“The lack of palliative care resources and shifting patient needs due to improvements in cancer therapeutics highlight the need for less resource-intensive and more patient-centered palliative care models. Moreover, the historical model of a referral system that relies on oncologists to identify patients with cancer who may benefit from early palliative care remains inadequate. [..]
In stepped care, all patients receive care for their condition, but with a minimum of required contact with a specialty-trained clinician. More intensive treatment with the clinician is reserved for patients who do not benefit sufficiently from the less intensive therapies. A key element of this model is that patients must be monitored systematically and “stepped up” to more intensive treatment if less exposure to the clinician does not achieve sufficient benefit. In addition to using fewer resources by requiring minimum contact for patients who do not need more frequent visits, applying a stepped-care model is also a means to deliver more patient-centered care, tailoring palliative care to patients’ clinical needs.
Methods
[..] Eligible patients were adults (aged ≥18 years) receiving care at a participating site and diagnosed with advanced lung cancer (non–small cell lung cancer; small cell lung cancer) or mesothelioma within the prior 12 weeks that was not being treated with curative intent; had a documented Eastern Cooperative Oncology Group performance status of 0 (fully active with no restrictions) to 2 (unable to work and in bed <50% of the day); and could read and respond to questions in English or Spanish. Patients were not eligible if they were already receiving outpatient palliative care, were enrolled in hospice, or had cognitive or psychiatric conditions prohibiting study consent or participation, as determined by the treating oncologists. Participants were scheduled for study visits for a minimum of 12 months. [..] Specifically, patients [assigned to early palliative care] were scheduled for palliative care visits every 4 weeks and were seen by the inpatient palliative care team during hospital admissions throughout their study participation. Patients assigned to stepped palliative care started step 1 of the intervention, which included an initial palliative care visit within 4 weeks of enrollment, with subsequent palliative care visits scheduled only at the time of a change in cancer treatment (due to cancer progression, treatment toxicity, or discontinuation of therapy) or after a hospitalization. Patients in step 1 were not required to be seen by the inpatient palliative care team during hospital admissions. Patients in step 1 completed a QOL measure (Functional Assessment of Cancer Therapy–Lung [FACT-L]; range, 0-136, with higher scores indicating better QOL) every 6 weeks for up to 18 months after enrollment. Those with a 10-point or greater decrease from baseline in their score were stepped up to step 2, in which they were scheduled to meet with the palliative care clinician every 4 weeks and also were seen by the inpatient palliative care team during hospital admissions for the remainder of the study period. A 10-point change in the FACT-L is clinically meaningful and correlates with outcomes such as disease progression.
Results
[..] Quality-of-life scores on the FACT-L at week 24 for patients assigned to stepped palliative care were noninferior to those assigned to early palliative care (adjusted mean score, 100.6 vs 97.8; difference, 2.9; lower 1-sided 95% confidence limit, −0.1; P < .001). In accordance with a more stringent 1-sided 2.5% significance level test for noninferiority, we also calculated a post hoc lower 1-sided 97.5% confidence limit for the primary QOL outcome (difference, 2.9; lower 1-sided 97.5% confidence limit, −0.7), which also supported noninferiority of stepped palliative care.
Discussion
[..] Although stepped palliative care was noninferior to early palliative care for QOL, and we detected no differences in patient-reported communication about end-of-life care, hospice length of stay was significantly shorter with stepped palliative care vs early palliative care. Thus, although both groups did meet quality metrics for length of stay in hospice on average (ie, >7 days), more frequent contact with palliative care, especially in the months before death, may facilitate earlier referrals for hospice. However, because patients with metastatic cancer, including lung cancer, are living longer, early palliative care starting at the time of diagnosis may no longer be a feasible model to ensure the delivery of high-quality care at the end of life. Integrating additional methods of prognostication, such as predictive modeling to identify patients at risk of death, with novel palliative care delivery models, such as stepped palliative care, warrants further investigation.
Full article, JS Temel, VA Jackson, A El-Jawahri et al. 2024.6.2