Outpatient Oncology Records Lack Goals-of-Care Documentation for Most Older Adults

Bridging the Communication Gap in Advanced Cancer Care

Effective management of complex chronic conditions requires rigorous documentation and clear communication across the multidisciplinary care team. In oncology, coordination between primary care providers and specialists is often hindered by fragmented information sharing and uncertainty regarding specific roles in the care continuum [1]. For older adults, this complexity is compounded by age-related vulnerabilities such as sarcopenia (the progressive loss of skeletal muscle mass and strength), which can significantly impact treatment tolerance and prognosis [2]. While clinical guidelines emphasize the importance of exercising clinical judgment to align medical strategies with a patient's specific health condition and personal values, the systematic implementation of these discussions remains a challenge [3, 4]. Ensuring that patient preferences are transparently reported is essential for maintaining the clarity and reliability of the care plan [5]. To address this gap, a retrospective study recently examined how consistently these critical goals-of-care conversations are captured in the outpatient setting for older adults with advanced malignancies.

Quantifying Documentation Rates in Outpatient Settings

The researchers conducted a retrospective cohort study to examine the prevalence of goals-of-care conversation documentation among older adults with advanced cancer. The study population consisted of 7,743 patients aged 65 years or older who received outpatient treatment at an academic cancer center in Boston, Massachusetts, between 2016 and 2019. To identify these conversations within the electronic health record, the authors utilized natural language processing, a machine-learning technique that scans unstructured clinical notes for specific concepts rather than relying solely on billing codes. Advanced cancer was defined using a validated algorithm based on those billing codes. The analysis utilized univariate methods, including Mann-Whitney U tests (a statistical method used to compare differences between two independent groups for continuous variables like age) and chi-square tests (used for categorical variables like marital status), to compare patient characteristics and documentation rates. Among the 7,743 patients in the cohort, the researchers found that only 43% had at least one instance of documented goals-of-care conversations. This finding indicates that fewer than half of older adults with advanced cancer had their care preferences formally recorded in the outpatient oncology setting. The median age of the total cohort was 72 years, and 51% were female. Patients with documentation tended to be slightly older (median age 73 versus 71 years; p < 0.001) and were more likely to be single (34% versus 29%) rather than partnered (65% versus 70%; p < 0.001). Clinical outcomes also differed significantly based on documentation status, with higher mortality rates observed among patients who had documented conversations. Specifically, the 6-month mortality rate was 23% for those with documentation compared to 13% for those without (p < 0.001), while the 12-month mortality rate was 44% versus 23% (p < 0.001). Despite these differences in age, marital status, and mortality, the researchers observed no significant variations in documentation rates based on gender, race, or Hispanic ethnicity. For practicing oncologists, these data suggest that while documentation is more frequent in patients with a higher risk of near-term mortality, a substantial gap remains in capturing the values and preferences of the broader outpatient population before a crisis occurs.

Demographic and Social Predictors of Care Planning

The study cohort comprised older adults with a median age of 72 years, and 51% of the participants were female. When analyzing the characteristics of patients who had goals-of-care conversations recorded in their electronic health records, the researchers identified specific demographic trends that influence clinical practice. Patients with documentation were older than those without, with a median age of 73 years compared to 71 years (p < 0.001). This age gap suggests that clinicians may be more likely to initiate or record these critical discussions as patients advance in years, perhaps reflecting a perceived increase in the urgency of clarifying treatment preferences for the oldest adults. Social support structures also appeared to influence the likelihood of documentation within the outpatient oncology setting. The researchers found that patients with documented conversations were more often single (34%) compared to those without documentation (29%). Conversely, patients with documentation were less often partnered (65%) than those without (70%; p < 0.001). For the practicing oncologist, these figures indicate that patients lacking a primary partner or spouse are more frequently identified as needing formal documentation to ensure their medical wishes are known. Partnered patients might be assumed to have an informal surrogate readily available, potentially leading to lower rates of formal record-keeping and creating a risk of miscommunication if the partner is unavailable or unaware of specific end-of-life preferences. Despite the variations observed in age and marital status, other demographic factors did not appear to drive documentation rates. The study found that no significant differences in goals-of-care documentation were observed by gender, race, or Hispanic ethnicity. This lack of variation suggests that the current gaps in documentation are widespread across demographic groups rather than being concentrated within specific populations. Consequently, clinical interventions aimed at improving the capture of patient values must address systemic workflow barriers that affect the entire older adult oncology population.

Clinical Implications of Reactive Documentation

The study findings suggest that documentation of goals-of-care conversations often occurs reactively as a patient's health declines, rather than as a proactive component of routine outpatient oncology. Documentation of these conversations in the electronic health record is considered a cornerstone of high-quality cancer care, as it supports treatment decisions informed by patients' values, preferences, and priorities. Furthermore, it serves as a critical communication tool across the health care team to ensure that all providers are aligned with the patient's wishes. However, the researchers found that mortality rates were significantly higher among patients with documentation compared to those without, indicating that these records are frequently tied to the end-of-life period rather than early outpatient management. The data reveal a stark contrast in survival outcomes based on documentation status. Specifically, the 6-month mortality rate was 23% for patients with documentation versus 13% for those without (p < 0.001). This trend persisted at the one-year mark, where the 12-month mortality rate reached 44% for patients with documentation compared to 23% for those without (p < 0.001). For the practicing clinician, these figures highlight a significant gap in care delivery. While documentation is essential for guiding complex medical decisions, it is currently most prevalent among those with the highest immediate risk of death. This reactive pattern underscores the need for scalable interventions, such as automated electronic health record prompts or standardized intake questionnaires, to ensure that patient values and preferences are initiated and documented in routine care well before an acute clinical decline occurs.

References

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2. Cruz‐Jentoft AJ, Bahat G, Bauer JM, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing. 2018. doi:10.1093/ageing/afy169

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