Educational training and pediatric palliative care referrals in hematologic malignancies: a quasi‑experimental study

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Abstract
Background: Timely integration of pediatric palliative care (PPC) is recommended alongside disease-directed treatment, yet referrals remain late and inconsistent. Structured screening and provider education may address clinician-level barriers, but evidence from pediatric oncology in low- and middle-income settings is limited. This study evaluated whether an educational intervention for pediatric oncologists was associated with changes in PPC referral practices for children with haematological malignancies screened using the Paediatric Palliative Screening Scale (PaPaS). Methods: We conducted a single-centre quasi-experimental study using a separate-samples pretest–posttest design. Children aged < 18 years with haematological malignancies were screened during August 2022, followed by a multimodal educational intervention for pediatric oncologists in September 2022 and post-intervention screening in October 2022. PaPaS v3 scores ≥ 15 indicated referral eligibility. The primary outcome was documented PPC referral among eligible children. Referral proportions were compared using a two-sided Fisher’s exact test. Results: Among 105 enrolled children (55 pre-intervention; 50 post-intervention), PaPaS eligibility was similar between periods (34.5% vs. 34.0%). Referral among eligible children increased from 15.8% (3/19) before the intervention to 64.7% (11/17) after the intervention (Fisher’s exact p = 0.005; odds ratio 9.78, 95% CI 2.01–47.68; relative risk 4.10, 95% CI 1.37–12.26; absolute risk difference 48.9% points, 95% CI 20.9–76.9). Total PaPaS scores did not differ significantly. Domain 4, Preferences of health professionals, increased, although this clinician-rated domain is susceptible to assessment bias. Conclusion: The educational intervention was associated with a higher frequency of PPC referrals among clinically eligible pediatric oncology patients, despite a stable assessed need. These findings suggest that clinician-related factors may contribute to under-referral and that educational strategies may help address this implementation gap. Larger studies with independent PaPaS assessment, extended follow-up, and evaluation of sustainability are needed. Clinical trial registration: - CTRI/2022/07/044157; registered on 1 July 2022.
Funding Information
  • Manipal Academy of Higher Education, Manipal