BOSTON – When a palliative care oncologist partners with a medical oncologist on everyday rounds and in everyday practice on an inpatient floor, both patients and the clinicians who provide their care benefit from the arrangement, an oncologist reports.
At Duke University Medical Center in Durham, N.C., where palliative care is integrated with medical oncology on an inpatient oncology ward, the “co-rounding” model is associated with improvements in quality outcomes, improved nursing and physician satisfaction, and increased collaboration and communication, said Dr. Richard F. Riedel of the medical center.
In a study comparing the periods before and after implementation of the co-rounding model, lengths of stay and 7- and 30-day readmission rates were significantly shorter with co-rounding.
“I’d like to think that decreased resource utilization through decreased ICU transfer rates and decreased readmissions will result in a cost savings that would certainly justify putting a second provider up on an inpatient ward,” he said at the Palliative Care in Oncology Symposium.
The co-rounding model was introduced at Duke in 2011. Under this system, a medical oncologist and palliative care oncologist meet three times daily with house staff, fellows, and other team members to discuss the care of all patients on the unit. They decide which physician will oversee care of which patient. Patients who have high symptom burdens, for example, might be assigned to the palliative care physician. The physicians and staff go on rounds together with support staff, including internal medicine house staff, physician assistants, and pharmacists, allowing both formal and “curbside” consultations about how best to manage each patient.
“Critical to the success of this model is open communication and collaboration. We have three points where we meet throughout the day, and we emphasize to our colleagues that we are one team – we do not work in silos,” Dr. Riedel said.
Before and after
To see whether the co-rounding model was really, as they thought, a better way of doing business, Dr. Riedel and his colleagues conducted a retrospective cohort analysis of all patients admitted to the solid tumor inpatient service before the intervention – 731 patients admitted from September 2008 through June 2010 – compared with 783 admitted from September 2011 through June 2012, in the first year of co-rounding.
They found that co-rounding was associated with a significantly lower mean length of stay (4.51 days pre-intervention to 4.16 post, P =.02), and in both 7-day and 30-day readmission rates (12.1% vs. 9.3%, P <.0001, and 32.1% vs 28.3%, P = .048, respectively).
Although there were numerically fewer ICU transfers post intervention, this difference was not significant. Similarly, there was a trend, albeit nonsignificant, toward more hospice referrals under co-rounding.
When the researchers surveyed registered nurses who worked in the unit during both periods, they found that most agreed that adding a palliative care specialist improved quality of care, allowed for earlier goals-of-care discussions with patients, improved the involvement of nurses in care planning, reduced stresses on the staff, and improved symptom management.
Importantly, the improvements came without making rounds take longer or detracting from any appropriate focus on oncologic care, the authors found.
Medical oncology faculty who had rounded at least 2 weeks under the new regimen were surveyed, and they uniformly reported that the palliative care providers added a valuable skill set, that palliative care was a necessary component of cancer care, and that the rounding experience was more enjoyable. They also agreed that palliative care is different from hospice care, and said they felt that the discussion of hospice for those patients with incurable disease did not come too soon in the course of care,
“Importantly, the majority of physicians felt that they learned some new ways to manage symptoms, and I can tell you that I certainly have. I’m a medical oncologist, I’m not a palliative-care trained physician,” Dr. Riedel said.
He acknowledged that the study was limited by its retrospective design and the lack of a patient satisfaction component. Also, the intervention occurred at a single large academic medical center, and involved a smaller physician-to-patient ratio that could have confounded results.
The symposium was cosponsored by AAHPM, ASCO, ASTRO, and MASCC.