Early integration of outpatient palliative care among adults with advanced cancer in a safety-net health system.
Authors: DiMartino Lisa , Merrill Vincent , Skinner Celette Sugg , Hogan Timothy P. , Sadeghi Navid , Wang Winnie , Roche-Green Alva , Hong Arthur S. 
Published: September 2024

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Background:
Medically underserved adults with cancer present at later disease stages. The American Society of Clinical Oncology recommends all advanced cancer patients receive early intervention by a palliative care (PC) team soon after diagnosis (within 8 weeks) and during active treatment. Few studies have examined early integration of PC in the outpatient setting among advanced cancer patients within a safety-net system. This study examined patterns of outpatient PC service delivery (referrals and visits) for advanced cancer patients seen in the primary safety-net provider of cancer care for under- and uninsured adults in Dallas, TX.
Methods:
Patients diagnosed with advanced-stage solid tumor and who had at least one outpatient oncology visit January 1, 2018 to July 31, 2023 at the safety-net system were identified via electronic health record. The primary outcome was timeliness of outpatient PC referral (categorical outcome). Among patients with an outpatient PC referral, we used Kruskal-Wallis to test univariate associations across key characteristics, including age, race/ethnicity, cancer site, preferred language, insurance, and diagnosis year. Further, we used multivariate logistic regression to evaluate associations between key characteristics and completed PC visits among those with any outpatient PC referral.
Results:
Among 1,572 eligible patients (mean age 59, range: 21-94), 44% were female and 76% were non-White. Diagnoses included lung (20%), gastrointestinal (17%), colorectal (14%), breast (9%), prostate (9%), head/neck (9%), pancreatic (8%), and gynecologic (6%) cancers. Over half (n=870, 55%) of patients received an outpatient PC referral during the study period. Of those with a referral, 486 (56%) patients were referred ≤ 8 weeks of diagnosis, 157 (18%) between 9 and 24 weeks, 105 (12%) between 25 and 52 weeks, and 122 (14%) > 52 weeks. Timeliness of referral varied according to race/ethnicity and cancer type (p<.05; Table). Two-thirds of referred patients (n=576) completed a PC visit during the study period. In the adjusted regression model, compared to males, females had higher odds of completing a PC visit – (aOR, 1.40; 95% CI, 1.01-1.94).
Conclusions:
Just over half of advanced cancer patients received a referral to the outpatient PC team. Nearly half of referred patients had the referral ordered after 8 weeks of diagnosis. Except for gender, there were no other factors associated with PC visit completion. These findings demonstrate a need and potential for interventions targeting PC service delivery to improve care for underserved cancer patients.

Time from diagnosis to PC referral.*

≤8 Weeks
9 - 24 Weeks
25 - 52 Weeks
> 52 Weeks

Cancer type (%)

Colorectal
50
16
17
17

Lung
64
17
11
8

Pancreatic
64
19
8
9

Prostate
30
17
12
40

Race/ethnicity, (%)

White
66
14
10
9

Black
54
22
12
12

Hispanic
52
17
13
18

Select cancer types shown where significant differences were found.

*p<.05.