Factors Associated with Referral of Patients with Advanced Cancer Utilizing a Palliative Care Referral Protocol
DOI:
https://doi.org/10.32635/2176-9745.RBC.2025v71n2.5015Keywords:
Palliative Care, Clinical Protocols, Patient SelectionAbstract
Introduction: Numerous barriers hinder timely referral to palliative care (PC) leading to inadequate symptom management and diminished quality of life. Standardizing referral criteria is essential to improve access to PC, emphasizing the urgency of early referral for patient support. Brazilian experts created the Palliative Care Referral Protocol (PCRP), a tool to categorize oncology patients based on clinical urgency, prioritizing appointments within 90, 45, and 15 days according to the severity. Objective: Evaluate factors influencing referral patterns of advanced cancer patients using a palliative care referral protocol. Method: Retrospective cohort study conducted at Hospital de Câncer de Barretos (Barretos, São Paulo, Brazil). Data from electronic medical records of cancer patients who met the inclusion criteria were analyzed using three instruments: Sociodemographic and Clinical Patient Characterization Questionnaire; Assessment Questionnaire of Referrals through PCRP according to clinical performance; Evaluation Questionnaire of Referrals without the PCRP. Statistical analyses utilized IBM-SPSS v.27.0, R v.4.3.2 software, and GGPLOT2 library, with significance of p < 0.05. Results: 1,492 patient records were identified, 323 were randomized (226 with PCRP and 97 without PCRP). PCRP-referred patients were predominantly females, with higher education, diagnosed with digestive cancer as primary tumor. Predictors for PC referral included exclusive PC treatment, higher KPS, and yellow performance group (ECOG). Referral according to the protocol were more detailed and justified. Conclusion: Targeted interventions and educational initiatives focused to healthcare providers are required to ensure timely access, emphasizing its key role in clinical practice. Longitudinal trials are needed to further validate the effectiveness of PCRP in clinical practice.
Downloads
References
Osman H, Shrestha S, Temin S, et al. Palliative care in the global setting: ASCO resource-stratified practice guideline. J Glob Oncol. 2018;4:1-24. doi: https://www.doi.org/10.1200/JGO.18.00026
Paiva CE, Paiva BSR, Menezes D, et al. Development of a screening tool to improve the referral of patients with breast and gynecological cancer to outpatient palliative care. Gynecol Oncol. 2020;158(1):153-7. doi: https://www.doi.org/10.1016/j.ygyno.2020.04.701 DOI: https://doi.org/10.1016/j.ygyno.2020.04.701
Valentino TCO, Paiva BSR, Oliveira MA, et al. Factors associated with palliative care referral among patients with advanced cancers: a retrospective analysis of a large Brazilian cohort. Support Care Cancer. 2018;26(6):1933-41. doi: https://www.doi.org/10.1007/s00520-017-4031-y DOI: https://doi.org/10.1007/s00520-017-4031-y
Freitas R, Oliveira LC, Mendes GLQ, et al. Barreiras para o encaminhamento para o cuidado paliativo exclusivo: a percepção do oncologista. Saúde debate.2022;46(133):331-45. doi: https://doi.org/10.1590/0103-1104202213306 DOI: https://doi.org/10.1590/0103-1104202213306
Cherny NI, Fallon M, Kaasa S, et al. Oxford textbook of palliative medicine. Oxford: Oxford University Press; 2015. doi: https://doi.org/10.1093/med/9780198821328.001.0001 DOI: https://doi.org/10.1093/med/9780199656097.001.0001
Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616-25. doi: https://www.doi.org/10.1056/NEJMoa1204410 DOI: https://doi.org/10.1056/NEJMoa1204410
Floriani CA, Schramm FR. Palliative care: interfaces, conflicts and necessities. Ciênc saúde coletiva. 2008;13(sup2):2123. doi: https://www.doi.org/10.1590/s1413-81232008000900017 DOI: https://doi.org/10.1590/S1413-81232008000900017
Hui D, Mori M, Watanabe SM, et al. Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol. 2016;17(12):e552-e9. doi: https://www.doi.org/10.1016/S1470-2045(16)30577-0 DOI: https://doi.org/10.1016/S1470-2045(16)30577-0
Nguyen L, De la Cruz M, Hui D, et al. Frequency and predictors of patient deviation from prescribed opioids and barriers to opioid pain-management in patients with advanced cancer. J Pain Symptom Manage. 2013;45(3):506-16. doi: http://dx.doi.org/10.1016/j.jpainsymman.2012.02.023 DOI: https://doi.org/10.1016/j.jpainsymman.2012.02.023
Gobatto CA, Araujo TCCF. Religiosidade e espiritualidade em oncologia: concepções de profissionais da saúde. Psicol USP. 2013;24(1):11-34. doi: https://doi.org/10.1590/S0103-65642013000100002 DOI: https://doi.org/10.1590/S0103-65642013000100002
Davis MP, Temel JS, Balboni T, et al. A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses. Ann Palliat Med. 2015;4(3):99-121. doi: https://www.doi.org/10.3978/j.issn.2224-5820.2015.04.04
Hui D, Kim SH, Roquemore J, et al. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer. 2014;120(11):1743-9. doi: https://www.doi.org/10.1002/cncr.28628 DOI: https://doi.org/10.1002/cncr.28628
Kirolo I, Tamariz L, Schultz EA, et al. Interventions to improve hospice and palliative care referral: a systematic review. J Palliat Med. 2014;17(8):957-64. doi: https://doi.org/10.1089/jpm.2013.0503 DOI: https://doi.org/10.1089/jpm.2013.0503
Hui D, Meng YC, Bruera S, et al. Referral criteria for outpatient palliative cancer care: a systematic review. Oncologist. 2016;21(7):895-901. doi: https://www.doi.org/10.1634/theoncologist.2016-0006 DOI: https://doi.org/10.1634/theoncologist.2016-0006
TASY [Internet]. Versão EMR HTML5. [São Paulo]: Philips; ©2004-2025. [Acess 2024 jun 25]. Available from: https://www.philips.com.br/
REDCap [Internet]. Version 15.2.1. Nashville: Vanderbilt University; 2024. [acess 2024 jun 29]. Available from: https://redcap.vanderbilt.edu/
Presidência da República (BR). Lei nº 13.709, de 14 de agosto de 2018. Lei Geral de Proteção de Dados Pessoais (LGPD). Diário Oficial da União, Brasília, DF. 2018 ago 14; Seção I.
SPSS®: Statistical Package for Social Science (SPSS)[Internet]. Version 27.0. [Nova York]. International Business Machines Corporation. [acess 2024 agu 9]. Disponível em: https://www.ibm.com/br-pt/spss?utm_content=SRCWW&p1=Search&p4=43700077515785492&p5=p&gclid=CjwKCAjwgZCoBhBnEiwAz35Rwiltb7s14pOSLocnooMOQh9qAL59IHVc9WP4ixhNTVM jenRp3-aEgxoCubsQAvD_BwE&gclsrc=aw.ds
R: The R Project for Statistical Computing [Internet]. Version 4.3.2 [place unknown]: The R foundation. 2021 nov 2 - [acess 2022 sept 6]. Available from: https://www.r-project.org/
Wickham H. ggplot2: elegant graphics for data analysis. New York: Springer-Verlag; 2016. doi: https: //doi.org/10.1007/978-0-387-98141-3
Conselho Nacional de Saúde (BR). Resolução n° 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União, Brasília, DF. 2013 jun 13; Seção I:59.
Hui D, Hannon BL, Zimmermann C, et al. Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin. 2018;68(5):356-76. doi: https://www.doi.org/10.3322/caac.21490 DOI: https://doi.org/10.3322/caac.21490
Haun MW, Estel S, Rucker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6(6):Cd011129. doi: https://www.doi.org/10.1002/14651858.CD011129.pub2 DOI: https://doi.org/10.1002/14651858.CD011129.pub2
Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis. JAMA. 2016;316(20):2104-14. doi: https://www.doi.org/10.1001/jama.2016.16840 DOI: https://doi.org/10.1001/jama.2016.16840
Hausner D, Tricou C, Mathews J, et al. Timing of palliative care referral before and after evidence from trials supporting early palliative care. Oncologist. 2021;26(4):332-40. doi: https://www.doi.org/10.1002/onco.13625 DOI: https://doi.org/10.1002/onco.13625
Ziegler LE, Craigs CL, West RM, et al. Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study. BMJ open. 2018;8(1):e018284. doi: https://www.doi.org/10.1136/bmjopen-2017-018284 DOI: https://doi.org/10.1136/bmjopen-2017-018284
Pellizzari M, Hui D, Pinato E, et al. Impact of intensity and timing of integrated home palliative cancer care on end-of-life hospitalization in Northern Italy. Support Care Cancer. 2017;25(4):1201-07. doi: https://www.doi.org/10.1007/s00520-016-3510-x DOI: https://doi.org/10.1007/s00520-016-3510-x
Jang RW, Krzyzanowska MK, Zimmermann C, et al. Palliative care and the aggressiveness of end-of-life care in patients with advanced pancreatic cancer. J Natl Cancer Inst. 2015;107(3):dju424. doi: https://www.doi.org/10.1093/jnci/dju424 DOI: https://doi.org/10.1093/jnci/dju424
Hui D, Anderson L, Tang M, et al. Examination of referral criteria for outpatient palliative care among patients with advanced cancer. Supportive Care in Cancer. 2019. doi: https://www.doi.org/10.1007/s00520-019-04811-3 DOI: https://doi.org/10.1007/s00520-019-04811-3
Cuviello A, Yip C, Battles H, et al. Triggers for palliative care referral in pediatric oncology. Cancers. 2021;13(6):1419. doi: https://doi.org/10.3390/cancers13061419 DOI: https://doi.org/10.3390/cancers13061419
Iqbal J, Sutradhar R, Zhao H, et al. Operationalizing outpatient palliative care referral criteria in lung cancer patients: a population-based cohort study using health administrative data. J Palliat Med. 2020;23(5):670-7. doi: https://www.doi.org/10.1089/jpm.2019.0515 DOI: https://doi.org/10.1089/jpm.2019.0515
Hui D, Heung Y, Bruera E. Timely palliative care: personalizing the process of referral. Cancers (basel). 2022;14(4):1047. doi: https://www.doi.org/10.3390/cancers14041047 DOI: https://doi.org/10.3390/cancers14041047
Wong A, Vidal M, Prado B, et al. Patients’ perspective of timeliness and usefulness of an outpatient supportive care referral at a comprehensive cancer center. J Pain Symptom Manage. 2019;58(2):275-81. doi: https://www.doi.org/10.1016/j.jpainsymman.2019.04.027 DOI: https://doi.org/10.1016/j.jpainsymman.2019.04.027
Dalberg T, McNinch NL, Friebert S. Perceptions of barriers and facilitators to early integration of pediatric palliative care: a national survey of pediatric oncology providers. Pediatr Blood Cancer. 2018;65(6):e26996. doi: https://www.doi.org/10.1002/pbc.26996 DOI: https://doi.org/10.1002/pbc.26996
Downloads
Published
How to Cite
Issue
Section
License
Os direitos morais e intelectuais dos artigos pertencem aos respectivos autores, que concedem à RBC o direito de publicação.
This work is licensed under a Creative Commons Attribution 4.0 International License.
