From metrics to practice: identifying preventable emergency department visits for patients with cancer

PURPOSE: To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis. METHODS: This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics. RESULTS: Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48). CONCLUSION: The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

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Observation Unit Use Among Patients with Cancer Following Emergency Department Visits: Results of a Multicenter Prospective Cohort from CONCERN

Academic Emergency Medicine ◽

10.1111/acem.14392 ◽

2021 ◽

Author(s):

Adam D. Klotz ◽

Jeffrey M. Caterino ◽

Danielle Durham ◽

Juan Felipe Rico ◽

Daniel J. Pallin ◽

...

Keyword(s):

Emergency Department ◽

Prospective Cohort ◽

Emergency Department Visits ◽

Observation Unit ◽

Patients With Cancer ◽

Multicenter Prospective Cohort

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Emergency Department Visits for Opioid Overdoses Among Patients With Cancer

JNCI Journal of the National Cancer Institute ◽

10.1093/jnci/djz233 ◽

2019 ◽

Vol 112 (9) ◽

pp. 938-943 ◽

Cited By ~ 5

Author(s):

Vikram Jairam ◽

Daniel X Yang ◽

James B Yu ◽

Henry S Park

Keyword(s):

At Risk ◽

Emergency Department ◽

Statistical Tests ◽

Temporal Trends ◽

The United States ◽

Emergency Department Visits ◽

Multivariable Logistic Regression Analysis ◽

Opioid Overdose ◽

Patients With Cancer ◽

Ed Visits

Abstract Background Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. Methods The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. Results Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. Conclusions Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.

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Emergency department visits for prescription and synthetic opioid overdoses among patients with cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.6579 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 6579-6579

Author(s):

Vikram Jairam ◽

Daniel X. Yang ◽

James B. Yu ◽

Henry S. Park

Keyword(s):

Cervical Cancer ◽

Emergency Department ◽

Cancer Patients ◽

The United States ◽

Emergency Department Visits ◽

Cancer Site ◽

Opioid Overdose ◽

Patients With Cancer ◽

Rate Of Increase ◽

Ed Visits

6579 Background: Patients with cancer may be at high risk of opioid dependence due to physical and psychosocial factors, although little data exists to inform providers and policymakers. Our aim is to examine overdoses from prescription and synthetic opiates leading to emergency department (ED) visits among patients with cancer in the United States. Methods: The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS) was queried for all patient visits with a primary diagnosis of prescription or synthetic opioid overdose between 2006 and 2015. Baseline differences between patients with and without cancer were assessed using chi-square and ANOVA testing. Overdose rates by primary cancer site were normalized using prevalence data from the Surveillance, Epidemiology, and End Results (SEER) Program. Weighted frequencies were used to create national estimates for all data analyses. Results: There were 682,820 weighted ED visits for synthetic opioid overdose, among which 34,547 (5.1%) visits were also associated with a diagnosis of cancer. During this timeframe, ED visits for opioid overdose among patients with cancer increased 2.5-fold, compared to 1.7-fold among those without cancer. 16.5% of patients with cancer had metastatic disease. Patients with cancer presenting for opioid overdose had higher risk of hospital admission (74.8% vs 49.6%), respiratory intubation (13.2% vs 12.2%), mortality (2.1% vs 1.1%), and cost-of-hospital-stay ($32,665 vs $31,824) compared to their non-cancer counterparts (all P < 0.05). Primary cancers with the highest normalized overdose rates (ED visits per 10,000 patients) were esophagus (134), liver & intrahepatic bile duct (124), and cervical cancer (124). Other common cancers had the following normalized overdose rates: lung (105), head and neck (70), and breast (26). Conclusions: Approximately 5% of all ED visits due to prescription and synthetic opioid overdose are among patients with cancer. The rate of increase in ED visits due to opioid overdose from cancer patients was nearly 50% higher than that from non-cancer patients over the 10-year study period. Patients with esophageal, liver, and cervical cancer may be at highest risk.

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Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer

JCO Oncology Practice ◽

10.1200/op.20.00617 ◽

2021 ◽

pp. OP.20.00617

Author(s):

Arthur S. Hong ◽

Hannah Chang ◽

D. Mark Courtney ◽

Hannah Fullington ◽

Simon J. Craddock Lee ◽

...

Keyword(s):

Emergency Department ◽

Acute Care ◽

Emergency Department Visits ◽

University Hospital ◽

Urgent Care ◽

Telephone Triage ◽

Patients With Cancer ◽

Oncology Care ◽

Ed Visits ◽

The University

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

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Correction to: Preventing emergency department visits among patients with cancer: a scoping review

Supportive Care in Cancer ◽

10.1007/s00520-020-05584-w ◽

2020 ◽

Vol 28 (9) ◽

pp. 4095-4096

Author(s):

Scott W. Kirkland ◽

Miriam Garrido-Clua ◽

Daniela R. Junqueira ◽

Sandra Campbell ◽

Brian H. Rowe

Keyword(s):

Emergency Department ◽

Scoping Review ◽

Emergency Department Visits ◽

Patients With Cancer

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Palliative home care and emergency department visits in the last 30 and 90 days of life: a retrospective cohort study of patients with cancer

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2021-002889 ◽

2021 ◽

pp. bmjspcare-2021-002889

Author(s):

Jennifer Mracek ◽

Madalene Earp ◽

Aynharan Sinnarajah

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Home Care ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Emergency Department Visits ◽

Palliative Home Care ◽

Patients With Cancer ◽

Diagnosis Of Cancer ◽

Ed Visits

ObjectivesEvaluate the association of specialist palliative home care (HC) on emergency department (ED) visits in the 30 and 90 days prior to death.MethodsThis retrospective cohort study using administrative data identified 6976 adults deceased from cancer between 2008 and 2015, living ≥180 days after diagnosis of cancer, and residing in the urban Calgary Zone of Alberta Health Services. All palliative HC and generalist HC services were examined. Regression analyses examined the relationships of HC type to ED visits in the last 30 or 90 days of life.ResultsIn the last 30 days of life, compared with patients receiving palliative HC, patients receiving only generalist HC, or no HC, were more likely to visit the ED (OR)generalist-HC 1.19; 95% CI 1.06 to 1.34; ORno-HC 1.54; 95% CI 1.31 to 1.82). In the last 90 days of life, compared with patients receiving palliative HC, those receiving generalist HC (OR 1.48; 95% CI 1.32 to 1.67) and no HC (OR 1.66; 95% CI 1.39 to 1.99) had increased odds of visiting the ED.ConclusionsReceiving generalist HC and no HC was associated with increased odds of visiting the ED in the last 30 and 90 days of life, when compared with patients receiving palliative HC. Improving access to palliative HC for patients at high risk of visiting the ED may reduce ED visits and acute care costs and improve quality of life in the last 90 days of life.

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Best Practices for Reducing Unplanned Acute Care for Patients With Cancer

Journal of Oncology Practice ◽

10.1200/jop.17.00081 ◽

2018 ◽

Vol 14 (5) ◽

pp. 306-313 ◽

Cited By ~ 29

Author(s):

Nathan R. Handley ◽

Lynn M. Schuchter ◽

Justin E. Bekelman

Keyword(s):

Emergency Department ◽

Best Practices ◽

Acute Care ◽

Clinical Pathways ◽

Optimal Strategies ◽

Emergency Department Visits ◽

Professional Organizations ◽

Early Palliative Care ◽

Patients With Cancer ◽

Unplanned Admissions

Variation and cost in oncology care represent a large and growing burden for the US health care system, and acute hospital care is one of the single largest drivers. Reduction of unplanned acute care is a major priority for clinical transformation in oncology; proposed changes to Medicare reimbursement for patients with cancer who suffer unplanned admissions while receiving chemotherapy heighten the need. We conducted a review of best practices to reduce unplanned acute care for patients with cancer. We searched PubMed for articles published between 2000 and 2017 and reviewed guidelines published by professional organizations. We identified five strategies to reduce unplanned acute care for patients with cancer: (1) identify patients at high risk for unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new loci for urgent cancer care; and (5) use early palliative care. We assessed each strategy on the basis of specific outcomes: reduction in emergency department visits, reduction in hospitalizations, and reduction in rehospitalizations within 30 days. For each, we define gaps in knowledge and identify areas for future effort. These five strategies can be implemented separately or, with possibly more success, as an integrated program to reduce unplanned acute care for patients with cancer. Because of the large investment required and the limited data on effectiveness, there should be further research and evaluation to identify the optimal strategies to reduce emergency department visits, hospitalizations, and rehospitalizations. Proposed reimbursement changes amplify the need for cancer programs to focus on this issue.

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