Outpatient Identification of High-Risk Gynecologic Cancers Increased Timely Goals of Care Conversations

Using systematic outpatient identification to identify patients with high-risk gynecologic cancers is feasible and sustainable and can increase the timeliness of goals of care conversations within this population, according to results from prospective research published in Gynecologic Oncology.

A sustained increase over time was observed in timely goals of care discussion documentation among patients with high-risk gynecologic cancers, with documentation increasing from 30.2% before implementation of systemic patient identification to 88.7% after implementation (P <.001).

“Timely goals of care discussions are a critical piece in the delivery of high-quality, goal-concordant cancer care at the end of life,” the investigators wrote. “Our study demonstrates the feasibility, acceptability, and effectiveness of an intervention designed to increase the conduct and documentation of these conversations. Further work is needed to address other high-quality cancer care metrics at the end of life.”

The research emphasized 4 important intervention compontents, which included clinician education on goal-concordant cancer care; building a consensus for a goals of care documentation template; identifying high-risk patients; and outpatient clinician notification.

Two cohorts of patients were compared in this research, including a pre-pilot cohort of consecutive outpatients from January 2016 to December 2016 who were considered to be high risk. The pilot cohort consisted of consecutive outpatients from August 2017 to May 2018 who were identified prospectively prior to the index encounter.

The research team defined the inclusion criteria for high-risk of death as having recurrent or progressive platinum-resistant ovarian cancer or any other recurrent or metastatic gynecologic cancers with disease evidence.

The primary objective of the research centered on improving timely goals of care conversation rates. Key secondary end points included hospice acceptance, death within 30 days of admission, and ICU admissions.

A total of 220 patients met the study’s inclusion criteria, including 96 patients who were pre-implementation and 124 who were post-implementation. The mean age at recurrent cancer diagnosis was 64.9 years. The majority of patients were White (62.7%) and Black (27.3%), and nearly all patients were not Hispanic or Latino (95.9%). Additionally, 47.3% of patients had platinum resistant ovarian cancer.

The time from first goals of care conversation to death increased among patients after implementation (283 vs 128 days; P <.001). No significant differences were observed before and after implementation among key secondary end points.

Seventy-five percent of gynecologic oncology providers returned completed surveys (9 of 12 providers) during the pilot period. Notably, 67% agreed that “notification accurately identified patients who needed a goals of care conversation” and 88% agreed that notification improved patient care delivery, was valuable to clinical care, and was not a burden with regard to daily work.

The study had some limitations, including the reporting of 2 different methods of analysis. Moreover, the investigators suggest that additional communication interventions were used during the study period, which may have impacted the increased rates of goals of care discussions during the post-implementation period.

“Physicians are often hesitant to discuss prognosis with patients for a variety of reasons,” the investigators explained. “By clearly defining a priori the clinical eligibility criteria for [goals of care] conversations in each cancer type, our initiative overcame the challenge of prognostication, one of the most common reasons physicians give when [goals of care] discussions are not performed.”

Reference

Davidson BA, Puechl AM, Watson CH, et al. Promoting timely goals of care conversations between gynecologic cancer patients at high-risk of death and their providers. Gynecol Oncol. 2021;S0090-8258(21)01635-8. doi:10.1016/j.ygyno.2021.12.009