Brittany A Davidson1, Allison M Puechl2, Catherine H Watson2, Stephanie Lim3, Luke Gatta3, Karen Monuszko4, Kerry Drury3, Emma S Ryan4, Shelley Rice5, Tracy Truong6, Jessica Ma7, Steve Power8, Weston Jordan8, Kelli Kurtovic3, Laura J Havrilesky9. 1. Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC 27710, United States of America; Duke Cancer Institute, Durham, NC 27710, United States of America. Electronic address: Brittany.davidson@duke.edu. 2. Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC 27710, United States of America. 3. Department of Obstetrics & Gynecology, Duke University, Durham, NC 27710, United States of America. 4. Duke University Medical School, Durham, NC 27710, United States of America. 5. Division of Palliative Care, Duke University Health System, Durham, NC 27710, United States of America. 6. Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, United States of America. 7. Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC 27705, United States of America. 8. Office of the Chief Medical Officer, Duke University Health System, Durham, NC 27710, United States of America. 9. Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC 27710, United States of America; Duke Cancer Institute, Durham, NC 27710, United States of America.
Abstract
OBJECTIVE: We designed a multi-faceted intervention to increase the rate of outpatient goals of care (GOC) conversations in women with gynecologic cancers who are at high-risk of death. METHODS AND MATERIALS: A multidisciplinary team developed an educational program around GOC conversations at end-of-life and chose criteria to prospectively identify patients at high-risk of death who might benefit from timely GOC conversations: recurrent or metastatic endometrial, cervical or vulvar cancer or platinum-resistant ovarian cancer. Gynecologic oncology provider consensus was built regarding the need to improve the quality and timing of GOC conversations. Eligible outpatients were prospectively identified and providers alerted pre-encounter; timely GOC documentation within 3 visits of high-risk identification was tracked. Our institution concurrently and subsequently tracked GOC documentation during the last 6 months of life among all established oncology patients. RESULTS: Of 220 pilot period high-risk patients (96 pre- and 124 during pilot period 2017-2018), timely GOC discussion documentation increased from 30.2% to 88.7% (p < 0.001) and this increase was sustained over time. In the post-pilot period (2019-2020), among patients seen by oncologists during last 6 months of life, compared to other cancer types, gynecologic cancer patients had a higher rate of GOC documentation (81% versus 9%; p < 0.001), a lower rate of receiving chemotherapy during the last 14 days of life (2% vs 5%; p = 0.051), and no difference in end-of-life admissions (29% vs 31%; p = NS). CONCLUSIONS: Implementation of systematic outpatient identification of high-risk gynecologic oncology patients is feasible, sustainable, and increases the timely conduct of GOC conversations.
OBJECTIVE: We designed a multi-faceted intervention to increase the rate of outpatient goals of care (GOC) conversations in women with gynecologic cancers who are at high-risk of death. METHODS AND MATERIALS: A multidisciplinary team developed an educational program around GOC conversations at end-of-life and chose criteria to prospectively identify patients at high-risk of death who might benefit from timely GOC conversations: recurrent or metastatic endometrial, cervical or vulvar cancer or platinum-resistant ovarian cancer. Gynecologic oncology provider consensus was built regarding the need to improve the quality and timing of GOC conversations. Eligible outpatients were prospectively identified and providers alerted pre-encounter; timely GOC documentation within 3 visits of high-risk identification was tracked. Our institution concurrently and subsequently tracked GOC documentation during the last 6 months of life among all established oncology patients. RESULTS: Of 220 pilot period high-risk patients (96 pre- and 124 during pilot period 2017-2018), timely GOC discussion documentation increased from 30.2% to 88.7% (p < 0.001) and this increase was sustained over time. In the post-pilot period (2019-2020), among patients seen by oncologists during last 6 months of life, compared to other cancer types, gynecologic cancer patients had a higher rate of GOC documentation (81% versus 9%; p < 0.001), a lower rate of receiving chemotherapy during the last 14 days of life (2% vs 5%; p = 0.051), and no difference in end-of-life admissions (29% vs 31%; p = NS). CONCLUSIONS: Implementation of systematic outpatient identification of high-risk gynecologic oncology patients is feasible, sustainable, and increases the timely conduct of GOC conversations.
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