Isaac Chua, MD, MPH, of the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital, is the lead author of a paper published in JAMA Network Open, “Changes in Palliative Care Specialist Use among Medicare Decedents with Poor Prognosis Malignancies .”
Q: How would you summarize your study for a lay audience?
For patients with a cancer diagnosis, early specialty palliative care is considered the standard of care. However, many patients with advanced cancer do not consistently receive specialty palliative care, especially during the early stages of their illness.
In our study, we wanted to see if recent changes in health care—the increased adoption of telehealth and availability of more advanced practice clinicians—changed specialty palliative care use for these patients.
We analyzed Medicare beneficiaries who died from cancers with poor prognoses between 2018 and 2023 and found that a growing number, but minority, of patients received any specialty palliative care in the year prior to their death. Delivery of specialty palliative care in the outpatient setting almost doubled, which was mostly driven by advanced practice clinicians. Additionally, telehealth constituted a persistent, sizable fraction of outpatient visits.
Despite these changes, specialty palliative care use among certain disadvantaged groups remained low.
Q: What question were you investigating?
Did specialty palliative care use among Medicare beneficiaries who died from poor-prognosis cancers change in the context of trends in health care—namely greater telehealth adoption and expansion of healthcare workforce via advanced practice clinicians? If so, how did it change and what did these changes look like?
Q: What methods or approach did you use?
We conducted a retrospective observational cohort study of all U.S. Medicare fee-for-service beneficiaries who died from poor-prognosis cancers between 2018 and 2023. We assessed the proportion of decedents who received any specialty palliative care in their last year of life, prior to any hospice enrollment.
We also described changes in specialty palliative care use by care modality (in person versus telehealth), setting (hospital versus outpatient), and clinician type (physician versus advanced practice clinicians). We also explored associations between patient characteristics and receipt of specialty palliative care and how these associations changed over time.
Q: What did you find?
We found that a small but growing number of Medicare beneficiaries with poor-prognosis cancers between 2018 and 2023 received any specialty palliative care in the year prior to their death. However, by the end of 2023, only a little more than one-third of decedents received any non-hospice palliative care in their last year of life.
We also found that outpatient palliative care visits, which includes telehealth visits, almost doubled, which was mostly driven by advanced practice clinician specialists; advanced practice clinicians have supplanted physicians as the main clinician type providing specialty palliative care in the outpatient setting.
However, despite these changes, certain disadvantaged groups, including decedents who were older, had lower incomes or were living in nonmetropolitan areas, remained less likely to receive any specialty palliative care.
Q: What are the implications?
Despite changes in specialty palliative care delivery, only a minority of Medicare decedents with poor-prognosis cancers received any specialty palliative care and low use of specialty palliative care among certain subpopulations persisted, suggesting that different strategies (in addition to increased telehealth adoption and workforce expansion via advance practice clinicians) are needed to overcome barriers to access.
Additionally, the steady use of telehealth by palliative care specialists suggests that this modality of palliative care delivery may be well suited for patients with poor-prognosis cancers. Although the proportion of telehealth use in specialty palliative care appears modest (roughly 18% of outpatient visits), the persistent use of telehealth in palliative care is notable, especially since telehealth use in most medical disciplines (except for psychiatry) have returned to pre-pandemic levels.
Q: What are the next steps?
The next step is to identify and understand the reasons for persistently low specialty palliative care use in certain disadvantaged patient populations, especially older adults, those with lower income and those living in nonmetropolitan areas. Thoughtful policy- and system-based interventions that address specific barriers to specialty palliative care use will likely be necessary to ensure that all patients with poor-prognosis cancers have access to these services.
