Behavioral economic interventions to embed early palliative care in community oncology (BE-EPiC): A pragmatic cluster-randomized trial.
Authors: Sedhom Ramy , Ferrell William J. , Chen Jinbo , Villarin Katherine , Li Yang , Berwanger Kara , Scarborough Bethann , Oyer Randall A. , Kumar Pallavi , Ganta Niharika , Sivendran Shanthi , Volpp Kevin , Bekelman Justin E. , Parikh Ravi Bharat 
Published: June 2024

12075

Background: Among patients with cancer, early outpatient specialty palliative care (PC) concurrent with cancer-directed treatment improves quality of life and symptom burden, decreases aggressive end-of-life care, and is endorsed by national guidelines. However, nearly half of patients with advanced cancer do not receive specialty PC prior to dying. The objective of this study was to test the impact of oncologist-directed default PC referral orders on early PC utilization and quality of life. Methods: This 2-arm pragmatic randomized trial was conducted in a large, rural community oncology practice. Eligible patients met one of 5 NCCN guideline-based indications (uncontrolled symptoms, recent hospitalization or ED visit, ECOG PS≥3; active stage IV malignancy; CNS metastasis) for specialty PC referral. Four teams, consisting of unique physicians, advance practice providers, and social workers, were randomized in a 1:1 fashion to intervention vs. control. Clinicians and care team members in the intervention arm received an electronic health record (EHR) message with a default pended PC referral order for eligible patients. Clinicians could opt out. Clinicians in the control arm received no EHR message. An adjusted cox proportional hazards model with clustered standard errors was used to assess the primary outcome of completed PC visits within 24 weeks of enrollment. Adjusted logistic regression models with inverse probability censoring weighting to account for differential mortality risk were used to assess secondary outcomes of absolute and change in quality of life per FACT-G score at 9 weeks, among intervention patients who received PC, compared to a random subset of controls. Results: Among 266 eligible patients, 252 (94.7%) were White, 147 (55.3%) were female, and 204 (78%) had stage IV disease. The most common cancers were gastrointestinal (26.3%), breast (19%), and lung (17%). In the intervention arm, physicians opted-out of 62% of referrals. Rates of completed palliative care visits were 14.6% in the intervention arm vs. 8.1% in the control arm (adjusted hazard ratio 1.34 [95% CI 1.25-1.54], p<0.001). Patient-reported quality of life was greater in the intervention arm than the control arm (mean change in FACT-G score at 9 weeks: 6.56 [SD 8.9] intervention vs. -4.48 [SD 13.5] control; adjusted difference 11.4, p=0.05). Rates of intensive end-of-life care were similar in both control and intervention groups. Conclusions: Compared with controls, default referrals to specialty PC among patients who met guideline-based criteria led to increases in completed palliative care visits and improved quality of life. Default PC referrals may be an effective strategy to improve access to early specialty palliative care in community oncology, although effect sizes were tempered by high opt-out rates. Clinical trial information: NCT05365997 .