At the tipping point, but yet not routine: Diffusion dynamics of inpatient palliative care

Background Early integration of specialised palliative care improves quality of life and outcomes in advanced cancer, yet its implementation in inpatient oncology remains inconsistent. This study evaluates the utilisation of specialised inpatient palliative care in German hospitals and interprets adoption patterns using Diffusion of Innovations theory. Methods We conducted a retrospective nationwide analysis of hospital cases reimbursed under the German diagnosis-related groups (DRG) system. The analysis included the most common oncological diseases and assessed utilisation of specialised inpatient palliative care overall and stratified by metastatic status, tumour entity, comorbidities, and treating medical specialties. Results Specialised inpatient palliative care was provided in 5.4% of hospital cases involving the most common malignant tumours. Among patients with organ metastases, utilisation increased to a median rate of 15.0% of hospital cases, with the highest rates observed in cases with brain (17.8%), bone (17.0%), and pleural metastases (16.1%). Palliative care involvement correlated positively with hospital mortality. Interpreted through diffusion of innovations theory, utilisation among patients with metastatic disease appears to have reached the tipping point associated with early adopters, while uptake among the early majority remains limited. Conclusion Despite longstanding guideline recommendations, specialised inpatient palliative care remains underutilised in German oncology care. From the perspective of diffusion of innovations theory, failure to move adoption beyond early adopters risks stagnation and prevents palliative care from becoming a routine component of inpatient oncology. To overcome this barrier, clinicians and policymakers should establish systematic referral pathways, implement interdisciplinary referral triggers, actively disseminate evidence on clinical effectiveness, increase awareness, strengthen palliative care training for healthcare professionals, and align reimbursement structures to support earlier and consistent palliative care integration.