The rapid transition of palliative care-related patient visits at a major academic cancer center to a model involving almost all telehealth-based encounters was associated with a dramatic increase in the number of documented serious illness conversations between patients and clinicians, according to a report published in JCO Oncology Practice.
Following awareness of the COVID-19 pandemic, the palliative care unit at the Dana-Farber Cancer Institute in Boston, Massachusetts, switched to a new model on March 16, 2020, that involved a transition to telehealth-based patient visits, including telephone and virtual visits.
“In our palliative care clinic, most of our patients have acute complex oncologic issues with high symptom burden and deferral was not an option,” the authors commented.
The number of overall patient visits documented in the electronic medical record was similar to prepandemic numbers within 2 weeks of the switch. Therefore, this study also evaluated the quality of care, particularly because, as noted by the researchers, “the palliative care clinical encounter is highly dependent on relationships and traditionally includes interdisciplinary in-person encounters.”
In an analysis of the impact this change had on palliative care delivery, the investigators noted the following observations:
- Greater continuity of palliative care was observed given that patients traveling long distances for in-person visits often scheduled multiple visits on the same day, thereby increasing the chance their primary palliative care provider would be unavailable
- No change was observed in the documented number of patient contact hours with a pharmacist
- Following changes in opioid prescribing practices made by the Commonwealth of Massachusetts, opioids could be prescribed to patients without necessitating a prior in-person visit
- The number of documented serious illness conversations between patients and outpatient clinic providers from February 2020 to April 2020 increased by more than 4-fold.
In offering a potential explanation for the latter observation, the study investigators postulated that fears related to the pandemic led patients and clinicians to engage in more of these conversations.
Although the palliative care clinicians mostly preferred video-based over telephone-based encounters with patients, technical challenges encountered included constraints imposed by login delays.
Other challenges were logistical barriers associated with telemedicine that may inhibit interactions between multiple members of the interdisciplinary team during a single visit. However, the use of a “virtual patient waiting room” to coordinate interactions between members of the palliative care team, with and without the patient, was suggested as a potential means of facilitating communication. In addition, remote symptom assessment and prognostication is unlikely to substitute fully for an in-person visit.
Furthermore, disparities with respect to patient access to video equipment were also noted, particularly for older patients, those considered socioeconomically disadvantaged, and patients who did not speak English.
In commenting on this finding, the investigators stated that “this disparity will only become more pronounced as we come to rely more heavily on virtual visits.”
“Although not all patients have the ability or resources to use technology for medical encounters,” the researchers noted, “For those who do, telemedicine has already made palliative care more accessible by allowing clinical encounters in the patient’s home.”
They further added, “Telehealth will be our new reality and we need to overcome the challenges to make optimal use of it for high-quality palliative care.”
Lally K, Kematick BS, Gorman D, Tulsky J. Rapid conversion of a palliative care outpatient clinic to telehealth.JCO Oncol Pract. Published online December 11, 2020. doi:10.1200/OP.20.00557