS scores, palliative referral decisions, and time to palliative encounters were collected. We compared symptom burden and time to consult based on ethnicity and insurance status (insured = Group A; under-insured and safety net = Group B).Results: The mean ESAS score for all patients at the initial visit was 19.9 (SD = 18.1). Safety net patients were significantly more likely to be Hispanic, younger in age, and have an underlying GI malignancy in comparison to insured patients; however, the symptom severity was similar between groups with over 40% of individuals reporting at least one severe symptom. Twenty-one referrals were made to palliative care. On average, Group B had 33.3 days longer wait times until their first potential visit (p < 0.01) when compared to Group A. Time to actual visit was on average 57.6 days longer for patients in Group B compared to patients in Group A (p = 0.01), averaging at 73.8 days for safety net patients.Conclusions: This project highlights the high symptom burden of oncology patients and disparities in access to services based on insurance coverage. This investigation revealed a 4-fold increase in the time to the first scheduled palliative care visit based on whether patients were insured vs. under-insured. While this study is limited by a small sample size, data suggest that under-insured oncology patients may have significant barriers to palliative care services, which may influence their cancer care quality.

Racial Disparities in Utilization of Palliative Care Among Patients Admitted With Advanced Solid Organ Malignancies

“…Perceived time to death or death acting as a mediator on the relationship between race and receipt of IPCC may contribute to the mixed findings of the association between race and IPCC in the literature. [21][22][23][24][25][26] Although several studies have found higher odds of IPCC for hospitalized black patients with cancer, a few have found no difference or higher odds of IPCC for black patients compared to white patients. [21][22][23][24][25][26] However, only one of these studies investigated death as a mediator of receipt of IPCC.…”

“…[21][22][23][24][25][26] Although several studies have found higher odds of IPCC for hospitalized black patients with cancer, a few have found no difference or higher odds of IPCC for black patients compared to white patients. [21][22][23][24][25][26] However, only one of these studies investigated death as a mediator of receipt of IPCC. 25 The absence of measurement of the potential mediator of death could explain the differences among these studies as highlighted by our findings of a transposed relationship between black race and IPCC when stratified by death.…”

“…[17][18][19][20] Furthermore, studies evaluating the use of nonhospice-based palliative care are often limited to a single center, a single type of malignancy, or do not specifically aim to investigate racial disparities in health care. [21][22][23][24][25][26] Black patients have higher rates of emergency department visits, hospitalizations, and intensive care unit care at EOL compared to white patients. 6,27,28 Inpatient palliative care consultations (IPCC) offer a unique opportunity to introduce black patients and their families to non-hospice-based palliative care services as blacks are more likely to be treated at the EOL in an inpatient setting.…”

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

“…After searching almost fourthly-thousand citations, 284 articles were included in our study, of which 147 were manuscripts that directly addressed end-of-life and hospice care, palliative care, as well as advance care planning and directives that include non-Hispanic Blacks. 4 …”

The Role of a Symptom Assessment Tool in Shaping Patient-Physician Communication in Palliative Care

“…20 In addition to its clinical significance, the ESAS has also been used as a trigger for referrals to specialized palliative care services. 6,21,22 Recently, a study found that patient exposure to the ESAS (measured by completing the ESAS at least once) was associated with improved survival in cancer patients. 23 While numerous studies have assessed the validity, clinical significance, and usability 7,12,13,16 of the ESAS, fewer studies have examined the patient experience surrounding the ESAS.…”