Patterns of Goals-of-Care Documentation in the Outpatient Oncology Setting: A Retrospective Cohort Study of Older Adults with Advanced Cancer

Abstract

Background:

Documentation of goals-of-care conversations (GOCC) in the electronic health record (EHR) is considered a cornerstone of high-quality cancer care. When done well, it can support treatment decisions that are informed by patients’ values, preferences, and priorities and serve as a critical communication tool across the health care team. Although inpatient and palliative care settings have been studied extensively, less is known about GOCC documentation in outpatient oncology.

Aim:

We examined the prevalence of GOCC documentation among older adults with advanced cancer in the outpatient setting and identified patient-level factors related to documentation.

Design:

We conducted a retrospective cohort study using natural language processing (NLP)-assisted chart review to identify documentation of GOCC. Advanced cancer was defined using a validated algorithm based on billing codes. Univariate analyses employed Mann–Whitney U tests for continuous variables and chi-square tests for categorical variables.

Setting/Subjects:

The cohort included older adults aged >65 years with advanced cancer who received outpatient treatment at an academic cancer center in Boston, MA, between 2016 and 2019.

Results:

Among 7743 patients, 43% had at least one instance of GOCC documentation. The median age was 72 years, and 51% were female. Compared with patients without documentation, those with documentation were older (median 73 vs. 71 years, p < 0.001), more often single (34% vs. 29%), and less often partnered (65% vs. 70%, p < 0.001). Mortality rates were also higher among patients with documentation: 6-month mortality was 23% versus 13% (p < 0.001), and 12-month mortality was 44% versus 23% (p < 0.001). No significant differences were observed by gender, race, or Hispanic ethnicity.

Conclusions:

Fewer than half of older adults with advanced cancer had documented GOCC in outpatient oncology. This gap underscores the need for scalable interventions to ensure that values and preferences are initiated and documented in routine care.