Oncology patients in the health care safety net: Is it too late for early palliative care?

128 Background: Studies have suggested that uninsured and Medicaid patients are more likely to present with late-stage cancer than Medicare patients, and may be more likely to be admitted urgently or emergently. However, studies of palliative care interventions for cancer patients suggest that the greatest impact can be achieved if these services begin "early" (≥ 90 days prior to death). In our urban public hospital, we examined where patients receive their initial cancer diagnosis, and at what stage they are diagnosed, in order to determine how to best implement community-based palliative care services.

METHODS: Retrospective cohort analysis of cancer patients diagnosed over a five year period. Hospital tumor registry data were used to determine the location of diagnosis (inpatient vs. outpatient), stage and type of cancer at diagnosis, and patient status at the end of the study period (alive vs. deceased).

RESULTS: Of the 2,928 patients diagnosed with cancer, 26% of patients (n = 759) were diagnosed while hospitalized. Patients who received their diagnosis while hospitalized were more likely to be diagnosed with stage 3-4 disease (49%, n = 372), vs. stage 0-1 (21%, n = 163). 25% of patients who received their diagnosis in the inpatient setting died within 90 days of initial diagnosis. Patients diagnosed in the outpatient setting were more likely to be diagnosed with stage 0-1 (40%, n = 865), vs. stage 3-4 (32%, n = 688). Patients diagnosed while hospitalized were 2.9 times more likely to be diagnosed with late stage disease, compared to those diagnosed as outpatients (95% CI 2.3-3.5, p < 0.0001).

CONCLUSIONS: A large minority of patients received their cancer diagnosis while hospitalized, and were more likely to be diagnosed with late-stage disease. Additionally, a significant proportion of these patients died within 90 days of their initial diagnosis. In order to provide "early" palliative care for cancer patients in public hospitals, palliative care programs may need to offer initial consultation visits while patients are hospitalized, and then connect them with prompt outpatient follow-up. Safety net programs with palliative care services for cancer patients should emphasize continuity across inpatient and outpatient settings.