title: Referral Criteria for Outpatient Palliative Cancer Care: A Systematic Review.
abstract: Outpatient palliative care clinics facilitate early referral and are associated with improved outcomes in cancer patients. However, appropriate candidates for outpatient palliative care referral and optimal timing remain unclear. We conducted a systematic review of the literature to identify criteria that are considered when an outpatient palliative cancer care referral is initiated.
  
  
  
  We searched Ovid MEDLINE (1948-2013 citations) and Ovid Embase (1947-2015 citations) for articles related to outpatient palliative cancer care. Two researchers independently reviewed each citation for inclusion and extracted the referral criteria. The interrater agreement was high (κ = 0.96).
  
  
  
  Of the 186 publications in our initial search, 21 were included in the final sample. We identified 20 unique referral criteria. Among these, 6 were recurrent themes, which included physical symptoms (n = 13 [62%]), cancer trajectory (n = 13 [62%]), prognosis (n = 7 [33%]), performance status (n = 7 [33%]), psychosocial distress (n = 6 [29%]), and end-of-life care planning (n = 5 [24%]). We found significant variations among the articles regarding the definition of advanced cancer and the assessment tools for symptom/distress screening. The Edmonton Symptom Assessment Scale (n = 7 [33%]) and the distress thermometer (n = 2 [10%]) were used most often. Furthermore, there was a lack of consensus in the cutoffs in symptom assessment tools and timing for outpatient palliative care referral.
  
  
  
  This systematic review identified 20 criteria including 6 recurrent themes for outpatient cancer palliative care referral. It highlights the significant heterogeneity regarding the timing and process for referral and the need for further research to develop standardized referral criteria.
  
  
  
  Outpatient palliative care clinics improve patient outcomes; however, it remains unclear who is appropriate for referral and what is the optimal timing. A better understanding of the referral criteria would help (a) referring clinicians to identify appropriate patients for palliative care interventions, (b) administrators to assess their programs with set benchmarks for quality improvement, (c) researchers to standardize inclusion criteria, and (d) policymakers to develop clinical care pathways and allocate appropriate resources. This systematic review identified 20 criteria including 6 recurrent themes for outpatient palliative cancer care referral. It represents the first step toward developing standardized referral criteria.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA dhui@mdanderson.org.
authors.forename: David
authors.initials: D
authors.lastname: Hui
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA Department of Palliative Care, Tan Tock Seng Hospital, Singapore.
authors.forename: Yee-Choon
authors.initials: YC
authors.lastname: Meng
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Bruera
authors.affiliation: Research Medical Library, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Yimin
authors.initials: Y
authors.lastname: Geng
authors.affiliation: Research Medical Library, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Ron
authors.initials: R
authors.lastname: Hutchins
authors.affiliation: Department of Palliative Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan.
authors.forename: Masanori
authors.initials: M
authors.lastname: Mori
authors.affiliation: Oncological Palliative Medicine, Hematology-Oncology, Cantonal Hospital, St. Gallen, Switzerland.
authors.forename: Florian
authors.initials: F
authors.lastname: Strasser
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
mesh_terms: D006801:Humans; D009369:Neoplasms / Q000523:psychology / Q000628:therapy*; D010045:Outpatients; D010166:Palliative Care; D011379:Prognosis; D012017:Referral and Consultation; D013727:Terminal Care
keywords: Access; Health systems; Neoplasms; Outpatients; Palliative care; Referral; Standards