Compounding or confounding?—addressing context-specific disparities in access to outpatient specialty palliative care
Despite proven benefit of outpatient specialty palliative care on symptom burden, quality-of-life, and survival, only 20-30% of eligible patients with gynecologic cancers receive a referral, even in high-resource health systems. Socioeconomically disadvantaged and culturally marginalized populations face inequitable access to specialty palliative care. However, the relationships between social determinants of health (SDOH) and palliative care utilization remain understudied. We evaluated rates of outpatient specialty palliative care referral and assessed disparities associated with SDOH. A single institution retrospective cohort quality improvement study evaluated gynecologic oncology patients receiving care in Kansas City, Kansas (midwestern United States) who met American Society of Clinical Oncology (ASCO) criteria for referral to outpatient specialty palliative care from 2019-2022. Eligible patients were stratified based on whether or not they were referred to an outpatient specialty palliative care provider. Groups were compared based on clinical factors [age, cancer site, stage, primary versus recurrent disease status, body mass index (BMI)], and SDOH (race, ethnicity, primary language, insurance status, having a primary care provider (PCP), distance from the hospital, rurality, and Area Deprivation Index (ADI). Descriptive statistics and multivariable logistic regression were performed, and odds ratios were calculated. During the study period, 432 gynecologic oncology patients were eligible for referral to outpatient specialty palliative care, of which 191 (44%) were referred and 146 (34%) ultimately saw a palliative care provider. Patients who received a palliative care referral more frequently had recurrent disease and lower BMI. Patients were referred to a palliative care provider less commonly if they lived in a rural or disadvantaged (>70th percentile ADI) county, lived further from a National Cancer Institute (NCI)-designated cancer center, or if they were established with a PCP. On multivariable logistic regression evaluating rurality, distance, deprivation, and primary care access, only rurality and primary care access remained significant. Rural patients were less likely to be referred to a palliative care provider [odds ratio (OR) 0.3, 95% confidence interval (CI): 0.17-0.54, P<0.001], and patients without a PCP were more likely to be referred to palliative care provider (OR 1.8, 95% CI: 1.1-2.95, P=0.01). Gynecologic cancer patients were less commonly referred to outpatient specialty palliative care if living in a distant, rural or disadvantaged county or if established with primary care. For our patient population, rurality and access to primary care were the primary SDOH driving referral to palliative care. This analysis demonstrates the importance of understanding effects of SDOH to tailor quality improvement interventions to prioritize the most pressing needs of a given patient population in a context-dependent manner.