State of Integration of Palliative Care at National Cancer Institute–Designated and Nondesignated Cancer Centers

Timely integration of specialist palliative care (PC) to oncologic care is associated with improved patient outcomes.¹ Although several studies have examined supportive and palliative care services at US cancer centers,^2,3 none to our knowledge have assessed the level of integration using a standardized set of indicators. In this study, we compared the level of integration between National Cancer Institute (NCI)–designated and non–NCI-designated cancer centers.

This is a preplanned analysis of a national survey to assess the structure, processes, and outcomes of the PC programs at US cancer centers.⁴ The study protocol was reviewed by the Institutional Review Board at The University of Texas MD Anderson Cancer Center and granted exemption status as a minimal-risk study that did not require patient data. Between April and August 2018, we surveyed the PC program leaders of all 62 NCI-designated cancer centers and a randomly selected sample of 62 of 1252 non–NCI-designated cancer centers (using RAND() in Microsoft Excel, Microsoft Office Professional Plus 2013 [Microsoft Corporation]) in the Commission on Cancer National Cancer Database. Among these centers, 61 NCI-designated cancer centers and 38 non–NCI-designated cancer centers had a PC program, and the PC program leaders were invited to participate.⁴ The survey included 13 integration indicators derived from international consensus to assess program structure (Nos. 1-3), processes (Nos. 4-6), outcomes (Nos. 7-9), and education (Nos. 10-13) (Table).⁵

Two Palliative Care and Oncology Integration Indexes (PCOIs) were computed: PCOI-9 included 9 indicators (Nos. 1-5 and 10-13), and PCOI-13 included all 13 indicators. These indexes had previously been evaluated for face validity, content validity, and ability to discriminate between groups.^5,6 Scores were prorated if at least 50% of the variables were available. A higher score indicates greater integration.⁶ We compared NCI-designated and non–NCI-designated centers using the Fisher exact test for categorical variables and the Kruskal-Wallis test for continuous variables. As part of the sensitivity analysis, we computed the PCOI scores using the worst-case scenario, in which missing variables were assigned a score of 0. We examined the association between PCOI scores and center characteristics with the Spearman correlation test using SPSS, version 24.0 (IBM). All tests were 2-sided and a P value of .05 or less was considered to be statistically significant.

The response rate was 52 of 61 (85%) for NCI-designated cancer centers and 27 of 38 (71%) for non–NCI-designated cancer centers. Both the median PCOI-9 and PCOI-13 scores were significantly higher among NCI-designated than non–NCI-designated cancer centers (Figure, A and B). Similar findings were found with worst-case scenario analyses (Figure, C and D). Higher PCOI scores were associated with longer PC program operation duration (PCOI-9: ρ, 0.34; P = .003; PCOI-13: ρ, 0.35; P = .003) and greater number of full-time equivalent physicians (PCOI-9: ρ, 0.43; P < .001; PCOI-13: ρ, 0.42; P < .001).

The Table shows the individual indicators. Although inpatient PC service was mostly available in both groups, NCI-designated centers were significantly more likely to have outpatient clinics, interdisciplinary teams, didactic PC lectures, and mandatory rotations for oncology fellows than non–NCI-designated cancer centers. Advance care planning was limited in both cohorts.

The NCI-designated cancer centers had more integrated PC services than the non–NCI-designated centers, likely because they had greater resources, staffing, and academic infrastructure. Given that more than 80% of patients with cancer are treated at non–NCI-designated centers, our findings highlight the need to further develop PC at these institutions. The NCI-designated centers may serve as models of integration.

Limitations of this study include the small sample size; self-reported data; missing data in some variables, such as timing of referral and center outcomes; and lack of adjustment of potential confounders, such as hospital size and resources. A study of European Society for Medical Oncology–designated cancer centers found that nontertiary care hospitals were more integrated than tertiary care hospitals, suggesting that smaller size may be advantageous.⁶

At the system level, systematic assessment of PCOI scores may facilitate benchmarking, comparisons over time, and setting standards for accreditation and recognition programs. At the institution level, PCOI scores may help to set goals and allocate resources for quality improvement initiatives. An individualized report card may be helpful. Advance care planning and education represent 2 key areas for further improvement.

Accepted for Publication: March 24, 2020.

Corresponding Author: David Hui, MD, MSc, Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1414, Houston, TX 77030 (dhui@mdanderson.org).

Published Online: July 2, 2020. doi:10.1001/jamaoncol.2020.1471

Author Contributions: Dr Hui 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: Hui, Bruera.

Acquisition, analysis, or interpretation of data: Hui, De La Rosa.

Drafting of the manuscript: Hui, Bruera.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hui.

Obtained funding: Hui.

Administrative, technical, or material support: Hui, Bruera.

Study supervision: Hui, Bruera.

Conflict of Interest Disclosures: Dr Hui reported receiving grants from the National Institutes of Health (NIH)/NCI (R01CA214960-01A1; R01CA225701-01A1; R01CA231471-01A1), National Institute of Nursing Research (R21NR016736-01), Helsinn Therapeutics, and Insys Therapeutics during the conduct of the study. Dr Bruera reported receiving grants from the NIH/NCI, National Institute of Nursing Research, and Helsinn Therapeutics during the conduct of the study. No other disclosures were reported.

Additional Contributions: We are grateful to all respondents for completing the surveys.