'Co-Rounding' Cuts Inpatient Oncology Stays, Readmissions

Nick Mulcahy

October 22, 2014

Good things happen when medical oncologists and palliative care specialists are equally responsibile for cancer care on a hospital's inpatient oncology unit, according to results from a novel study.

This pioneering collaborative model, dubbed "co-rounding," means that a physician from each specialty is present all day on the unit, as opposed to the usual model in which palliative care is consultative and a specialist stops by the floor.

Co-rounding significantly reduced hospital stays and readmission rates for inpatient cancer patients at the Duke University Medical Center in Durham, North Carolina, said Dr Richard Riedel, the lead author of a study on the concept.

There is "increasing recognition" that palliative care is valuable, "not just at the end of life," but throughout the entire "trajectory" of cancer and its care, Dr Riedel explained.

He spoke during a presscast in advance of the inaugural Palliative Care in Oncology Symposium, which will be held October 24 and 25 in Boston.

Palliative care has been shown to improve outcomes in the cancer outpatient setting and when it is a consultative service, but never when it is an integrated inpatient service, Dr Riedel noted.

The Duke team compared two cohorts of inpatients with solid tumors: one from 2009 and 2010, before co-rounding was implemented (n = 731); and one from 2011 and 2012, after it was implemented (n = 738).

About 75% of the patients had either recurrent or metastatic solid tumors, including lung, breast, and colorectal.

The mean length of stay was significantly lower after co-rounding was implemented than before (4.51 to 4.17 days; P = .02).

In addition, absolute 7-day readmission rates were lower after co-rounding than before (12.1% vs 9.3%), as were 30-day readmission rates (32.1% vs 28.3%). In fact, relative improvement in 7-day readmission rates was significant (23%; P < .0001), as was relative improvement 30-day readmission rates (12%; P = .048).

In an earlier study, the majority of readmissions of cancer patients were related to nausea/vomiting and pain, Dr Riedel reported. Palliative care doctors are "best" at managing both of these problems, he said, which could be why the outcomes of this study were so positive.

After the implementation of co-rounding, there was a trend toward increased hospice referral (P = .09) and a 15% decrease in intensive care unit transfers, but neither difference was statistically significant.

Co-rounding "certainly has had impressive results in this study," said presscast moderator Jyoti Patel, MD, from the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago.

At Northwestern, palliative care is delivered as a consultative service, she explained. The consulting specialists often see inpatient oncology patients late in the day, or even a day after admission. "We lose a day or so with the back and forth" of communication between the specialties, she said.

At Duke, co-rounding means that there are formal meetings three times a day in which the attending medical oncologist and palliative care physician discuss all patients in the unit with the full team.

A patient's needs dictates which attending physician oversees the care. Typically, patients with a higher symptom burden are assigned to the palliative care specialist. The hospital support staff, such as internal medicine house staff, physician assistants, and pharmacists, round with both attending physicians.

"To our knowledge, this is the first example where palliative care physicians and medical oncologists are working side by side every day on an inpatient oncology ward," said Dr Riedel in a press statement. "We're seeing it's a partnership worth keeping."

The model of care "fosters open communication and consultation," he added. And participating physicians, nurses, and other healthcare professionals have "very favorable impressions" of co-rounding.

The multidisciplinary 2014 Palliative Care in Oncology Symposium is sponsored by the American Society of Clinical Oncology, the American Academy of Hospice and Palliative Medicine, the American Society for Radiation Oncology, and the Multinational Association of Supportive Care in Cancer.

Dr Riedel and several coauthors report financial relationships with various healthcare and pharmaceutical companies.

2014 Palliative Care in Oncology Symposium: Abstract 3. To be presented October 25, 2014.

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