Oncology Fellow–Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer

Abstract

PURPOSE ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identied low rates of PC utilization in their longitudinal clinic as a metric needing improvement. METHODS A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he rst-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was dened as evaluation in the outpatient PC clinic hosted in the cancer center. The team identied the following barriers to referral: orders difcult to nd in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or conrm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identied opportunities. Data were obtained from the EMR. RESULTS The rst PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention. CONCLUSION A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stake-holders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.