Abstract
Dear Editor:
Outpatient palliative care provides continuity of care for patients living with serious illness and reduces the risk of unnecessary rehospitalizations and emergency department visits. 1 This type of service improves quality of life and prolongs survival. 2 The role of midlevel practitioners involved in outpatient palliative care is a novel concept, although several descriptive reports of the roles of advanced practice nurses and newly emerging clinical pharmacists have been previously described.3–5 Studies indicate a positive impact when specialized care is deferred to midlevel practitioners supported by oversight from physicians through collaborative practice protocols.6,7
A prospective, cohort study was conducted with the primary objective of assessing intervention outcomes performed by midlevel palliative care practitioners, specifically a pharmacist and a nurse practitioner, working under a collaborative practice protocol that permitted initiation and adjustments in therapy for pain and symptom management. This study was approved by the Institutional Review Board of the University of California, San Diego Medical Center. Data on patients' pain, health-related quality of life (HRQOL), and function were obtained using validated survey instruments (e.g., Brief Pain Inventory [Short Form] and SF12 Health Survey).8,9 Study group patients were referred to the palliative care service by their oncologist and were seen by a midlevel practitioner on an outpatient basis for pain and symptom management. Control group patients managed outpatient by their oncologist for pain and symptom management were identified through electronic medical records. Telephone encounters assessed pain, HRQOL, and function for both study and control group patients. Patients were contacted within two weeks after diagnosis of cancer-related pain. Informed consent was obtained from all patients. During the baseline telephone encounter, demographic information was collected, and both surveys were conducted. Follow-up telephone encounters occurred six to eight weeks later after the initial survey. The Wilcoxon signed rank test was utilized for comparison between study groups (SAS v9.2, Cary, NC).
Fourteen patients (eight study patients and six control patients) completed the study. The majority of patients were Caucasian and diagnosed with Stage 3 or 4 solid tumors. Females were more prevalent in the study group (63% versus 50%), with age (mean±SD) 49.5±15.2 years (study patients) and 57.7±8.4 years (control patients). There was no difference between groups in all measures of the Pain Inventory survey. In the measurement of HRQOL and function, control group patients felt more calm/peaceful at baseline (3.1±1 versus 2.3±1.1; p=0.04) and a higher energy level at follow-up (4.3±0.5 versus 2.9±1.5; p=0.02) compared to study group patients.
Preliminary study results suggest that midlevel practitioners for a palliative care service are able to provide care for patients similar to care provided by their oncologist in terms of pain and symptom management. Oncologists are encouraged to utilize such services, if offered at their institution. Efforts are ongoing to continue enrollment to increase sample size.