Outpatient Palliative Care Practices

The field of palliative care has grown rapidly in the United States, with most of the focus on the development of inpatient palliative care consultation services.¹ However, the number of outpatient palliative care programs is increasing, with evidence of improved patient and family clinical outcomes.^2-4 Little is known about the structures and processes of existing outpatient palliative care services, including those serving patients with cancer. Learning about existing outpatient palliative care practices may be useful to palliative care programs hoping to expand into the outpatient arena.⁵ This project was designed to learn the structural components of a national sample of leading outpatient palliative care practices.

Faculty from the Palliative Care Leadership Center (PCLC) Initiative of the Center to Advance Palliative Care sent surveys to 12 leading outpatient palliative care practices in 2008. The 12 practices were selected on the basis of reputation, geographic diversity, and sustainability. We collected information regarding clinics' physical location, census, primary illnesses seen, referral sources, staffing, funding sources, and data tracking. Our project was exempted from institutional review board review.

Of the 12 practices, 11 responded to the survey with data representing the prior year of clinical operation. These practices were part of the following medical centers: Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire; Fairview Health Services & the University of Minnesota Medical Center, Minneapolis; Massachusetts General Hospital, Boston; Medical College of Wisconsin/Froedtert Hospital, Milwaukee; Palliative Care Center of the Bluegrass, Lexington, Kentucky; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; M. D. Anderson Cancer Center, Houston, Texas; Northwestern University Medical Center, Chicago, Illinois; University of California, San Diego John Moores Cancer Center, San Diego; University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco; and VCU Massey Cancer Center, Richmond, Virginia.

The aggregate results are listed in the Table. Surveyed outpatient palliative care practices are generally small in scope, seeing approximately 500 patients annually over a 3-day-per-week practice. These practices primarily see patients with cancer and are typically affiliated with cancer practices. While outpatient palliative care practices have a great variety of staffing models, most practices include physicians and advance practice nurses. Palliative care practices are supported primarily through an even mix of billing revenues and institutional support.

These data provide a description of a select group of nationally prominent outpatient palliative care practices. Our results are limited by selection bias; the practices surveyed are primarily from large, academic medical centers. Other than a description of the proportion of patients with cancer, our data do not include other patient demographic or disease-specific information (including disease severity and prognosis), which may be important when considering how to structure and staff an outpatient practice. Notably, nearly one-half of the funding for these comparison practices was provided by the institution with which they were affiliated.

Despite its limitations, we believe our survey to be the first of its kind, offering developing palliative care programs a glimpse of existing outpatient practice structures, operations, and finances. This may be especially useful for oncology programs and cancer centers, as palliative care is increasingly recognized as vital to comprehensive cancer care.⁶ Additional research is needed that expands on this work to measure the clinical impact of outpatient palliative care practices, financial viability, and health system outcomes, including hospital and hospice admission rates.

Correspondence: Dr Rabow, Department of Medicine, UCSF Medical Center at Mount Zion, 1701 Divisadero St, Ste 500, San Francisco, CA 94143-1732 (mrabow@medicine.ucsf.edu).

Author Contributions: Dr Rabow had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Rabow, Braun, and Weissman. Acquisition of data: Rabow, Smith, Braun, and Weissman. Analysis and interpretation of data: Rabow, Smith, and Weissman. Drafting of the manuscript: Rabow and Smith. Critical revision of the manuscript for important intellectual content: Rabow, Braun, and Weissman. Statistical analysis: Rabow, Smith, Braun, and Weissman. Administrative, technical, and material support: Rabow, Braun, and Weissman. Study supervision: Rabow and Weissman.

Financial Disclosure: None reported.

Funding/Support: Drs Rabow and Weissman and Ms Braun have received support from the Center to Advance Palliative Care. No funding was sought or received for this research.