Educational training tied to higher pediatric palliative care referrals in single-center study

Children with hematologic malignancies who were clinically eligible for pediatric palliative care were referred far more often after their oncologists completed a structured educational program, according to a quasi-experimental study published in BMC Pediatrics. Before the training, fewer than one in six eligible children at the single center received a documented palliative care referral; afterward, nearly two in three did, even though the proportion of children meeting referral criteria remained essentially unchanged. The findings suggest that clinician-related factors, rather than shifts in patient need, may contribute to late and inconsistent palliative care integration in pediatric oncology.

Timely integration of pediatric palliative care alongside disease-directed treatment is a recommended standard, yet referrals in practice often arrive late or not at all. To measure whether provider education could narrow this gap, researchers at the study center screened children younger than 18 years with hematologic malignancies using the Paediatric Palliative Screening Scale, version 3, in which scores of 15 or higher indicate referral eligibility. The study used a separate-samples pretest–posttest design: 55 children were screened in August 2022, a multimodal educational intervention for pediatric oncologists was delivered in September 2022, and a new cohort of 50 children was screened in October 2022. The primary outcome was a documented palliative care referral among children who met the eligibility threshold. The study was registered with the Clinical Trials Registry of India on 1 July 2022 under identifier CTRI/2022/07/044157.

Across the two screening periods, the assessed need for palliative care was stable. PaPaS eligibility was 34.5 percent in the pre-intervention cohort and 34.0 percent in the post-intervention cohort, and total PaPaS scores did not differ significantly between periods. What changed was referral behavior. Among eligible children, documented referrals rose from 15.8 percent, or 3 of 19 children, before the intervention to 64.7 percent, or 11 of 17 children, afterward. The difference was statistically significant on a two-sided Fisher’s exact test, with a p value of 0.005. The odds ratio was 9.78, with a 95 percent confidence interval of 2.01 to 47.68, and the relative risk was 4.10, with a 95 percent confidence interval of 1.37 to 12.26. The absolute risk difference was 48.9 percentage points, with a confidence interval of 20.9 to 76.9.

One screening domain moved alongside the referral increase: Domain 4, which captures the preferences of health professionals, rose after the intervention. The authors caution, however, that this domain is rated by the clinicians themselves and is therefore susceptible to assessment bias, so it should be interpreted with care.

The study’s design carries limitations that the authors acknowledge. It was conducted at a single center with separate samples before and after the intervention, meaning the two cohorts were not the same children, and the post-intervention observation window was short. The PaPaS assessment was not performed independently of the treating team, and the study did not evaluate whether the referral gains persisted over time. The authors call for larger studies with independent PaPaS assessment, extended follow-up, and explicit evaluation of the sustainability of the effect before the approach is generalized.

Within those constraints, the results carry an implementation message. Evidence from pediatric oncology in low- and middle-income settings has been limited, and this study suggests that clinician-level barriers to referral may be addressable through structured education. Because the proportion of eligible children stayed flat while referral behavior changed sharply, the intervention appears to have been associated with the decision to refer rather than with any change in underlying clinical need. The authors conclude that educational strategies may help close the under-referral gap, positioning provider training as a practical complement to structured screening tools like PaPaS in settings where pediatric palliative care referrals remain late and inconsistent.

Subject of Research: Effect of educational training on pediatric palliative care referrals for children with hematologic malignancies

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

Article References: Nayak, M. G., Ghoshal, A., Bhat K, V., Damani, A., Nair, S., Rao, K. S., MV, A., Pai, R. R., Uppi, M., Serrao, A. J., Lakshmi R, V., Kotian, D., & Salins, N. (2026). Educational training and pediatric palliative care referrals in hematologic malignancies: a quasi‑experimental study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07906-z

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07906-z

Keywords: pediatric palliative care, pediatric oncology, hematologic malignancies, PaPaS screening scale, educational intervention, quasi-experimental study, referral practices, clinician education, implementation gap, BMC Pediatrics, Educational, training