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The impact of routine Edmonton symptom assessment system use on receiving palliative care services: results of a population-based retrospective-matched cohort analysis
  1. Lisa Barbera1,2,3,4,
  2. Rinku Sutradhar3,4,
  3. Craig C Earle3,4,
  4. Doris Howell4,5,
  5. Nicole Mittman6,
  6. Qing Li3,
  7. Deva Thiruchelvam3 and
  8. Hsien Seow3,7
  1. 1 Radiation Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
  2. 2 Oncology, University of Calgary, Calgary, Alberta, Canada
  3. 3 Institute for Clincal Evaluative Sciences, Toronto, Ontario, Canada
  4. 4 University of Toronto, Toronto, Ontario, Canada
  5. 5 Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
  6. 6 Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  7. 7 McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Lisa Barbera, Radiation Oncology, Tom Baker Cancer Centre, Calgary, Canada; lisa.barbera{at}


Background In 2007, Cancer Care Ontario began standardised symptom assessment as part of routine care using the Edmonton Symptom Assessment System (ESAS).

Aim The purpose of this study was to evaluate the impact of ESAS on receipt of palliative care when compared with a matched group of unexposed patients.

Design A retrospective-matched cohort study examined the impact of ESAS screening on initiation of palliative care services provided by physicians or homecare nurses. The study included adult patients diagnosed with cancer between 2007 and 2015. Exposure was defined as completing ≥1 ESAS during the study period. Using 4 hard and 14 propensity score-matched variables, patients with cancer exposed to ESAS were matched 1:1 to those who were not. Matched patients were followed from first ESAS until initiation of palliative care, death or end of study.

Results The final cohort consisted of 204 688 matched patients with no prior palliative care consult. The pairs were well matched. The cumulative incidence of receiving palliative care within the first 5 years was higher among those exposed to ESAS compared with those who were not (27.9% (95% CI: 27.5% to 28.2%) versus 27.9% (95% CI: 27.5% to 28.2%)), when death is considered as a competing event. In the adjusted cause-specific Cox proportional hazards model, ESAS assessment was associated with a 6% increase in palliative care services (HR: 1.06, 95% CI: 1.04 to 1.08).

Conclusion We have demonstrated that patients exposed to ESAS were more likely to receive palliative care services compared with patients who were not exposed. This observation provides real-world data of the impact of routine assessment with a patient-reported outcome.

  • cancer
  • clinical assessment
  • supportive care
  • symptoms and symptom management

Data availability statement

No data are available.

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  • Contributors All authors (LB, RS, CE, DH, NM, QL, DT and HS) made substantial contribution to the conception or design of the work; and the acquisition, analysis or interpretation of data for the work; drafting the work or revising it critically for important intellectual content. Final approval of the version to be published was provided by all the authors. Agreement to be accountable for all aspects of the work was given by LB, RS and QL.

  • Competing interests LB: Genentech (honorarium). DH: Carevive (consultancy fees, member of scientific advisory board).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.