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Design and Participants: This nonblinded, noninferiority trial at three academic medical centers evaluated a stepped-care model (PC visits occurring only at key points in patients’ cancer trajectories and using a quality-of-life decrement to trigger more intensive PC) to deliver less resource-intensive and more patient-centered PC for patients with advanced lung cancer. Step 1 was an initial PC visit at 4 weeks or less postenrollment and subsequent visits only at the time of a treatment change or posthospitalization. During step 1, patients completed a quality-of-life measure (FACT-L; range=0-136, higher indicating better quality of life) every 6 weeks, and those with a 10-point or more decrease from baseline were stepped up to meet with the PC clinician every 4 weeks (step 2). Patients assigned to early PC had visits every 4 weeks postenrollment. Noninferiority (margin=−4.5) of the effect of stepped vs early PC on FACT-L at 24 weeks was measured. Analyses used t tests and linear regression models.
Results: Patients (N=507) were aged mean 67 years old; 51% female; and 85% White and 11% Black. The number of visits by 24 weeks was mean 2.4 for stepped and 4.7 for early (adjusted mean difference=−2.3; P<.001). FACT-L scores at 24 weeks for stepped were noninferior to early (adjusted mean=101 vs 98; difference=2.9; lower 1-sided 95% confidence limit=−0.1; P<.001 for noninferiority). Although the end-of-life care preference communication rate was also noninferior between groups, noninferiority was not demonstrated for hospice length of stay (adjusted mean=20 days with stepped vs 35 with early; P=.91).
Commentary: Workforce shortages4 and advances allowing advanced cancer patients to live longer5 present challenges in delivering beneficial3 early PC. This study evaluates a systems-based solution that rations PC resources. It preserves quality by allowing patients to meet PC early and timing subsequent visits with sentinel events likely to coincide with increased need. Despite decreasing the demand on PC, this approach requires significant care coordination. Future research in automated risk stratification and electronic medical record–based notifications may help institutions with limited coordinating resources replicate these findings. Additionally, as hospice length of stay was significantly shorter in the stepped model, it is essential to consider which outcomes we are willing to compromise for the sake of the over-extended workforce.
Bottom Line: Early PC intervention with follow up coordinated at high-risk times presents an opportunity to reduce workforce demand and expand access to PC while maintaining quality in patients with advanced cancer.
Reviewer: Scott H. Maurer, MD FAAHPM, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
References:
1. Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med. 2004;164(1):83-91. doi:10.1001/archinte.164.1.83.
2. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-749. doi:10.1001/jama.2009.1198.
3. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi:10.1056/NEJMoa1000678.
4. Lupu D, Quigley L, Mehfound N, et al. The growing demand for hospice and palliative medicine physicians: will the supply keep up? J Pain Symptom Manage. 2018;55(4):1216-1223. doi:10.1016/j.jpainsymman.2018.01.011.
5. Howlader N, Forjaz G, Mooradian MJ, et al. The effect of advances in lung-cancer treatment on population mortality. N Engl J Med. 2020;383(7):640-649. doi:10.1056/NEJMoa1916623.
Source: Temel JS, Jackson VA, El-Jawahri A, et al. Stepped palliative care for patients with advanced lung cancer: a randomized clinical trial. JAMA. 2024;332(6):471-481. doi:10.1001/jama.2024.10398.
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