Association of Inpatient and Outpatient Pediatric Palliative Care with Healthcare Utilization and End-of-Life Outcomes in Pediatric Oncology

Background: Pediatric palliative care (PPC) is associated with improved end-of-life (EOL) outcomes. Inpatient and outpatient PPC have unique roles during the disease course. Yet, it is unknown whether the location of PPC receipt (inpatient vs outpatient) is associated with healthcare utilization and EOL outcomes for pediatric oncology patients. Procedure: A retrospective single-institution chart review of pediatric patients (age 0-28) with cancer who died between January 2015 – December 2022 was performed to compare EOL outcomes and healthcare utilization metrics among only inpatient PPC, any outpatient PPC, and non-PPC recipients. Demographics and clinical factors were analyzed by location of PPC receipt. Results: Among 450 patients, 292 (64.9%) received PPC (inpatient only (35%), any outpatient (65%)). The proportion of patients who died without receiving PPC dropped from 69% to 22% following development of an outpatient PPC clinic (p<0.001). In the last six months, one month and week of life, inpatient PPC recipients spent more days admitted to the hospital and intensive care unit (all p<0.001), and had more intensive medical interventions performed (p<0.01). Outpatient PPC recipients were less likely to receive IV chemotherapy (p<0.01) or intubation (p=0.05), and more likely to receive hospice, die at home, and have an outpatient Do-Not-Resuscitate order (all p<0.001). Conclusions: PPC receipt substantially increased after the creation of an outpatient PPC clinic, suggesting that outpatient PPC is critical in the provision of PPC to children with cancer. Outpatient PPC was associated with fewer hospital days, IV chemotherapy and intubation at EOL, while improving hospice enrollment and home death.