Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits

A concept analysis of transitional care for people with cancer

AIM

Transitional care as the journey between different caregivers in multiple healthcare centres is crucial for the provision of care to people with cancer, but it is often complex and poorly coordinated. This study aimed to analyse the concept of transitional care for people with cancer.

DESIGN

Rodgers' evolutionary concept analysis.

METHODS

A systematic literature search was conducted on the databases of PubMed (including MEDLINE), EMBASE, Scopus and Web of Science to retrieve articles published between 2000 and 2022.

RESULTS

Twenty-nine eligible articles were selected and their findings were classified in terms of related concepts and alternative terms, antecedents, attributes and consequences. Attributes included three main categories, namely 'nurse-related attributes', 'organisation-related attributes' and 'patient-related attributes'. Antecedents of transitional care for people with cancer were categorized into two main categories: 'patient-related antecedents' and 'caregiver-related antecedents'. Consequences were categorized into 'psychological consequences' and 'objective consequences'.

Acute home-based care for patients with cancer to avoid, substitute, and follow emergency department visits: a conceptual framework using Porter’s Five Forces

Background

Patients with cancer constitute a large and increasing segment of patients who receive unscheduled hospital-based care due to treatment-related symptoms and disease progression. The initial hospital-based touchpoint for these unscheduled hospitalizations is often the emergency department. Traditional models of emergency department and inpatient hospital-based care are saturated and incapable of scaling to accommodate the future, increased needs projected for this population. New models of care are necessary to address this gap. Acute home-based care is a promising tool potentially providing patient-centric, efficient care to eligible patients.

Methods

We applied Porter’s Five Forces framework that addresses the bargaining power of buyers and suppliers, threat of substitutes and new entrants, and industry rivalries plus the sixth force of regulation to clarify the factors that will promote or challenge the adoption of a home-based cancer care referral model before or following emergency department visits. Exploring this framework provides insights into the complexities of scaling an acute home-based cancer care model and highlights ways for health systems including hospitals, emergency departments, physician groups, and individual emergency physicians and oncologists to optimize their roles in this emerging model of care.

Results

We found that current workforce shortages, as well as workflow, infrastructure, and regulatory complexities, pose major challenges that unless carefully addressed may restrict the growth of acute home-based cancer care. Additional uncertainties persist around appropriate payment models and the competitive landscape. Key promoting factors include the recognized need in the cancer community and among payers for new models to decrease unscheduled hospitalizations and emergency department visits as well as the uptake of home-based and technology-enabled solutions during the COVID-19 pandemic. A better understanding of these forces helps to clarify the risks and opportunities as new entrants build their programs.

Conclusions

Acute home-based cancer care is a promising tool to complement traditional outpatient clinics, emergency departments, and inpatient hospital-based models of cancer care. New technologies and policies increasingly enable a broader scope of cancer care in the home setting.

Evaluation of quality indicators near death in older adult cancer decedents in Japan: A nationwide retrospective cohort study

OBJECTIVES

End-of-life cancer care is important; however, data on hospitalization and costs for older patients have been lacking. We aimed to examine quality indicators and costs for older patients in Japan.

METHODS

Using the Diagnosis Procedure Combination database, a national database of acute-care hospitals in Japan, we retrospectively collected data on cancer decedents aged ≥65 years. We evaluated the quality indicators (hospitalizations, length of stay in the hospital, emergency hospitalizations, emergency hospitalizations using an ambulance, intensive care unit [ICU] admissions, length of stay in the ICU, interval between last chemotherapy use and death, and chemotherapy within 14 days before death) and hospitalization costs at 30, 90 and 180 days before death. We compared the outcomes across age groups (65-74, 75-84 and ≥ 85 years).

RESULTS

Between January 2011 and March 2015, we identified 369 616 cancer decedents. From 180 to 30 days before death, there were increases in emergency hospitalizations, emergency hospitalizations using an ambulance, and the mean costs per hospital day. Overall, 16.7% of patients receiving chemotherapy last received this treatment on the day before death or the day of death. Costs decreased with increasing age. The group aged ≥85 years had the shortest hospital and ICU stays and the lowest multiple hospitalizations, ICU admissions, chemotherapy within 14 days before death, and costs.

CONCLUSIONS

Many older adult patients had emergency hospitalizations and received chemotherapy just prior to death, and there is room for improvement in appropriate end-of-life care. Oldest old patients consumed relatively few medical resources.

Emergency department visits among people with cancer: Frequency, symptoms, and characteristics

OBJECTIVE

People with cancer are increasingly more likely to visit an emergency department for acute care than the general population. They often have long wait times and more exposure to infection and receive treatment from staff less experienced with cancer-related problems. Our objective was to examine emergency department (ED) visits among people with cancer to understand how often and why they seek care.

METHODS

We conducted a retrospective study of ED visits using the National Syndromic Surveillance Program BioSense Platform. Cancer reported during an ED visit was identified using International Classification of Diseases, Tenth Revision codes for any cancer type, including bladder, breast, cervical, colorectal, kidney, liver, lung, ovary, pancreas, prostate, or uterine cancers. Symptoms prompting the visit were identified for people with cancer who visited EDs in the United States from June 2017 to May 2018 in ≈4500 facilities, including 3000 EDs in 46 states and the District of Columbia (66% of all ED visits during a 1-year period).

RESULTS

Of 97 million ED visits examined, 710,297 (0.8%) were among people with cancer. Percentages were higher among women (50.1%) than men (49.5%) and among adults aged ≥65 years (53.6%) than among those ≤64 years (45.7%). The most common presenting symptoms were pain (19.1%); gastrointestinal (13.8%), respiratory (11.5%), and neurologic (5.3%) complaints; fever (4.9%); injury (4.1%); and bleeding (2.4%). Symptom prevalence differed significantly by cancer type.

CONCLUSIONS

The Centers for Medicare & Medicaid Services encourages efforts to reduce acute care visits among people with cancer. We characterized almost 70% of ED visits among this population.

Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland

Background

People with advanced cancer frequently attend unscheduled care, but little is known about the factors influencing presentations. Most research focuses on accident and emergency (A&E) and does not consider GP out-of-hours (GPOOH).

Aim

To describe the frequency and patterns of unscheduled care use by people with cancer in their last year of life and to examine the associations of demographic and clinical factors with unscheduled care attendance.

Design and setting

Retrospective cohort study of all 2443 people who died from cancer in Tayside, Scotland, during 2012–2015. Clinical population datasets were linked to routinely collected clinical data using the Community Health Index (CHI) number.

Method

Anonymised CHI-linked data were analysed in SafeHaven, with descriptive analysis, using binary logistic regression for adjusted associations.

Results

Of the people who died from cancer, 77.9% (n = 1904) attended unscheduled care in the year before death. Among unscheduled care users, most only attended GPOOH (n = 1070, 56.2%), with the rest attending A&E only (n = 204, 10.7%), or both (n = 630, 33.1%). Many attendances occurred in the last week (n =1360, 19.7%), last 4 weeks (n = 2541, 36.7%), and last 12 weeks (n = 4174, 60.3%) of life. Age, sex, deprivation, and cancer type were not significantly associated with unscheduled care attendance. People living in rural areas were less likely to attend unscheduled care: adjusted odds ratio (aOR) 0.64 (95% confidence interval = 0.50 to 0.82). Pain was the commonest coded clinical reason for presenting (GPOOH: n = 482, 10.5%; A&E: n = 336, 28.8%). Of people dying from cancer, n = 514, 21.0%, were frequent users (≥5 attendances/year), and accounted for over half (n = 3986, 57.7%) of unscheduled care attendances.

Conclusion

Unscheduled care attendance by people with advanced cancer was substantially higher than previously reported, increased dramatically towards the end of life, was largely independent of demographic factors and cancer type, and was commonly for pain and palliative care.

Decline of Physical Activity in Terminally Ill Patients Could Be Useful for Predicting Short-Term Survival

BACKGROUND

Although it is recommended that all terminally ill patients receive advance care planning (ACP), this is occasionally challenging because of the difficulty in predicting survival. There are some indexes for predicting survival, but few are accurate, especially at the terminal stages of illness.

METHODS

Twenty-two patients at the terminal stages of cancer were retrospectively analyzed. We assessed their physical activity and condition using activities of daily living (ADL) scores for 1 month before the death. The ADL scores included 7 items: walking, bathing, grooming, dressing, eating, transferring, and toileting.

RESULTS

Survival time after the first decline of physical activity was calculated (median: 13 days, 95% confidence interval [95% CI]: 5.6-20.4 days). Survival time after the second (median: 5 days, 95% CI: 0-10.9 days), third (median: 5 days, 95% CI: 0-13.4 days), and fourth (median time: 1 day, 95% CI: not applicable due to small size) decline of physical activity was also calculated.

CONCLUSION

Change in physical activity seems helpful for estimating survival time, especially at the end of life, and this index could be useful for coordinating final ACP.

Reasons for emergency department visits among advanced cancer patients in their last week of life

For advanced cancer patients, an emergency department (ED) visit in the last week of life may result in aggressive care that is inappropriate and futile. The objective of this study is to explore the characteristics of advanced cancer patients who present to ED in the last week of life. Specifically, we describe the spectrum of presenting symptoms. This was a retrospective cross-sectional study of ED attendances in the Singapore General Hospital during a one-year period. The electronic medical record system was used to retrieve demographic data, characteristics of the ED visits and presenting complaints. A total of 145 patients with advanced cancer dying in hospital within seven days of an ED visit were included. Breathlessness was the most common reason for presenting to ED (85 patients, 58.62%), followed by pain (50 patients, 34.48%), generalised weakness or lethargy (39 patients, 26.90%) and decreased appetite or anorexia (35 patients, 24.14%). Strategies to improve end-of-life care can focus on pre-emptive management of breathlessness and pain. Community programmes can also help prepare families for symptoms like generalised weakness and appetite loss which may signal a progression of the disease. Supportive and palliative care interventions will need to be implemented in the ED setting to better manage the symptoms suffered by these advanced cancer patients.