Improving palliative care integration for patients with stage IV lung cancer at UConn Health by initiating a best practice advisory (BPA) in the electronic medical record (EMR).
Authors: Sarah Loschiavo, Lisa Holle, Carolyn Guarino, Ruth Kalish, Cheryl Coppola, Wendy Thibodeau
Journal: Journal of Clinical Oncology (2021)

331 Background: The American Society of Clinical Oncology (ASCO) practice updates on the integration of palliative care into standard oncology practice provides a key recommendation that patients with advanced cancer should receive palliative care services. Specifically, ASCO recommends that all patients with stage IV cancer receive a referral to an interdisciplinary palliative care team early in their course of disease and within 8 weeks of diagnosis. At UConn Health, it has been previously documented that only 28% of patients with stage IV cancer receive a referral to the palliative care team. To improve the quality of cancer care, a BPA with standardized criteria for palliative care referral was developed and implemented for patients with stage IV lung cancer. In this pilot study, the goal was to get 80-90% of patients a referral to palliative care team within 8 weeks of stage IV lung cancer diagnosis. Methods: The Model for Improvement using Plan-Do-Study-Act Cycles was completed: 1) created an EMR report to identify patients with stage IV lung cancer; 2) completed a retrospective review of patients with stage IV lung cancer referred to palliative care 6 months prior to BPA implementation; 3) created and implemented BPA; 4) educated providers about palliative care referral and BPA; 5) retrospectively reviewed referrals 6 months following BPA implementation; and 6) evaluated potential barriers. The palliative care EMR BPA was developed in collaboration with information technology specialists. The BPA alert populates the EMR when the provider opens a patient chart or visit encounter for all patients with 1) diagnosis of lung cancer; 2) stage IV disease; and 3) does not have a current order for palliative care referral. Results: Prior to BPA implementation (January 1, 2020- July 31, 2020), 8 of 28 patients (32%) with stage IV lung cancer were referred to palliative care service. The BPA became active on 9/15/2020. Within the six months following BPA implementation, 16 patients were newly diagnosed with stage IV lung cancer. Of these 16 patients, 81% of them had a referral to palliative care made within 8 weeks of clinical staging. Several barriers were identified with current process, including lack of staging tool use by all providers; lack of documentation of all data required for staging tool to automatically calculate stage, and inability to track patients who declined palliative care appointment. Conclusions: Incorporating a BPA reminding providers to consider a palliative care referral improved referrals of patients with newly diagnosed stage IV lung cancer to the palliative care clinic within 8 weeks of diagnosis, improving compliance with ASCO’s practice guidance on integration of palliative care. Next steps are to address barriers and expand the use of palliative care referral BPA to all patients with stage IV cancer.