Patient factors associated with early vs late referral to supportive oncology.
Authors: Crowley Fionnuala , Sheng Tianxiang , Zeng Li , Hobensack Mollie , Bilani Nadeem , Sheppard Richard Stephen , Barley Kevin M. , Popp Beth , Afezolli Debora , Kelly Lauren , Wey Winston , Chen Joanna , Austin Vanessa , Bajwa Aleena , Easton Eve , Pagala Arlyn , Kim Emily , Smith Cardinale B. , Gelfman Laura P. 
Published: September 2024

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Background:
ASCO guidelines recommend early palliative care (PC) for patients with advanced cancer, defined as referral within 8 weeks of diagnosis. Early referral has been associated with improved quality of life, survival and a reduction in healthcare utilization at the end of life. We sought to determine the role of sociodemographic and clinical patient factors on timing of referral to an embedded supportive oncology (SO) practice and impact on utilization.
Methods:
Patients ≥18 years with advanced cancer who first received a SO visit between 01/01/2021-06/30/2023 were included. Data on patient demographics, cancer treatment and mortality were extracted from the electronic health record. Early referral to SO was defined as a visit <3 months after diagnosis of advanced cancer. We used descriptive statistics to summarize patients’ sociodemographics, clinical characteristics, and healthcare utilization, and multivariable linear regression analysis to identify factors associated with the timing of referrals.
Results:
Of the 782 patients, 39.1% were referred early. Poorer functional status (p<0.001) and certain cancer types (p<0.01) were associated with earlier referrals. There were significant differences in timing of referral by cancer type with highest early rates among Head and Neck (53%,) GI (48%), Lung (46%) and GYN (43%) and lowest among GU (29%) and Breast (11%; p < 0.001). Those with Medicare as the primary insurance had an increase in referral time (138 days) compared to Medicaid patients (p<0.001). Patients whose primary symptom was pain were referred earlier than patients with other non-pain symptoms although this did not reach statistical significance (p=0.084). Patients with an earlier referral had more ED visits and hospitalizations both before (p=0.001 and p< 0.001, respectively) and after (p=0.186 and p=0.007, respectively) referral compared to those referred later. Overall, there was no difference in mean referral times between 2021 (483d) and 2023 (533d).
Conclusions:
There remains significant disparities in the timing of referrals to SO based on sociodemographic and clinical factors. While early SO referral is associated with several benefits, the variability in referral timing underscores the need for targeted strategies to promote timely access to PC. Moving forward, efforts should focus on developing standardized referral protocols and addressing barriers to early PC access to ensure equitable and optimal patient outcomes.

Patient demographics and characteristics.

Category
Overall N=782
Early N=306
Late N=476
p-value

Age (mean]
63.3
63.6
63.1
0.689

Race (%)

0.736

Asian
88 (11)
39 (13)
49 (10)

Black or African-American
194 (25)
72 (24)
122 (26)

Hispanic
192 (25)
80 (26)
112 (24)

White
260 (33)
95 (31)
165 (35)

Other/Patient Declined
48 (6)
20 (7)
28 (6)

Insurance (%)

0.080

Commercial
197 (28)
73 (26)
124 (29)

Medicaid
175 (25)
83 (27)
92 (19)

Medicare
330 (47)
123 (40)
207 (44)

Other
6 (0)
1 (0)
5 (1)