The PACES Study: A controlled before and after pragmatic trial of a cancer clinic–based intervention to increase early referral to specialist palliative care.
Authors: Sinnarajah Aynharan , Watanabe Sharon , Tang Patricia A. , Kerba Marc , Tan Amy , Earp Madalene , Biondo Patricia , Fong Andrew , Blacklaws Kelly , Bond Camille , Vandale Janet , Simon Jessica 
Published: June 2022

6501 Background: Early referral to specialist palliative care (SPC) can improve symptom and quality of life outcomes that matter most to cancer patients during the late stage of their illness. We tested a multifaceted oncologist-facing intervention (Palliative Care Early and Systematic) in the real-world setting of a busy cancer clinic for its ability to increase the proportion of patients who receive early SPC (defined as SPC ≥90 days before death). Methods: This is a pragmatic controlled before-and-after study performed in 18 outpatient cancer clinics in two tertiary cancer centers in neighboring metropolitan cities. The control city was chosen to match as closely as possible the intervention city for population size, characteristics, and health services availability. Adults deceased from colorectal cancer (CRC) between April 2017 to December 2020 residing in either the intervention or control city. Decedents who did not visit an oncologist in the year prior to death were excluded as they were unlikely to have received the intervention. Patients who died ≤120 days after diagnosis with CRC were excluded as providers would have had insufficient time to implement the intervention. In the baseline phase (April 2017 to December 2018) patients received usual care. In the intervention phase (April 2019 to December 2020), new clinical practice guidelines and resources were implemented to increase early SPC referrals by oncologists. These changes included: a) systematically screening patients attending treatment clinics for unmet PC needs and alerting the primary oncologist, b) addition of a community-based palliative clinical nurse specialist to handle increased referrals and enhance communication and co-management of patient needs among providers, and c) implementation of templated ‘shared care’ letters (all providers and patient) to improve awareness of patients’ needs. The primary outcome was the proportion of CRC decedents who received early SPC. Results: 695 decedents were included: 341 in the baseline phase (153 control, 188 intervention) and 354 in the intervention phase (145 control, 209 intervention). From baseline to intervention, in the intervention arm, the proportion of decedents who received early SPC increased from 45% to 57%; in the control arm the proportion decreased from 48% to 44% (17% difference in differences; 95%CI -2% to 32%; P=0.03). Conclusions: A multifaceted intervention aimed at increasing oncologists’ awareness of their patients’ appropriateness for early SPC increased by 17% the proportion of patients receiving early SPC as compared to controls. Additional research is needed to determine if in a real-world clinical setting further increasing the proportion of patients receiving early PC beyond 57% is feasible, and to understand the role of screening and alerting for oncologists.