Unplanned Hospitalization Among Individuals With Cancer in the Year After Diagnosis

Deconditioning in Hospitalized Patients with Cancer

OBJECTIVES

Provide an overview of hospital-associated deconditioning in hospitalized patients with cancer, including risk factors and trajectory of deconditioning. Discuss interdisciplinary roles in preventing deconditioning, best practices, and oncology nursing implications.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms Hospital*, Mobility, Immobility, Deconditioning, Cancer, and Oncology. Peer-reviewed research studies, review articles, and websites of professional organizations were reviewed to provide an overview on mobility concerns in hospitalized patients with cancer.

RESULTS

Thirty-eight references were included in this overview of hospital-associated deconditioning (HAD) in patients with cancer. HAD is a widespread phenomenon with grave consequences. Patients with cancer are particularly vulnerable to HAD due to their cancer diagnosis and treatment effects. Physical activity in hospitalized patients is one of the most important practices to prevent HAD and is achieved through standardized mobility assessment and interdisciplinary collaboration.

CONCLUSIONS

Promoting mobility in hospitalized patients with cancer is essential to prevent the complications of HAD.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are leaders of the interdisciplinary approach to enhance inpatient mobility. As they are most often at the bedside, nurses assess patients' level of mobility, recognize risk factors for HAD, and implement safe mobility interventions. Nurses experience barriers to promoting mobility including workforce shortages, high workloads, and competing priorities.

Unplanned Hospital Admissions in Patients With Solid Tumors in Brazil: Causes and Progressive Disease's Impact on Outcomes

PURPOSE

Most patients with cancer will be hospitalized throughout the disease course. However, most evidence on the causes and outcomes of these hospitalizations comes from administrative data or small retrospective studies from high-income countries.

METHODS

This study is a retrospective cohort of patients with solid tumors hospitalized from February 1, 2021, to December 31, 2021, in a tertiary cancer center in São Paulo, Brazil. We collected data on cancer diagnosis, symptoms at admission, hospitalization diagnosis, and survival clinical outcomes during in-hospital stay (in-hospital mortality) and after discharge (readmission rates and overall survival [OS]). Progressive disease (PD) diagnosis during admission was retrieved from manual chart review if explicitly stated by the attending physician. We modeled in-hospital mortality and postdischarge OS with logistic regression and Cox proportional hazards models, respectively.

RESULTS

A total of 3,726 unique unplanned admissions were identified. The most common symptoms at admission were pain (40.6%), nausea (16.8%), and dyspnea (16.1%). PD (34.0%), infection (31.1%), and cancer pain (13.4%) were the most frequent reasons for admission. The in-hospital mortality rate was 18.9%. Patients with PD had a high in-hospital mortality rate across all tumor groups and higher odds of in-hospital death (odds ratio, 3.5 [95% CI, 3.0 to 4.2]). The 7-, 30-, and 90-day readmission rates were 11.9%, 33.5%, and 54%, respectively. The postdischarge median OS (mOS) was 12.6 months (95% CI, 11.6 to 13.7). Poorer postdischarge survival was observed among patients with PD (mOS, 5 months v 18 months; P < .001; hazard ratio, 2.4 [95% CI, 2.1 to 2.6]).

CONCLUSION

PD is a common diagnosis during unplanned hospitalizations and is associated with higher in-hospital mortality rates and poorer OS after discharge. Oncologists should be aware of the prognostic implications of PD during admission and align goals of care with their patients.

Characterizing Patients Presenting on Hospital Admission With Central Line-Associated Bloodstream Infections: A Multicenter Study

BACKGROUND

There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To clarify the burden of CLABSIs in these patients, we characterized patients with CLABSI present on hospital admission (POA).

METHODS

Retrospective cross-sectional analysis of patients with CLABSI-POA in 3 health systems covering 11 hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via record review. Cox proportional hazard analysis was used to assess factors associated with the all-cause mortality rate within 30 days.

RESULTS

A total of 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among patients with CLABSI-POA, mortality risk increased with age (hazard ratio vs age <20 years by age group: 20-44 years, 11.2 [95% confidence interval, 1.46-86.22]; 45-64 years, 20.88 [2.84-153.58]; ≥65 years, 22.50 [2.98-169.93]) and lack of insurance (2.46 [1.08-5.59]), and it decreased with CVC removal (0.57 [.39-.84]).

CONCLUSIONS

CLABSI-POA is associated with significant in-hospital mortality risk. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.

Trends in chemotherapy use for early-stage breast cancer from 2006 to 2019

BACKGROUND

Little is known about how use of chemotherapy has evolved in breast cancer patients. We therefore describe chemotherapy patterns for women with stage I-IIIA breast cancer in the Optimal Breast Cancer Chemotherapy Dosing (OBCD) Study using data from KPNC (Kaiser Permanente Northern California) and KPWA (Kaiser Permanente Washington).

FINDINGS

Among 33,670 women, aged 18 + y, diagnosed with primary stage I-IIIA breast cancer at KPNC and KPWA from 2006 to 2019, we explored patterns of intravenous chemotherapy use, defined here as receipt of intravenous cytotoxic drugs and/or anti-HER2 therapies. We evaluated trends in chemotherapy receipt, duration over which chemotherapy was received, and number of associated infusion visits. In secondary analyses, we stratified by receipt of anti-HER2 therapies (trastuzumab and/or pertuzumab), given their longer duration. 38.9% received chemotherapy intravenously, declining from 40.2% in 2006 to 35.6% in 2019 (p-trend < 0.001). Among 13,089 women receiving chemotherapy, neoadjuvant treatment increased (4.1-14.7%; p-trend < 0.001), as did receipt of anti-HER2 therapies (20.8-30.9%) (p-trend < 0.001). The average treatment duration increased (5.3 to 6.0 months; p-trend < 0.001), as did the number of infusion visits (10.8 to 12.5; p-trend < 0.001). For those receiving anti-HER2 therapies, treatment duration and average number of visits decreased; among those not receiving anti-HER2 therapies, number of visits increased, with no change in duration.

CONCLUSIONS

While the prevalence of chemotherapy receipt has decreased over time, the use of neoadjuvant chemotherapy has increased, as has use of anti-HER2 therapies; duration and number of administration visits have also increased. Understanding these trends is useful to inform clinical and administrative planning.

More competent informal caregivers reduce advanced cancer patients' unplanned healthcare use and costs

BACKGROUND

Patients with metastatic cancer experience high healthcare use and costs, most of which are unplanned. We aimed to assess whether patients with more competent informal caregivers have lower unplanned healthcare use and costs.

METHODS

This study used data from a prospective cohort of patients with solid metastatic cancer. Patients and their informal family caregivers were surveyed every 3 months until patients' death. Patients' unplanned healthcare use/costs were examined through hospital records. Caregivers responded to the 4-item Caregiver Competence Scale. First, in a deceased subsample of patients and their caregivers, we used patients' last 2 years of data (226 dyads) to assess the association between caregivers' competency (independent variable) and patients' unplanned healthcare use/costs (outcomes). Next, in a prospective sample of patient-caregiver dyads (up to 15 surveys), we assessed whether patients' functional well-being and psychological distress moderated the association between caregivers' competency and unplanned healthcare use/costs (311 dyads).

RESULTS

In the deceased subsample, during last 2 years of patients' life, caregivers' higher competency lowered the odds of patients' unplanned healthcare use [OR (CI) = 0.86 (0.75, 0.98), p = 0.03], and was associated with a significant reduction in unplanned healthcare costs [Coeff (CI) = -0.19 (-0.36, -0.01), p = 0.03]. In the prospective sample, patients' functional well-being and psychological distress moderated the association between caregivers' competency and patients' unplanned healthcare use/costs.

CONCLUSION

With deterioration in patients' condition and an increase in caregiving demands, improving caregivers' competency can reduce patients' unplanned healthcare use and costs. This should be further tested in future trials.

High risk of rehospitalization within 1 year following a pulmonary embolism-insights from the Danish nationwide registries from 2000-2020

AIM

To identify the absolute risk, causes, and factors associated with rehospitalization within 1 year of discharge with a pulmonary embolism (PE).

METHODS AND RESULTS

Using the Danish nationwide registries, all patients admitted with a first-time PE between 2000 and 2020 and discharged alive were included. Subsequent hospitalizations were categorized and crude cumulative incidences were used to estimate the absolute risk (AR) of any rehospitalization and specific causes of rehospitalizations. Risk factors for rehospitalization were investigated using cause specific Cox regression models.A total of 55 201 patients were identified. The median age of the study population was 70 years (inter quartile range: 59;79), and the most prevalent comorbidities were cancer (29.3%) and ischemic heart disease (12.7%). The 1-year AR of any rehospitalization after discharge with a PE was 48.6% (95% confidence interval (CI); 48.2%-48.8%). The most common cause for being rehospitalized was due to respiratory disease [1-year AR: 9.5% (95% CI: 9.3%-9.8%)], followed by cardiovascular disease [1-year AR: 6.3% (95% CI: 5.9%-6.5%)], cancer [1-year AR: 6.0% (95% CI: 5.8%-6.4%)], venous thromboembolism [1-year AR: 5.2% (95% CI: 5.0%-5.2%)], and symptom diagnoses [1-year AR: 5.2% (95% CI: 5.0%-5.4%)]. Factors that were associated with an increased risk of rehospitalization were cancer, liver disease, chronic obstructive pulmonary disease, chronic kidney disease, and immobilization.

CONCLUSION

Patients with PE have a high risk of rehospitalization, with almost half of patients being rehospitalized within 1 year. Identification of high-risk patients may help target interventions aiming at reducing the risk of rehospitalization.

Impact of Electronic Patient-Reported Outcomes on Unplanned Consultations and Hospitalizations in Patients With Cancer Undergoing Systemic Therapy: Results of a Patient-Reported Outcome Study Compared With Matched Retrospective Data

BACKGROUND

The evaluation of electronic patient-reported outcomes (ePROs) is increasingly being used in clinical studies of patients with cancer and enables structured and standardized data collection in patients' everyday lives. So far, few studies or analyses have focused on the medical benefit of ePROs for patients.

OBJECTIVE

The current exploratory analysis aimed to obtain an initial indication of whether the use of the Consilium Care app (recently renamed medidux; mobile Health AG) for structured and regular self-assessment of side effects by ePROs had a recognizable effect on incidences of unplanned consultations and hospitalizations of patients with cancer compared to a control group in a real-world care setting without app use. To analyze this, the incidences of unplanned consultations and hospitalizations of patients with cancer using the Consilium Care app that were recorded by the treating physicians as part of the patient reported outcome (PRO) study were compared retrospectively to corresponding data from a comparable population of patients with cancer collected at 2 Swiss oncology centers during standard-of-care treatment.

METHODS

Patients with cancer in the PRO study (178 included in this analysis) receiving systemic therapy in a neoadjuvant or noncurative setting performed a self-assessment of side effects via the Consilium Care app over an observational period of 90 days. In this period, unplanned (emergency) consultations and hospitalizations were documented by the participating physicians. The incidence of these events was compared with retrospective data obtained from 2 Swiss tumor centers for a matched cohort of patients with cancer.

RESULTS

Both patient groups were comparable in terms of age and gender ratio, as well as the distribution of cancer entities and Joint Committee on Cancer stages. In total, 139 patients from each group were treated with chemotherapy and 39 with other therapies. Looking at all patients, no significant difference in events per patient was found between the Consilium group and the control group (odds ratio 0.742, 90% CI 0.455-1.206). However, a multivariate regression model revealed that the interaction term between the Consilium group and the factor "chemotherapy" was significant at the 5% level (P=.048). This motivated a corresponding subgroup analysis that indicated a relevant reduction of the risk for the intervention group in the subgroup of patients who underwent chemotherapy. The corresponding odds ratio of 0.53, 90% CI 0.288-0.957 is equivalent to a halving of the risk for patients in the Consilium group and suggests a clinically relevant effect that is significant at a 2-sided 10% level (P=.08, Fisher exact test).

CONCLUSIONS

A comparison of unplanned consultations and hospitalizations from the PRO study with retrospective data from a comparable cohort of patients with cancer suggests a positive effect of regular app-based ePROs for patients receiving chemotherapy. These data are to be verified in the ongoing randomized PRO2 study (registered on ClinicalTrials.gov; NCT05425550).

TRIAL REGISTRATION

ClinicalTrials.gov NCT03578731; https://www.clinicaltrials.gov/ct2/show/NCT03578731.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29271.

Trends and predictors of unplanned hospitalization among oral and oropharyngeal cancer patients; an 8-year population-based study

PURPOSE

The incidence of oral cancers, particularly HPV-related oropharyngeal cancer, is steadily increasing worldwide, presenting a significant healthcare challenge. This study investigates trends and predictors of unplanned hospitalizations for oral cavity cancer (OCC) and oropharyngeal cancer (OPC) patients in the province of Alberta, Canada.

METHODS

This retrospective, population-based, cohort study used administrative data collected from all hospitals in the province. Using the Alberta Cancer Registry (ACR), a cohort of adult patients diagnosed with a single primary OCC or OPC between January 2010 and December 2017 was identified. Linking this cohort with the Discharge Abstract Database (DAD), trends in hospitalizations, primary diagnoses, and predictors of unplanned hospitalization (UH) and 30-day unplanned readmission were analyzed.

RESULTS

Of 1,721 patients included, 1,244 experienced 2,228 hospitalizations, with 48 % being categorized as UH. The UHs were significantly associated with a higher mortality rate, 18.5 % as compared to 4.6 % for planned, and influenced by sex, age groups, comorbidities, cancer types, stages, and treatment modalities. The rate of UH per patient decreased from 0.69 to 0.54 visits during the study period (P = 0.02). Common diagnoses for UH were palliative care and post-surgical convalescence, while surgery-related complications such as infection and hemorrhage were frequent in 30-day unplanned readmissions. Predictors of UH included cancer stage, material deprivation, and treatment, while cancer type and comorbidity predicted readmissions.

CONCLUSION

The rate of UHs showed a noteworthy decline in this study, which could be a result of enhanced care coordination. Furthermore, identified primary diagnosis and predictors associated with UHs and readmissions, provide valuable insights for enhancing the quality of care for cancer patients.

The burden of cervical cancer survivorship: Understanding morbidity and survivorship needs through hospital admissions

Objective

To describe disease- and treatment-related survivorship burden amongst survivors of cervical cancer and identify risk factors for hospital admissions after initial treatment.

Methods

Retrospective chart review including patients treated for cervical cancer from 2014 to 2020 at a single urban academic institution. Clinical, demographic, and hospital admission characteristics were summarized. Associations between patient characteristics and likelihood of admission were examined using univariate and multivariate regression.

Results

Of 366 patients undergoing surveillance following completion of primary treatment, 156 (43 %) were hospitalized for cancer or treatment-related sequela in the median follow-up of 3.6 years (IQR 1.4-6.4), with a median of 2 admissions (IQR 1-4.5) per patient and 570 unique admissions. While 65 (35 %) of admitted patients had multiple reasons for admission, the most common reasons for admission were: gastrointestinal complications (43 %), infection (38 %), genitourinary complications (33 %), and pain control (23 %). A substantial proportion of admitted patients underwent interventions including surgical procedures (57 %), transfusion of blood products (40 %), and interventional radiology procedures (28 %) and utilized supportive care services including case management (53 %), physical therapy (40 %), and occupational therapy (36 %). On multivariate analysis, odds of admission were higher among Black patients (aOR 2.4, p <.01), uninsured patients (aOR 2.7, p <.05), those with lower performance status (aOR 1.4, p <.05), and those with recurrence (aOR 5.5, p <.001).

Conclusion

Survivors of cervical cancer represent a high-risk population frequently hospitalized after initial treatment. Black patients, uninsured patients, those with recurrence, and those with lower performance status faced higher odds of admission. Comprehensive, team-based care is necessary to address complex survivorship needs.

Rate, Timing, and Duration of Unplanned Readmissions Due to Cardiovascular Diseases among Hospitalized Patients with Cancer in the United States

Background

Cardiovascular disease (CVD) can lead to unplanned care in patients with cancer, which may affect their prognosis and survival. We aimed to compare the rates, timing, and length of stay of unplanned CVD readmission in hospitalized patients with and without cancer.

Methods

This study used the 2017-2018 Nationwide Readmissions Database to identify adult hospitalized patients with and without cancer. The primary outcome was 180-day unplanned CVD readmission rates. CVD was defined based on a composite variable that included atrial fibrillation, coronary artery disease, cardiomegaly, cardiomyopathy, heart failure, peripheral artery disease, and stroke. For patients readmitted due to CVD, the timing between admissions (based on the mean number of days between index hospitalization and readmission) and length of stay were further identified.

Results

After matching, 300,398 patients were included in the two groups. The composite CVD readmission rates were significantly higher in patients with cancer (5.92% vs 4.10%; odds ratio (OR) 1.47, 95% CI 1.44-1.51, p < 0.001). Patients with cancer were also associated with shorter mean number of days to composite CVD readmission (60.48 days vs 68.32 days, p < 0.001) and longer length of stay of composite CVD readmission (8.21 days vs 7.13 days, p < 0.001). These trends were maintained in analyses of the individual CVD.

Conclusions

Hospitalized patients with cancer experienced higher rates of unplanned readmission due to CVD, and their CVD readmissions occurred sooner and required longer lengths of stay compared to patients without cancer. Efforts to reduce unplanned CVD readmissions, such as providing optimized chronic post-discharge care, may improve the health outcomes of patients with cancer.

Thirty-day mortality in hospitalised patients with lung cancer: incidence and predictors

OBJECTIVES

Patients with lung cancer experience high rates of hospitalisation, mainly due to the high risk of complications that emerge during the natural history of the disease. We designed a retrospective, single-centre, observational study aimed at defining the clinical predictors of 30-day mortality in hospitalised patients with lung cancer.

METHODS

Clinical records from the first admission of patients with lung cancer to the oncology ward of the University Hospital of Parma from 1 January 2017 to 1 January 2022 were collected.

RESULTS

251 consecutive patients were enrolled at the time of data cut-off. In the univariate analysis, baseline clinical predictors of 30-day mortality were Eastern Cooperative Oncology Group performance status (ECOG PS) (≥2 vs 0-1: 27.5% vs 14.8%, p=0.028), high Blaylock Risk Assessment Screening Score (BRASS) (high vs intermediate-low: 34.3% vs 11.9%, p<0.001), presence of pain (yes vs no: 24.4% vs 11.7%, p=0.009), number of metastatic sites (≥3 vs <3: 26.5% vs 13.4%, p=0.017) and presence of bone metastases (yes vs no: 29.0% vs 10.8%, p=0.001). In the multivariate analysis, high BRASS remained significantly associated with increased 30-day mortality (high vs intermediate-low; OR 2.87, 95% CI 1.21 to 6.78, p=0.016).

CONCLUSION

Our results suggest that baseline poor ECOG PS, high BRASS, presence of pain, high tumour burden and presence of bone metastases could be used as clinical predictors of 30-day mortality in hospitalised patients with lung cancer. In particular, the BRASS scale should be used as a simple tool to predict 30-day mortality in hospitalised patients with lung cancer.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

BACKGROUND

Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups.

AIM

To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care.

DESIGN

Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information.

SETTING/PARTICIPANTS

Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019.

RESULTS

The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019.

CONCLUSIONS

Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Patterns and outcome of unplanned care in lung cancer patients: an observational study in a medical oncology department

Background

There is increasing interest in unplanned care utilization among lung cancer patients and its evaluation should allow the identification of areas for quality improvement. Being a major priority for transformation in oncology, we aim to measure the risk and burden of unplanned care in a medical oncology department and identify factors that determine acute care.

Methods

This was an observational retrospective cohort study that included all lung cancer patients treated at Puerta de Hierro-Majadahonda University Hospital between January 1st 2016 and December 31st 2020. Data cut off: June 30th, 2021. The main objective was to assess the incidence of unplanned care, emergency department (ED) visits and unplanned hospital admissions, from the first visit to the medical oncology service and its potential conditioning variables, considering patient death as a competitive event. As secondary objectives, a description and a quality of unplanned care evaluation was carried out.

Results

A total of 821 lung cancer patients, all histologies and stages, were included (median follow-up: 32.8 months). Six hundred and eighty-one patients required consultation in the ED (82.9%), and 558 required an unplanned admission (68%). Eighty-six percent of ED consultations and 80.9% of unplanned hospital admissions were related to cancer or its treatment. The 1-year cumulative incidence for ED consultation and for unplanned hospital admission was 71.3% (95% CI: 67.8-74.5%) and 56.7% (95% CI: 53-60%), respectively. In the multivariable analysis, a higher tumor stage increased the risk of consultation in the ED, while a higher stage, Eastern Cooperative Oncology Group performance status (ECOG PS) 2 compared to ECOG PS 0, male sex, opioid or steroid use at first consultation increased the risk of unplanned admission.

Conclusions

Our study shows that lung cancer patients have an extremely high demand for unplanned care. It is an early need and related to cancer in the majority of consultations and admissions and therefore a key issue for the management of oncology departments. We must optimize the follow-up of patients with a higher risk of unplanned care, advanced lung cancer or symptomatic patients, incorporating remote monitoring strategies and early interventions, as developing specific urgent care pathways for a better comprehensive cancer care.

Financial toxicity in cancer patients and subsequent risk of repeat acute care utilization

Background

Acute care (AC) visits by cancer patients are costly sources of healthcare resources and can exert a financial burden of oncology care both for individuals with cancer and healthcare systems. We sought to identify whether cancer patients who reported more severe initial financial toxicity (FT) burdens shouldered excess risks for acute care utilization.

Methods

In 225 adult patients who participated in the Economic Strain and Resilience in Cancer (ENRICh) survey study of individuals receiving ambulatory cancer care between March and September 2019, we measured the baseline FT (a multidimensional score of 0-10 indicating the least to most severe global, material, and coping FT burdens). All AC visits, including emergency department (ED) and unplanned hospital admissions, within 1-year follow-up were identified. The association between the severity of FT and the total number of AC visits was tested using Poisson regression models.

Results

A total of 18.6% (n = 42) of patients had any AC visit, comprising 64.3% hospital admissions and 35.7% ED visits. Global FT burden was associated with the risk of repeat AC visits within 1-year follow-up (RR = 1.17, 95% CI 1.07-1.29, P < 0.001 for every unit increase), even after adjusting for sociodemographic and disease covariates. When examining subdimensions of FT, the burden of depleted FT coping resources (coping FT) was strongly associated with the risk of repeat AC visits (RR = 1.27, 95% CI 1.15-1.40, P < 0.001) while material FT burden showed a trend toward association (RR = 1.07, 95% CI 0.99-1.15, P = 0.07).

Conclusion

In this prospective study of acute oncology care utilization outcomes among adult cancer patients, FT was a predictor of a higher burden of acute care visits. Patients with severely depleted material and also practical and social coping resources were at particular risk for repeated visits. Future studies are needed to identify whether early FT screening and intervention efforts may help to mitigate urgent acute care utilization burdens.

Getting ready for real-world use of electronic patient-reported outcomes (ePROs) for patients with cancer: A National Comprehensive Cancer Network ePRO Workgroup paper

Electronic patient‐reported outcome (ePRO) programs may offer advantages for patients with cancer, clinicians, health care systems, payors, and society in general; but developing and maintaining an ePRO program will require cancer centers to navigate defining meaningful problems, collecting ePROs, implementing action when those ePROs require intervention without over‐burdening clinicians, and monitoring the successes and failures of their ePRO programs. Physician informaticists from the National Comprehensive Cancer Network Electronic Health Record Advisory Group offer 10 guiding principles to consider when contemplating, building, or refining an ePRO program for patients with cancer.

External Validation of Risk Factors for Unplanned Hospitalization in Older Adults With Advanced Cancer Receiving Chemotherapy

BACKGROUND

Older adults (age ≥65 years) receiving chemotherapy are at risk for hospitalization. Predictors of unplanned hospitalization among older adults receiving chemotherapy for cancer were recently published using data from a study conducted by the Cancer and Aging Research Group (CARG). Our study aimed to externally validate these predictors in an independent cohort including older adults with advanced cancer receiving chemotherapy.

METHODS

This validation cohort included patients (n=369) from the GAP70+ trial usual care arm. Enrolled patients were aged ≥70 years with incurable cancer and were starting a new line of chemotherapy. Previously identified risk factors proposed by the CARG study were ≥3 comorbidities, albumin level <3.5 g/dL, creatinine clearance <60 mL/min, gastrointestinal cancer, ≥5 medications, requiring assistance with activities of daily activities (ADLs), and having someone available to take them to the doctor (ie, presence of social support). The primary outcome was unplanned hospitalization within 3 months of treatment initiation. Multivariable logistic regression was applied including the 7 identified risk factors. Discriminative ability of the fitted model was performed by calculating the area under the receiver operating characteristic (AUC) curve.

RESULTS

Mean age of the cohort was 77 years, 45% of patients were women, and 29% experienced unplanned hospitalization within the first 3 months of treatment. The proportions of hospitalized patients with 0-3, 4-5, and 6-7 identified risk factors were 24%, 28%, and 47%, respectively (P=.04). Impaired ADLs (odds ratio, 1.76; 95% CI, 1.04-2.99) and albumin level <3.5 g/dL (odds ratio, 2.23; 95% CI, 1.37-3.62) were significantly associated with increased odds of unplanned hospitalization. The AUC of the model, including the 7 identified risk factors, was 0.65 (95% CI, 0.59-0.71).

CONCLUSIONS

The presence of a higher number of risk factors was associated with increased odds of unplanned hospitalization. This association was largely driven by impairment in ADLs and low albumin level. Validated predictors of unplanned hospitalization can help with counseling and shared decision-making with patients and their caregivers.

CLINICALTRIALS

gov identifier: NCT02054741.

Treatment Patterns, Survival, Quality of Life, and Healthcare Resource Use Among Patients With Triple-Class Refractory Multiple Myeloma in US Clinical Practice: Findings From the Connect MM Disease Registry

BACKGROUND

Adults with triple-class refractory (TCR) multiple myeloma (MM) have limited treatment options and poor prognosis, but the burden of TCR MM has not been well characterized. This study evaluated treatment patterns, overall survival (OS), health-related quality of life (HRQoL), and healthcare resource use (HCRU) among patients with TCR MM in US clinical practice.

PATIENTS AND METHODS

Patients with TCR MM in the Connect MM Registry (NCT01081028; a large, US, multicenter, prospective observational cohort study of patients with newly diagnosed MM) were included. Patient characteristics, treatment patterns, HRQoL, and HCRU were analyzed using descriptive statistics. OS was calculated using Kaplan-Meier methodology for the overall cohort and for patients with/without ≥1 post-TCR line of therapy (LOT).

RESULTS

A total of 232 patients with TCR MM were included; 155 (67%) had ≥1 post-TCR LOT (post-TCR-Treated subgroup; median 9.9 months of follow-up). Most common post-TCR treatments were carfilzomib (47%), pomalidomide (40%), and daratumumab (26%); median treatment duration was 3.3 months. Median OS was 9.9 months in the overall population, 10.8 months in post-TCR-Treated patients, and 2.6 months for those with no new post-TCR LOT. HRQoL deteriorated and pain increased over 1 year of follow-up, with clinically meaningfully changes in EQ-5D (mean, -0.06 points) and FACT-G (mean, -9.9 points). 124 (53%) patients had ≥1 all-cause hospitalization and 58 (25%) had ≥1 MM-related hospitalization; median annualized length of stay was 35.3 and 42.9 days, respectively.

CONCLUSION

The burden of TCR MM is substantial, emphasizing the need for more effective treatment options in the TCR setting.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

IMPORTANCE

An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

OBJECTIVE

To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

RESULTS

Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

CONCLUSIONS AND RELEVANCE

In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Bayesian Network Analysis for Prediction of Unplanned Hospital Readmissions of Cancer Patients with Breakthrough Cancer Pain and Complex Care Needs

Background: Unplanned hospital readmissions (HRAs) are very common in cancer patients. These events can potentially impair the patients’ health-related quality of life and increase cancer care costs. In this study, data-driven prediction models were developed for identifying patients at a higher risk for HRA. Methods: A large dataset on cancer pain and additional data from clinical registries were used for conducting a Bayesian network analysis. A cohort of gastrointestinal cancer patients was selected. Logical and clinical relationships were a priori established to define and associate the considered variables including cancer type, body mass index (BMI), bone metastasis, serum albumin, nutritional support, breakthrough cancer pain (BTcP), and radiotherapy. Results: The best model (Bayesian Information Criterion) demonstrated that, in the investigated setting, unplanned HRAs are directly related to nutritional support (p = 0.05) and radiotherapy. On the contrary, BTcP did not significantly affect HRAs. Nevertheless, the correlation between variables showed that when BMI ≥ 25 kg/m², the spontaneous BTcP is more predictive for HRAs. Conclusions: Whilst not without limitations, a Bayesian model, combined with a careful selection of clinical variables, can represent a valid strategy for predicting unexpected HRA events in cancer patients. These findings could be useful for calibrating care interventions and implementing processes of resource allocation.

Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial

Importance

Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings.

Objective

To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting.

Design, Setting, and Participants

This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat.

Interventions

Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group).

Main Outcomes and Measures

The primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use.

Results

Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control.

Conclusions and Relevance

In this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT03154190.

Prognostic value of the veterans affairs frailty index in older patients with non-small cell lung cancer

BACKGROUND

Older patients with non-small cell lung cancer (NSCLC) are a heterogeneous population with varying degrees of frailty. An electronic frailty index such as the Veterans Affairs Frailty Index (VA-FI) can potentially help identify vulnerable patients at high risk of poor outcomes.

METHODS

NSCLC patients ≥65 years old and diagnosed in 2002-2017 were identified using the VA Central Cancer Registry. The VA-FI was calculated using administrative codes from VA electronic health records data linked with Medicare and Medicaid data. We assessed associations between the VA-FI and times to mortality, hospitalization, and emergency room (ER) visit following diagnosis by Kaplan-Meier analysis and multivariable stratified Cox models. We also evaluated the change in discrimination and calibration of reference prognostic models after adding VA-FI.

RESULTS

We identified a cohort of 42,204 older NSCLC VA patients, in which 55.5% were classified as frail (VA-FI >0.2). After adjustment, there was a strong association between VA-FI and the risk of mortality (HR = 1.23 for an increase of four deficits or, equivalently, an increase of 0.129 on VA-FI, p < 0.001), hospitalization (HR = 1.16 for four deficits, p < 0.001), and ER visit (HR = 1.18 for four deficits, p < 0.001). Adding VA-FI to baseline prognostic models led to statistically significant improvements in time-dependent area under curves and did not have a strong impact on calibration.

CONCLUSION

Older NSCLC patients with higher VA-FI have significantly elevated risks of mortality, hospitalizations, and ER visits following diagnosis. An electronic frailty index can serve as an accessible tool to identify patients with vulnerabilities to inform clinical care and research.

Community prescribing trends and prevalence in the last year of life, for people who die from cancer

Background

People who die from cancer (‘cancer decedents’) may latterly experience unpleasant and distressing symptoms. Prescribing medication for pain and symptom control is essential for good-quality palliative care; however, such provision is variable, difficult to quantify and poorly characterised in current literature. This study aims to characterise trends in prescribing analgesia, non-analgesic palliative care medication and non-palliative medications, to cancer decedents, in their last year of life, and to assess any associations with demographic or clinical factors.

Methods

This descriptive study, analysed all 181,247 prescriptions issued to a study population of 2443 cancer decedents in Tayside, Scotland (2013–2015), in the last year of life, linking prescribing data to demographic, and cancer registry datasets using the unique patient-identifying Community Health Index (CHI) number. Anonymised linked data were analysed in Safe Haven using chi-squared test for trend, binary logistic regression and Poisson regression in SPSSv25.

Results

In their last year of life, three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics. Only four in ten cancer decedents were prescribed all medications in the ‘Just in Case’ medication categories and only one in ten was prescribed breakthrough analgesia in the last year of life. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. The number of prescriptions for non-palliative care medications, including anti-hypertensives, statins and bone protection, decreased over the last year, but was still substantial. Cancer decedents who were female, younger, or had lung cancer were more likely to be prescribed strong opioids; however, male cancer decedents had higher odds of being prescribed breakthrough analgesia. Cancer decedents who had late diagnoses had lower odds of being prescribed strong opioids.

Conclusions

A substantial proportion of cancer decedents were not prescribed strong opioids, breakthrough medication, or medication to alleviate common palliative care symptoms (including ‘Just in Case’ medication). Many patients continued to be prescribed non-palliative care medications in their last days and weeks of life. Age, gender, cancer type and timing of diagnosis affected patients’ odds of being prescribed analgesic and non-analgesic palliative care medication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00996-3.

Cost-Savings Analysis of an Individualized Exercise Oncology Program in Early-Stage Breast Cancer Survivors: A Randomized Clinical Control Trial

PURPOSE

In an attempt to promote the integration of exercise oncology as a standard part of clinical practice, economic evaluations are warranted. Thus, the purpose of this study was to prospectively analyze cost savings of an individualized exercise oncology program when patients were randomly assigned.

METHODS

For this open-label, randomized, prospective, comparative clinical trial, patients with early-stage breast cancer (stage I-II) were randomly assigned into two groups: the control group (CG, n = 120) and the exercise training group (EX, n = 123). Patients in the exercise intervention group completed 12 weeks of prescribed, individualized exercise that aligned with ACSM exercise guidelines for cancer survivors. The CG received the current standard of care, which includes a resource guide with various options available to the cancer survivor.

RESULTS

In the EX group, all physical fitness measures significantly improved compared with baseline (P < .001), while remaining unchanged for the CG (P > .05). Patients in the CG had the highest total mean health care utilization across all measures (CG: $8,598 US dollars, compared with EX: $6,356 US dollars) for emergency visits, outpatient visits, and office-base visits that were not a part of their treatment plan. At baseline, the mean Eastern Cooperative Oncology Group (ECOG) scores did not significantly differ (P > .05); however, at follow-up, a larger proportion of the EX group had ECOG scores of 0 or 1, compared with the CG (P < .05). Finally, patient-reported outcomes were significantly higher in the exercise group, compared with the CG at the 12-week follow-up (P < .001).

CONCLUSION

A supervised, individualized 12-week exercise intervention led to significant improvements in fitness parameters and ECOG scores, as well as a decrease in unplanned health care utilization among early-stage breast cancer survivors.

Methodological approaches to measuring the incidence of unplanned emergency department presentations by cancer patients receiving systemic anti-cancer therapy: a systematic review

Background

The need to mitigate the volume of unplanned emergency department (ED) presentations is a priority for health systems globally. Current evidence on the incidence and risk factors associated with unplanned ED presentations is unclear because of substantial heterogeneity in methods reporting on this issue. The aim of this review was to examine the methodological approaches to measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy in order to determine the strength of evidence and to inform future research.

Methods

An electronic search of Medline, Embase, CINAHL, and Cochrane was undertaken. Papers published in English language between 2000 and 2019, and papers that included patients receiving systemic anti-cancer therapy as the denominator during the study period were included. Studies were eligible if they were analytical observational studies. Data relating to the methods used to measure the incidence of ED presentations by patients receiving systemic anti-cancer therapy were extracted and assessed for methodological rigor. Findings are reported in accordance with the Synthesis Without Meta-Analysis (SWiM) guideline.

Results

Twenty-one articles met the inclusion criteria: 20 cohort studies, and one cross-sectional study. Overall risk of bias was moderate. There was substantial methodological and clinical heterogeneity in the papers included. Methodological rigor varied based on the description of methods such as the period of observation, loss to follow-up, reason for ED presentation and statistical methods to control for time varying events and potential confounders.

Conclusions

There is considerable diversity in the population and methods used in studies that measure the incidence of unplanned ED presentations by patients receiving systemic anti-cancer therapy. Recommendations to support the development of robust evidence include enrolling participants at diagnosis or initiation of treatment, providing adequate description of regular care to support patients who experience toxicities, reporting reasons for and characteristics of participants who are lost to follow-up throughout the study period, clearly defining the outcome including the observation and follow-up period, and reporting crude numbers of ED presentations and the number of at-risk days to account for variation in the length of treatment protocols.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01555-3.

Perceptions of the Cardiologists and Oncologists: Initial Step for Establishing Cardio-Oncology Service

Background: Over the last years, there was no established cardio-oncology service in Iraq and no firm data about the incidence of cardiovascular disease (CVD) among patients with cancer. As an initial step, we decided to conduct a national cardio-oncology online survey for cardiologists, oncologists, and their residents which would help us to understand the expected prevalence, problems, and readiness for collaboration between the two specialties.

Objectives: For evaluating the current national practice in the cardiology and oncology specialty fields and to identify the hidden gaps associated with the development or worsening of CVD among patients with cancer.

Methods: An online survey including 19-question for cardiologists/cardiology residents (CCRs) and 30-question for oncologists/oncology residents (OORs) about cardio-oncology service was sent to them including all Iraqi cities using Google document form during December 2020.

Results: The total number of responses was 164, mainly 62.2% from CCRs while 37.8% from OORs. Hypertension was the main baseline risk factor (71%). A 77.5% of CCRs prescribe cardiovascular drugs vs. 35.5% by OORs. About 76.5% of CCRs and 79% of OORs are facing difficulties in the management of patients with cancer with established CVD. CVD was the leading cause of both hospitalization (30.7%) and mortality (48.4%). About 62.8% of CCRs and 64.5% of OORs have an interest to work in cardio-oncology service.

Conclusion: Based on the perception of cardiologists and oncologists, CVD is the main cause of hospitalization and mortality among patients with cancer. High interest among CCRs and OORs to work in cardio-oncology service. Positive initiatives are available to take the action plan in this emerging field.

Cost-Effectiveness of Nutrient Supplementation in Cancer Survivors

Cancer patients are at risk for malnutrition; the aim of this study was to provide a cost-effectiveness analysis of dietary supplementation in cancer survivors. We estimated prevalence of supplementation, hospitalization rates, quality of life (QOL), cost of care and mortality among cancer survivors. We built a decision analytic model to simulate life-long costs of health care and supplementation and QOL among cancer survivors with and without supplementation. Cost of supplements was derived from national pharmacy databases including single- and multivitamin formularies. One-way and probabilistic sensitivity analysis were performed to evaluate the robustness of the incremental cost-effectiveness ratio (ICER) to changes in supplementation costs and duration. The study cohort represented the national cancer survivor population (average age 61 years, 85% white, 52% male, and 94% insured). Hospitalization rates for supplement users and non-users were 12% and 21%, respectively. The cost of hospitalization was $4030. Supplementation was associated with an additional 0.48 QALYs (10.26 vs. 9.78) at the incremental cost of $2094 ($236,933 vs. $234,839) over the remaining lifetime of survivors (on average 13 years). Adequate nutrition provides a cost-effective strategy to achieving potentially optimum health. Further studies are needed to determine the effects of specific nutrient doses and supplementation on long-term outcomes per cancer type.

The Appropriate First-Line Chemotherapy Regimen for Incurable Pancreatic Cancer in Clinical Practice: A Consideration of Patients' Overall Survival and Quality of Life

Purpose: For incurable pancreatic cancer, the therapeutic goal is to prolong survival and maintain the quality of life (QOL). Unexpected outpatient consultation (OCT) and emergency hospitalization lead to QOL deterioration. The National Comprehensive Cancer Network (NCCN) guidelines recommend 5-fluorouracil/leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX) and gemcitabine plus albumin-bound paclitaxel (nabPTX+GEM) as the preferred first-line regimens. Japanese clinical practice guidelines further recommend GEM and tegafur/gimeracil/oteracil potassium (S-1). Currently, no treatment strategy considers QOL at any stage during a patient's clinical course.

Methods: In this study, hospital-free survival (HFS), defined as the period without hospitalization and OCT, was introduced as a new indicator of the qualitative aspect of overall survival (OS). We compared OS, length of hospitalization (LOH), OCT, and HFS for the four first-line chemotherapy groups.

Results: No significant difference was observed in the median OS and HFS, nor was there a strong correlation between OS and LOH, based on the four first-line chemotherapy groups. In contrast, there were strong correlations between OS and OCT and between OS and HFS in all first-line chemotherapy groups. The ratio of OCT to OS was similar for mFOLFIRINOX and nabPTX+GEM. S-1 had the lowest OCT-to-OS ratio. The ratio of HFS to OS declined from highest to lowest in the order S-1, nabPTX+GEM, mFOLFIRINOX, and GEM.

Conclusion: Our findings suggested existence of correlation differences between OS and HFS between first-line mFOLFIRINOX and first-line nabPTX+GEM. In addition, a good HFS was obtained with S-1 alone in some cases. In the future, clinical trials for chemotherapy should examine QOL during the entire clinical course.

Factors Associated With Unplanned Acute Care Services for Patients With Newly Diagnosed Hematologic Malignancies

PURPOSE

This study evaluated risk factors predicting unplanned 30-day acute service utilization among adults subsequent to hospitalization for a new diagnosis of leukemia, lymphoma, or myeloma. This study explored the prevalence of medical complications (aligned with OP-35 measure specifications from the Centers for Medicare & Medicaid Services [CMS] Hospital Outpatient Quality Reporting Program) and the potential impact of psychosocial factors on unplanned acute care utilization.

METHODS

This study included 933 unique patients admitted to three acute care inpatient facilities within a nonprofit community-based health care system in southern California from 2012 to 2017. Integrated comprehensive data elements from electronic medical records and facility oncology registries were leveraged for univariate statistics, predictive models constructed using multivariable logistic regression, and further exploratory data mining, with predictive accuracy of the models measured with c-statistics.

RESULTS

The mean age of study participants was 65 years, and 55.1% were male. Specific diagnoses were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days postdischarge, and over half of these patients presented with one or more symptoms associated with the CMS medical complication measure. The predictive models, with c-statistics ranging from 0.7 and above for each type of hematologic malignancy, indicated good predictive qualities with the impact of psychosocial functioning on the use of acute care services (P values < .05), including lack of consult for social work during initial admission (lymphoma or myeloma), history of counseling or use of psychotropic medications (lymphoma), and past substance use (myeloma).

CONCLUSION

This study provides insights into patient-related factors that may inform a proactive approach to improve health outcomes, such as enhanced care transition, monitoring, and support interventions.

A systematic review and meta-analysis of unplanned hospital visits and re-admissions following radical prostatectomy for prostate cancer

INTRODUCTION

Unplanned visits (UPV) - re-admissions and emergency room (ER) visits - are markers of healthcare system quality. Radical prostatectomy (RP) is a commonly performed cancer procedure, where variation in UPV represents a gap in care for prostate cancer patients. Here, we systematically synthesize the rates, reasons, predictors, and interventions for UPV after RP to inform evidence-based quality improvement (QI) initiatives.

METHODS

A systematic review was performed for studies from 2000-2020 using keywords: "re-admission," "emergency room/department," "unplanned visit," and "prostatectomy." Studies that focused on UPV following RP and that reported rates, reasons, predictors, or interventions, were included. Data was extracted via a standardized form. Meta-analysis was completed.

RESULTS

Sixty studies, with 406 107 RP patients, were eligible; 16 028 UPV events (approximately 5%) were analyzed from 317 050 RP patients. UPV rates after RP varied between studies (ER visit range 6-24%; re-admissions range 0-56%). The 30-day and 90-day ER visit rates were 12% and 14%, respectively; the 30-day and 90-day re-admission rates were 4% and 9%, respectively. A total of 55% of all re-admissions after RP are directly due to postoperative genitourinary (GU)-related complications, such as strictures, obstructions, fistula, bladder-related, incontinence, urine leak, renal problems, and other unspecified urinary complications. The next most common re-admission reasons were anastomosis-related, infection-related, cardiovascular/pulmonary events, and wound-related issues. Thirty-four percent of all ER visits after RP are directly due to urine-related issues, such as retention, urinoma, obstruction, leak, and catheter problems. The next most common ER visit reasons were abdominal/gastrointestinal issues, infection-related, venous thromboembolic events, and wound-related issues. Predictors for increased re-admission included: open RP, lymph node dissection, Charlson comorbidity index ≥2, low surgeon/hospital case volume, and socioeconomic determinants of health. Of the 10 interventions evaluated, a 3.4% average reduction in UPV rate was observed, highlighting an approximate two-fold decrease. Meta-analysis demonstrated a significant benefit of interventions over controls, with odds ratio 0.62 (95% confidence interval 0.46-0.84). Interventions that used multidisciplinary, nurse-centered, programs, with patient self-care/empowerment were more beneficial than algorithmic patient care pathways and preoperative patient education.

CONCLUSIONS

Twenty years of international, retrospective experience suggests UPV after RP are often related to GU complications and infection- or wound-related factors. QI interventions to reduce UPV should target these factors. While many re-admissions after RP appear to be unavoidable, ER visits have more opportunity for volume reduction by QI. The interventions evaluated herein have the potential to reduce UPV after RP.

Impact of CYP2D6 Pharmacogenomic Status on Pain Control Among Opioid-Treated Oncology Patients

BACKGROUND

Several opioids have pharmacogenomic associations impacting analgesic efficacy. However, germline pharmacogenomic testing is not routinely incorporated into supportive oncology. We hypothesized that CYP2D6 profiling would correlate with opioid prescribing and hospitalizations.

MATERIALS AND METHODS

We analyzed 61,572 adult oncology patients from 2012 to 2018 for opioid exposures. CYP2D6 metabolizer phenotype (ultra-rapid [UM], normal metabolizer [NM], intermediate [IM], or poor [PM]), the latter two of which may cause inefficacy of codeine, tramadol, and standard-dose hydrocodone, was determined for patients genotyped for reasons unrelated to pain. The primary endpoint was number of opioid medications received during longitudinal care (IM/PMs vs. NMs). Secondary endpoint was likelihood of pain-related hospital encounters.

RESULTS

Most patients with cancer (n = 34,675, 56%) received multiple opioids (average 2.8 ± 1.6/patient). Hydrocodone was most commonly prescribed (62%), followed by tramadol, oxycodone, and codeine. In the CYP2D6 genotyped cohort (n = 105), IM/PMs received a similar number of opioids (3.4 ± 1.4) as NMs (3.3 ± 1.9). However, IM/PMs were significantly more likely to experience pain-related hospital encounters compared with NMs, independent of other variables (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-23.6; p = .03). IM/PMs were also more likely to be treated with later-line opioids that do not require CYP2D6 metabolism, such as morphine and hydromorphone (OR = 3.3; 95% CI, 1.1-9.8; p = .03).

CONCLUSION

CYP2D6 genotype may identify patients with cancer at increased risk for inadequate analgesia when treated with typical first-line opioids like codeine, tramadol, or standard-dose hydrocodone. Palliative care considerations are an integral part of optimal oncology care, and these findings justify prospective evaluation of preemptive genotyping as a strategy to improve oncology pain management.

IMPLICATIONS FOR PRACTICE

Genomic variation in metabolic enzymes can predispose individuals to inefficacy when receiving opioid pain medications. Patients with intermediate and/or poor CYP2D6 metabolizer status do not adequately convert codeine, tramadol, and hydrocodone into active compounds, with resulting increased risk of inadequate analgesia. This study showed that patients with cancer frequently receive CYP2D6-dependent opioids. However, patients with CYP2D6 intermediate and poor metabolizer status had increased numbers of pain-related hospitalizations and more frequently required the potent non-CYP2D6 opioids morphine and hydromorphone. This may reflect inadequate initial analgesia with the common "first-line" CYP2D6-metabolized opioids. Preemptive genotyping to guide opioid prescribing during cancer care may improve pain-related patient outcomes.

Occupational Therapy's Role with Oncology in the Acute Care Setting: A Descriptive Case Study

As individuals with cancer actively undergo medical treatment, they often experience profound impairments and side-effects that impact their physical and psychosocial functioning and well-being. As occupational therapy practitioners working in acute care, challenges when working with those with oncological diseases may include high acuity, impact on multiple body systems, and fluctuating symptom presentation and levels of function. Thus, it is critical for occupational therapy practitioners to be skilled in identifying and addressing the distinct needs of cancer survivors in the acute care setting. This manuscript presents a descriptive case study to highlight occupational therapy's role in cancer rehabilitation in the acute care setting.

Unplanned emergency department visits and hospital admissions of older adults under treatment for cancer in the ambulatory/community setting

PURPOSE

This study aims to identify the incidence and risk/protective factors for (1) unplanned emergency department (ED) visits and hospital admissions (HA) and (2) nausea/vomiting/dehydration (NVD) at time of treatment in older adults under treatment for cancer.

MATERIALS AND METHODS

This is a exploratory retrospective cohort study of adults (60 and older) with cancer. Adults were included if they had a new cancer diagnosis and were being treated with chemotherapy. Study outcomes included the number of ED visits and HA (cycles 1-4) and NVD at the time of receiving chemotherapy (cycles 2-4). Repeated measures, Poisson regression was used to obtain risk ratios with 95% confidence intervals for independent predictors of outcomes.

RESULTS

Of 402 study participants, 20% experienced an ED visit, and 18% experienced a HA. Common reasons for ED visits were pain (23.5%) and NVD (20.4%). Common reasons for HA were infection (34.4%) and NVD (22.2%). Multivariate analysis showed risk factors for ED visits included chemotherapy cycle 1, having esophageal cancer, being treated with ≥ 3 chemotherapy agents, and increasing levels of functional impairment. Risk factors for HA included chemotherapy cycle 1, increasing levels of functional impairment, intravenous fluids between treatment, and being prescribed antiemetics for home use. Predictors of NVD at time of chemotherapy treatment included Hispanic ethnicity, insurance status, cancer type, chemotherapy emetic potent, treatment frequency, intravenous fluids between cycles, and number of home antiemetics.

CONCLUSION

Unplanned ED visits and HA occur in older adults under treatment for cancer due to numerous treatment-related side effects. Helping older adults identify and manage side effects early may reduce the number of unplanned admissions.

A Machine Learning Model Approach to Risk-Stratify Patients With Gastrointestinal Cancer for Hospitalization and Mortality Outcomes

PURPOSE

Patients with gastrointestinal (GI) cancer frequently experience unplanned hospitalizations, but predictive tools to identify high-risk patients are lacking. We developed a machine learning model to identify high-risk patients.

METHODS AND MATERIALS

In the study, 1341 consecutive patients undergoing GI (abdominal or pelvic) radiation treatment (RT) from March 2016 to July 2018 (derivation) and July 2018 to January 2019 (validation) were assessed for unplanned hospitalizations within 30 days of finishing RT. In the derivation cohort of 663 abdominal and 427 pelvic RT patients, a machine learning approach derived random forest, gradient boosted decision tree, and logistic regression models to predict 30-day unplanned hospitalizations. Model performance was assessed using area under the receiver operating characteristic curve (AUC) and prospectively validated in 161 abdominal and 90 pelvic RT patients using Mann-Whitney rank-sum test. Highest quintile of risk for hospitalization was defined as "high-risk" and the remainder "low-risk." Hospitalizations for high- versus low-risk patients were compared using Pearson's χ² test and survival using Kaplan-Meier log-rank test.

RESULTS

Overall, 13% and 11% of patients receiving abdominal and pelvic RT experienced 30-day unplanned hospitalization. In the derivation phase, gradient boosted decision tree cross-validation yielded AUC = 0.823 (abdominal patients) and random forest yielded AUC = 0.776 (pelvic patients). In the validation phase, these models yielded AUC = 0.749 and 0.764, respectively (P < .001 and P = .002). Validation models discriminated high- versus low-risk patients: in abdominal RT patients, frequency of hospitalization was 39% versus 9% in high- versus low-risk groups (P < .001) and 6-month survival was 67% versus 92% (P = .001). In pelvic RT patients, frequency of hospitalization was 33% versus 8% (P = .002) and survival was 86% versus 92% (P = .15) in high- versus low-risk patients.

CONCLUSIONS

In patients with GI cancer undergoing RT as part of multimodality treatment, machine learning models for 30-day unplanned hospitalization discriminated high- versus low-risk patients. Future applications will test utility of models to prompt interventions to decrease hospitalizations and adverse outcomes.

Prediction of Unplanned Hospitalizations in Older Patients Treated with Chemotherapy

PURPOSE

To determine the incidence of unplanned hospitalization (UH) and to identify risk factors for UH in elderly patients with cancer who start chemotherapy.

METHODS

In all, 493 patients over 70 years starting new chemotherapy regimens were prospectively included. A pre-chemotherapy geriatric assessment was performed, and tumor and treatment variables were collected. The association between these factors and UH was examined by using multivariable logistic regression. Score points were assigned to each risk factor.

RESULTS

During the first 6 months of treatment, 37% of patients had at least one episode of UH. Risk factors were the use of combination chemotherapy at standard doses, a MAX2 index ≥1, a Charlson comorbidity score ≥2, albumin level <3.5 g/dL, falls in the past 6 months ≥1, and weight loss >5%. Three risk groups for UH were established according to the score in all patients: 0-1: 17.5%; 2: 34%; and 3-7: 57% (p < 0.001). The area under receiver operation characteristic (ROC) curve was 0.72 (95% CI: 0.67-0.77).

CONCLUSION

This simple tool can help to reduce the incidence of UH in elderly patients with cancer who are scheduled to initiate chemotherapy treatment.

Palliative Thoracic Radiotherapy for Non-Small Cell Lung Cancer in Outpatients: Reasons for Unplanned Hospitalization and Its Impact on Survival

Background

The aims of the study were to examine the rates of and reasons for unplanned hospitalization after start of palliative radiotherapy or chemoradiation (CRT), and to study whether unplanned hospitalization deteriorates patients’ prognosis. In addition, risk factors were identified.

Methods

A retrospective review of 136 patients treated with palliative radiotherapy or CRT was performed. Inclusion criteria were prescribed total dose at least 30 Gy and outpatient at the start of treatment. Uni- and multivariate analyses were employed.

Results

Fifty-eight patients (43%) were hospitalized within 3 months from start of radiotherapy or CRT. Their median overall survival was 6.7 months as compared to 11.1 months in non-hospitalized patients (P = 0.09). The median length of hospitalization was 8 days (range 1 - 61). In patients with possibly treatment-related hospitalization (n = 32), median survival was 5.0 months, significantly shorter than the 11.1 months observed in the remaining patients (P = 0.006). In multivariate analysis, only one variable was significantly associated with higher risk of unplanned hospitalization: previous hospitalization in the last 4 weeks before commencing radiotherapy or CRT.

Conclusions

Unplanned hospitalization occurred frequently in a standard care setting without early involvement of a dedicated palliative team. Patients with preceding hospitalization might represent a group that is particularly vulnerable, thus qualifying for a targeted intervention aiming at continued outpatient care.

Intensity of end-of-life health care and mortality after systemic anti-cancer treatment in patients with advanced lung cancer

BACKGROUND

We aimed to study the mortality and intensity of health care in patients with advanced lung cancer who received systemic anti-cancer treatment (SACT) compared with patients who were not eligible for SACT (no-SACT).

METHODS

A retrospective cohort of patients with lung cancer, who were treated at the North Estonia Medical Centre from 2015 to 2017, was linked to population-based health care data from the Estonian Health Insurance Fund. We calculated 14- and 30-day mortality after SACT and used a composite measure of intensity of care, comprised from the following: emergency department visit, admission to hospital, admission to intensive care unit, receipt of radiotherapy or systemic treatment.

RESULTS

The median overall survival (OS) of patients who received at least one cycle of SACT (n = 489) was 9.1 months and in patients with no-SACT (n = 289) 1.3 months (hazard ratio [HR] = 4.23, 95% CI = 3.60-5.00). During the final 30 days of life, intensive EOL care was received by 69.9% of the SACT patients and 43.7% of the no-SACT patients. Intensive EOL care in the last 30 days of life is more probable among patients in the SACT group (odds ratio [OR] = 3.58, 95% CI = 2.54-5.04, p <  0.001), especially in those with a stage IV disease (OR = 1.89, 95% CI = 1.31-2.71, p = 0.001). In the SACT group 6.7 and 14.7% of patients died within 14 days and 30 days after the last cycle, respectively.

CONCLUSIONS

Significant proportion of patients with advanced lung cancer continue to receive intensive care near death. Our results reflect current patterns of EOL care for patients with lung cancer in Estonia. Availability of palliative care and hospice services must be increased to improve resource use and patient-oriented care.

Relative Impact of Anticancer Therapy on Unplanned Hospital Care in Patients With Non-Small-Cell Lung Cancer

PURPOSE

In lung cancer, unplanned hospital care is a significant driver of costs. While toxicities of cancer therapies are well-known, there are little data on their relative contribution to unplanned care. This study aims to (1) determine the relative impact of tyrosine-kinase inhibitor (TKI) therapy, immune checkpoint inhibitor immunotherapy, and cytotoxic chemotherapy on unplanned hospital care and (2) identify potential strategies to prevent unplanned hospital encounters in patients with non-small-cell lung cancer (NSCLC).

METHODS

A research database search of the electronic health record was used to identify 97 patients with established NSCLC who were undergoing either TKI therapy, immunotherapy, or chemotherapy at our institution and visited our emergency department (ED) in 2018. The resulting 173 ED encounters were reviewed to determine (1) the cause (cancer, therapy, other, or rule-out) of each encounter and (2) whether the encounter was preventable.

RESULTS

A small portion (9%) of all unplanned hospital encounters were therapy related (2% in the TKI therapy group, 12% in the immunotherapy group, and 21% in the chemotherapy group). Cancer itself was the leading cause (54%) of the encounters. Over 20% of all encounters were classified as preventable, and half of those encounters were deemed unnecessary.

DISCUSSION

TKI therapy, immunotherapy, and, to a lesser extent, chemotherapy are relatively small drivers of unplanned acute hospital care for patients with NSCLC. A significant share of unplanned hospital encounters may be prevented through proactive evidence-based initiatives.

Unplanned hospitalizations in older patients with cancer: Occurrence and predictive factors

BACKGROUND

This study aims to investigate the occurrence of unplanned hospitalizations in older patients with cancer and to determine predictive factors.

METHODS

A prospective Belgian multicentre (n = 22), observational cohort study was performed. Patients ≥70 years with a malignant tumor were included. Patients underwent G8 screening followed by geriatric assessment (GA) if abnormal at baseline and were followed for unplanned hospitalizations at approximately three months. Uni- and multivariable regression models were performed to determine predictive factors associated with unplanned hospitalizations in older patients with an abnormal G8.

RESULTS

In total, 7763 patients were included in the current analysis of which 2409 (31%) patients with a normal G8 score and 5354 (69%) with an abnormal G8 score. Patients with an abnormal G8 were hospitalized more frequently than patients with a normal G8 (22.9% versus 12.4%; p < 0.0001). Reasons for unplanned hospitalizations were most frequently cancer related (25.7%) or cancer therapy related (28%). In multivariable analysis, predictive factors for unplanned hospitalizations in older patients with cancer and an abnormal G8 were female gender, absence of surgery, chemotherapy, ADL dependency, malnutrition and presence of comorbidities.

CONCLUSION

Older patients with cancer and an abnormal G8 screening present a higher risk (23%) for unplanned hospitalizations. Predictive factors for these patients were identified and include not only patient and treatment related factors but also GA related factors.

The impact of initial treatment strategy and survival time on quality of end-of-life care among patients with oesophageal and gastric cancer: A population-based cohort study

BACKGROUND

Oesophageal and gastric cancer are highly lethal malignancies with a 5-year survival rate of 15-29%. More knowledge is needed about the quality of end-of-life care in order to understand the burden of the illness and the ability of the current health care system to deliver timely and appropriate end-of-life care. The aim of this study was to describe the impact of initial treatment strategy and survival time on the quality of end-of-life care among patients with oesophageal and gastric cancer.

METHODS

This register-based cohort study included patients who died from oesophageal and gastric cancer in Sweden during 2014-2016. Through linking data from the National Register for Esophageal and Gastric Cancer, the National Cause of Death Register, and the Swedish Register of Palliative Care, 2156 individuals were included. Associations between initial treatment strategy and survival time and end-of-life care quality indicators were investigated. Adjusted risk ratios (RRs) with 95% confidence intervals were calculated using modified Poisson regression.

RESULTS

Patients with a survival of ≤3 months and 4-7 months had higher RRs for hospital death compared to patients with a survival ≥17 months. Patients with a survival of ≤3 months also had a lower RR for end-of-life information and bereavement support compared to patients with a survival ≥17 months, while the risks of pain assessment and oral assessment were not associated with survival time. Compared to patients with curative treatment, patients with no tumour-directed treatment had a lower RR for pain assessment. No significant differences were shown between the treatment groups regarding hospital death, end-of-life information, oral health assessment, and bereavement support.

CONCLUSIONS

Short survival time is associated with several indicators of low quality end-of-life care among patients with oesophageal and gastric cancer, suggesting that a proactive palliative care approach is imperative to ensure quality end-of-life care.

Quantified Kinematics to Evaluate Patient Chemotherapy Risks in Clinic

PURPOSE

Performance status (PS) is a key factor in oncologic decision making, but conventional scales used to measure PS vary among observers. Consumer-grade biometric sensors have previously been identified as objective alternatives to the assessment of PS. Here, we investigate how one such biometric sensor can be used during a clinic visit to identify patients who are at risk for complications, particularly unexpected hospitalizations that may delay treatment or result in low physical activity. We aim to provide a novel and objective means of predicting tolerability to chemotherapy.

METHODS

Thirty-eight patients across three centers in the United States who were diagnosed with a solid tumor with plans for treatment with two cycles of highly emetogenic chemotherapy were included in this single-arm, observational prospective study. A noninvasive motion-capture system quantified patient movement from chair to table and during the get-up-and-walk test. Activity levels were recorded using a wearable sensor over a 2-month period. Changes in kinematics from two motion-capture data points pre- and post-treatment were tested for correlation with unexpected hospitalizations and physical activity levels as measured by a wearable activity sensor.

RESULTS

Among 38 patients (mean age, 48.3 years; 53% female), kinematic features from chair to table were the best predictors for unexpected health care encounters (area under the curve, 0.775 ± 0.029) and physical activity (area under the curve, 0.830 ± 0.080). Chair-to-table acceleration of the nonpivoting knee (t = 3.39; P = .002) was most correlated with unexpected health care encounters. Get-up-and-walk kinematics were most correlated with physical activity, particularly the right knee acceleration (t = -2.95; P = .006) and left arm angular velocity (t = -2.4; P = .025).

CONCLUSION

Chair-to-table kinematics are good predictors of unexpected hospitalizations, whereas the get-up-and-walk kinematics are good predictors of low physical activity.

InSight Care Pilot Program: Redefining Seeing a Patient

PURPOSE

Early detection and management of symptoms in patients with cancer improves outcomes. However, the optimal approach to symptom monitoring and management is unknown. InSight Care is a mobile health intervention that captures symptom data and facilitates patient-provider communication to mitigate symptom escalation.

PATIENTS AND METHODS

Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. Technology supporting the program included the following: a predictive model that identified patient risk for a potentially preventable acute care visit; a secure patient portal enabling communication, televisits, and daily delivery of patient symptom assessments; alerts for concerning symptoms; and a symptom-trending application. The main outcomes of the pilot were feasibility and acceptability evaluated through enrollment and response rates and symptom alerts, and perceived value evaluated on the basis of qualitative patient and provider interviews.

RESULTS

The pilot program enrolled 100 high-risk patients with solid tumors and lymphoma (29% of new treatment starts v goal of 25%). Over 6 months of follow-up, the daily symptom assessment response rate was 56% (the goal was 50%), and 93% of patients generated a severe symptom alert. Patients and providers perceived value in the program, and archetypes were developed for program improvement. Enrolled patients were less likely to use acute care than were other high-risk patients.

CONCLUSION

InSight Care was feasible and holds the potential to improve patient care and decrease facility-based care. Future work should focus on optimizing the cadence of patient assessments, the workforce supporting remote symptom management, and the return of symptom data to patients and clinical teams.

Hospitalizations and length of stay of cancer patients: A cohort study in the Brazilian Public Health System

The hospitalizations are part of cancer care and has been studied by researchers worldwide. A better understanding about their associated factors may help to achieve improvements on this area. The aims of this study were to investigate the association between demographic and clinical characteristics and hospitalizations, as well as between these characteristics and the length of stay (LOS), within the first year of outpatient treatment, for the most incident cancers in the Brazilian population. In this cohort study, we investigated 417,477 patients aged 19 years or more, who started outpatient cancer treatment, from 2010-2014, for breast, prostate, colorectal, cervix, lung and stomach cancers. The outcomes evaluated were: i) Hospitalizations within the first year of outpatient cancer treatment; and ii) LOS of the hospitalized patients. It was performed a binary logistic regression to evaluate the association between the explanatory variables and the hospitalizations and a negative binomial regression to evaluate their influence on the length of hospital stay. The hospitalizations occurred for 34% of patients, with a median of LOS of 6 days (IQR: 2-15). Female patients were 16% less likely to be hospitalized (OR: 0.84; 95% CI: 0.82-0.86), with lower average of LOS (AR: 0.98; 95% CI: 0.97-0.99), each additional year of age reduced in 2% the hospitalization odds (OR: 0.98; 95% CI: 0.98-0.99) and in 1% the average of LOS (AR: 0.99; 95% CI: 0.98-0.99), patients from South region had twice more chances of hospitalization than from North region (OR: 2.01; 95% CI: 1.93-2.10) and patients with colorectal cancer had greater probability of hospitalization (OR: 4.42; 95% CI: 4.27-4.48), with the highest average of LOS (AR: 1.37; 95% CI: 1.35-1.40). In view of our results, we consider that the government must expand the policies with potential to reduce the number of hospitalizations.