The Value of an Embedded Outpatient Palliative Care Program in Malignant Hematology: Concurrent Care and the Impact on Health Care Utilization

Background: Patients with hematologic malignancies are less likely to be referred to palliative care (PC) compared to those with solid malignancies. There is little that is known about the healthcare utilization of patients with hematologic malignancies who receive outpatient PC concurrently with cancer-directed therapy. The aim of this study was to describe the demographic and clinical characteristics and health care utilization of patients with hematologic malignancies who received longitudinal, concurrent outpatient PC.

Methods: We conducted a single-center, retrospective cohort study of all patients with hematologic malignancies who received embedded outpatient PC at the malignant hematology clinic between April 1, 2017 and December 31, 2018. Patients were referred to PC by their primary oncologist or hematology nurse practitioner (NP). Patients referred to PC were seen by a PC NP with expertise in hematologic malignancies. Follow-up visits with the outpatient PC NP were scheduled as needed. Demographics, clinical characteristics, and reasons for referral were extracted from the electronic health record. For patients who were followed by PC for at least 6 months, the number of hospitalizations and emergency department (ED) visits, as well as inpatient costs were compared from the 6 months prior to enrollment in PC to the 6 months after enrollment in PC. Approval for this study was obtained from the UCSF IRB.

Results: Overall, 80 patients who were seen in the malignant hematology clinic were referred for embedded PC during our study period. Of these patients, 45% (n= 36) were female. Median age was 57 years (range: 27–89). Common primary diagnoses were myeloma (47.3%, n= 38), lymphoma (18.8%, n= 15), and acute myeloid leukemia (15%, n= 12). The most frequent reasons for referral to PC were pain (32.7%, n= 34), fatigue (16.3%, n= 17), and mood disorders (11.5%, n= 12). There were 9 referrals (8.7%) for advance care planning prior to bone marrow transplant (BMT). One quarter of the patients (n= 20) were referred to PC for two or more reasons. Patients were followed in the PC clinic for a median of 3.18 months (mean 8.03 months, range 0 – 36 months, SD 9.6 months) and patients had a median of 3 PC visits (mean 5, range 1–27, SD 6). The median overall survival of the patient population was 36.5 months (SD 35.8 months).

There were 31 patients who were followed in the PC clinic for at least 6 months and were included in our healthcare utilization analyses. The total number of hospital encounters decreased from 1.48 inpatient admissions/ED visits in the 6-months before enrollment in PC to 0.71 per patient in the 6-months after enrollment in PC (p=0.04). Total inpatient direct costs per patient were $52,250.65 in the 6 months before PC enrollment and $30,360.90 in the 6 months after enrollment (p=0.18). The cost of inpatient medical hospitalizations went from $23,457.68 to $4,621.26 per patient (p=0.05), the cost of procedure-based hospitalizations, which included hospitalization for BMT, went from $27,667.84 to $25,434.48 (p=0.90), and the cost of ED visits went from $1,125.13 to $305.16 (p=0.25).

Conclusion: Our study suggests that outpatient PC has an important role for patients with hematologic malignancies far upstream of the end-of-life period. Patients were referred for a wide variety of reasons, including management of various symptoms and advance care planning prior to BMT. There was a statistically significant and substantial decrease in the number of hospital and ED encounters per patient after enrollment in PC. There was also a trend towards overall cost savings, although this did not reach statistical significance. Further research is warranted to explore the effects of outpatient PC co-management on symptoms, rates of advance care planning, and patient/family experience for patients with hematologic malignancies.