An ED pilot intervention to facilitate outpatient acute care for cancer patients

Characteristics of unplanned hospitalisations among cancer patients in Singapore

INTRODUCTION

Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable.

METHODS

Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions.

RESULTS

Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED.

CONCLUSION

Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.

Cancer Patients' Prehospital Emergency Care: Post Hoc Analysis from the French Prospective Multicenter Study EPICANCER

Background: Very little data are available concerning the prehospital emergency care of cancer patients. The objective of this study is to report the trajectories and outcomes of cancer patients attended by prehospital emergency services. Methods: This was an ancillary study from a three-day cross-sectional prospective multicenter study in France. Adult patients with cancer were included if they called the emergency medical dispatch center Service d’Aide Médicale Urgente (SAMU). The study was registered on ClinicalTrials.gov (NCT03393260, accessed on 8th January 2018). Results: During the study period, 1081 cancer patients called the SAMU. The three most frequent reasons were dyspnea (20.2%), neurological disorder (15.4%), and fatigue (13.1%). Among those patients, 949 (87.8%) were directed to the hospital, among which 802 (90.8%) were directed to an emergency department (ED) and 44 (5%) were transported directly to an intensive care unit (ICU). A mobile intensive care unit (MICU) was dispatched 213 (31.6%) times. The decision to dispatch an MICU seemed generally based on the patient’s reason for seeking emergency care and the presence of severity signs rather than on the malignancy or the patient general health status. Among the patients who were directed to the ED, 98 (16.1%) were deceased on day 30. Mortality was 15.4% for those patients directed to the ED but who were not admitted to the ICU in the next 7 days, 28.2% for those who were admitted to ICU in the next 7 days, and 56.1% for those patients transported by the MICU directly to the ICU. Conclusion: Cancer patients attending prehospital emergency care were most often directed to EDs. Patients who were directly transported to the ICU had a high mortality rate, raising the question of improving triage policies.

Diminuer le recours au service des urgences pour les patients externes présentant des symptômes aigus de cancer : revue intégrative sur l’émergence des centres de soins d’urgence en cancérologie

Cette revue intégrative de la littérature avait pour but de cerner les possibilités de recherche en sciences infirmières concernant la gestion des symptômes aigus du cancer des patients externes dans les centres de soins d’urgence en cancérologie. Les patients aux prises avec des symptômes aigus du cancer (ex. fièvre, troubles gastro-intestinaux ou douleur non soulagée) venant d’un milieu de soins externes sollicitent principalement sur les services des urgences pour se faire évaluer et traiter. Cependant, ce modèle de soins n’est plus viable et fait ressortir les inefficacités du système de soins de santé. Les centres de soins d’urgence en cancérologie permettent aux patients qui présentent ces symptômes d’être traités par des spécialistes en oncologie au sein de centres de cancérologie pour patients externes. Malheureusement, les rares travaux de recherche sur les centres de soins d’urgence en cancérologie, tant sur le plan opérationnel qu’expérimental, rendent difficile l’adoption de ce nouveau modèle de soins par d’autres. Voici les questions centrales qui ont guidé cette revue intégrative : 1) Quel est l’état de la science concernant les centres de soins d’urgence en cancérologie, et quelles sont les différences si on les compare aux services d’urgences en matière de traitement prodigué aux patients externes présentant des symptômes aigus du cancer? 2) Où sont les centres de soins d’urgences en cancérologie dans le monde, et que sait-on de leurs activités cliniques et modèles de dotation?

Reducing emergency department utilization for outpatient acute cancer symptoms: An integrative review on the advent of urgent cancer clinics

The purpose of this integrative literature review was to identify nursing research opportunities related to outpatient acute cancer symptom management within emerging urgent cancer clinics (UCCs). Patients with acute cancer symptoms (e.g., fevers, gastrointestinal disturbances, or uncontrolled pain) from ambulatory settings predominantly rely on emergency departments (EDs) for assessment and treatment. However, this model of care is no longer sustainable and emphasizes healthcare system inefficiencies. Urgent cancer clinics allow patients to have these symptoms treated by oncology experts within ambulatory cancer centres. Unfortunately, limited research on urgent cancer clinics both operationally and experientially makes it difficult for others to adopt this new model of care. The core questions that guided this integrative review were: 1) What is the state of the science regarding UCCs, and what differences exist when compared to EDs in the management of outpatient acute cancer symptoms? and 2) Where do UCCs exist around the world, and what is understood about UCCs related to clinic operations and staffing models?

Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD

RATIONALE & OBJECTIVE

Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.

STUDY DESIGN

Scoping review of quantitative and qualitative studies.

SETTING & POPULATION

Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).

SELECTION CRITERIA FOR STUDIES

MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.

DATA EXTRACTION

Intervention and study characteristics were extracted using standardized tools.

ANALYTICAL APPROACH

Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.

RESULTS

77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.

LIMITATIONS

Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.

CONCLUSIONS

Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.

Treatment-Related Complications of Systemic Therapy and Radiotherapy

Importance

Systemic therapy and radiotherapy can be associated with acute complications that may require emergent care. However, there are limited data characterizing complications and the financial burden of cancer therapy that are treated in emergency departments (EDs) in the United States.

Objectives

To estimate the incidence of treatment-related complications of systemic therapy or radiotherapy, examine factors associated with inpatient admission, and investigate the overall financial burden.

Design, Setting, and Participants

A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was performed. Between January 2006 and December 2015, there was a weighted total of 1.3 billion ED visits; of these, 1.5 million were related to a complication of systemic therapy or radiotherapy for cancer. Data analysis was conducted from February 22 to December 23, 2018. External cause of injury codes, Clinical Classifications Software, International Classification of Diseases, Ninth Revision, Clinical Modification, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), Clinical Modification codes were used to identify patients with complications of systemic therapy or radiotherapy.

Main Outcomes and Measures

Patterns in treatment-related complications, patient- and hospital-related factors associated with inpatient admission, and median and total charges for treatment-related complications were the main outcomes.

Results

Of the 1.5 million ED visits included in the analysis, 53.2% of patients were female and mean age was 63.3 years. Treatment-related ED visits increased by a rate of 10.8% per year compared with 2.0% for overall ED visits. Among ED visits, 90.9% resulted in inpatient admission to the hospital and 4.9% resulted in death during hospitalization. Neutropenia (136 167 [8.9%]), sepsis (128 171 [8.4%]), and anemia (117 557 [7.7%]) were both the most common and costliest (neutropenia: $5.52 billion; sepsis: $11.21 billion; and anemia: $6.78 billion) complications diagnosed on presentation to EDs; sepsis (odds ratio [OR], 21.00; 95% CI, 14.61-30.20), pneumonia (OR, 9.73; 95% CI, 8.08-11.73), and acute kidney injury (OR, 9.60; 95% CI, 7.77-11.85) were associated with inpatient admission. Costs related to the top 10 most common complications totaled $38 billion and comprised 48% of the total financial burden of the study cohort.

Conclusions and Relevance

Emergency department visits for complications of systemic therapy or radiotherapy increased at a 5.5-fold higher rate over 10 years compared with overall ED visits. Neutropenia, sepsis, and anemia appear to be the most common complications; sepsis, pneumonia, and acute kidney injury appear to be associated with the highest rates of inpatient admission. These complications suggest that significant charges are incurred on ED visits.

Taking care of our own: A narrative review of cancer care services-led models of care providing emergent care to patients with cancer

PURPOSE

To synthesise available evidence on cancer care services-led models of care in the acute care setting that aim to reduce emergency presentations and/or hospital admissions for patients with cancer.

METHODS

A narrative review of studies describing models of care for patients with cancer and emergent healthcare needs was undertaken. Four databases were searched using keywords to identify primary research or quality improvement articles published between January 2005-June 2017.

RESULTS

After a systematic search, 22 studies were included in the review. The methodological quality of the included studies was poor when assessed using the Mixed Methods Appraisal Tool. Most studies were retrospective and set in a single centre. The overarching outcomes associated with the most commonly described models of care (telephone advice services and/or unplanned care and assessment units) were improved coordination of care/continuity of care, prompt access to specialist care, reduced utilisation of emergency departments, fewer hospital admissions and reduced cost. At the time of this review, evaluation of Nurse Practitioner-led services and acute oncology services had been limited.

CONCLUSIONS

Findings indicate several models of care reduce emergency presentations and/or hospitalisations for those living with cancer and improve patient outcomes. What remains unclear is which underlying mechanisms reduce emergency presentations and/or hospitalisations for patients with cancer and whether successful models of care are uniquely suited to specific contexts of care or applicable across different healthcare settings. More research is needed to assist healthcare services to develop and evaluate models of care to address the emergent needs of people with cancer.

Treat-and-Release Emergency Department Utilization by Patients With Gynecologic Cancers

PURPOSE:

Seventeen percent of patients with cancer visit the emergency department (ED) annually, often with nonemergent complaints. We sought to describe the burden of treat-and-release ED utilization by patients with gynecologic cancers and to identify opportunities for improved triage.

MATERIALS AND METHODS:

Patients with gynecologic cancer diagnoses who were treated and released were identified within the Nationwide Emergency Department Sample, a stratified sample of US hospital-based ED visits, from 2009 to 2013. Sample weights were applied to generate national estimates. Associations with visit charges were assessed with weighted multivariable linear regression.

RESULTS:

Between 2009 and 2013, there were an estimated 174,092 annual treat-and-release ED visits by patients with gynecologic cancer (95% CI, 163,480 to 184,703 visits), which corresponded to $736 million in annual charges with an average visit charge of $4,232 (95% CI, $4,099 to $4,366). Annual visits and total charges increased significantly over the 5 years under study. Visits were more frequent for patients with cervical cancer (44.1%) versus ovarian (27.8%) and uterine (24.6%) cancer. These patients were younger and more likely to be from low socioeconomic status areas. The most common primary diagnoses were similar across cancers, including abdominal pain (10.5%), chest pain (6.1%), and urinary tract infection (5.2%). The most frequent diagnostics were culture/smear, computed tomography scan, and x-ray, and the most frequent therapeutic procedures included wound care, transfusion, and paracentesis.

CONCLUSION:

Patients with gynecologic cancers, and cervical cancer in particular, are frequently seen in the ED with issues that could be less expensively managed in an outpatient clinic or urgent care setting. Visit frequency, but not per-visit cost, is increasing over time.

Best Practices for Reducing Unplanned Acute Care for Patients With Cancer

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.

Emergency oncology: development, current position and future direction in the USA and UK

The need for supportive and palliative care services in patients with cancer is well established. However, the emerging unique challenges of acutely unwell patients with cancer necessitate the need for research into the optimal strategies and pathways for their management. The clinical challenges of emergency oncology alongside its increasing financial burden have led to an interest as to the best strategies for delivering this care. In the USA and UK, varying models of emergency and acute care are developing. There is a clear need for non-oncology physicians with an interest in the management of oncological emergencies to be at the heart of this work. This paper considers the current situation in the USA and UK and the future directions for the delivery of this care.