Inpatient admissions related to immune-related adverse effects (irAE) among patients treated with immune checkpoint inhibitors for advanced malignancy: A tsunami is coming, but are we ready?

127

Background: Disruption of the immune system with immune checkpoint inhibitors can result in a multitude of immune-related adverse effects (irAE). While irAEs have been well-reported in clinical trials, the impact and magnitude of irAE’s in the real-world, particularly inpatient is unclear. Methods: Data was collected on patients with advanced malignancy who experienced a suspected irAE needing admission to an academic hospital (Feb 2011 to June 2017). Each case was reviewed comprehensively by minimum of two reviewers, including one sub-specialist. In addition, oncologists at our institution were surveyed regarding their confidence about managing patients with irAEs. Results: Over a span of 6 years, there were 343 hospitalizations for suspected irAEs and the majority (65%; N = 223) were confirmed irAEs that required treatment with immunosuppression or therapy stopped as result. The mean length of stay was 6.3 days (range 1 to 31 days), readmission rate for another irAE event 25%, total readmission rate 61.7%, and inpatient mortality 8%. The most common irAEs were enterocolitis (43.9%), pulmonary (16%), hepatic (15%), neurological (8.9%), endocrinopathies (7.1%), rheumatological (4%), dermatological (3%), cardiovascular (3%), renal (1.8%), and allergy (1.3%). Over the past 5 years, there was a significant increase in admissions due to irAEs (admissions in 2016 vs 2011, odds ratio = 3.07; p < 0.01). The Cancer Center survey (N = 26) revealed majority of oncologists do not feel very comfortable managing irAEs, and 48% felt that irAE complications should be managed on a different service. Conclusions: irAEs from immune checkpoint inhibitors can result in prolonged hospitalizations, high rate of readmissions, and mortality. The number of patients admitted due to irAEs has significantly increased by more than three-fold in the recent years, but majority of oncologists do not feel very comfortable managing irAEs. Consequently, there is a critical need for coordinated multidisciplinary approach, comprehensive provider education, and translational research program for early detection and intervention.

Predictors of Posthospital Transitions of Care in Patients With Advanced Cancer

Purpose Patients with advanced cancer experience potentially burdensome transitions of care after hospitalizations. We examined predictors of discharge location and assessed the relationship between discharge location and survival in this population. Methods We conducted a prospective study of 932 patients with advanced cancer who experienced an unplanned hospitalization between September 2014 and March 2016. Upon admission, we assessed patients' physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire-4). The primary outcome was discharge location (home without hospice, postacute care [PAC], or hospice [any setting]). The secondary outcome was survival. Results Of 932 patients, 726 (77.9%) were discharged home without hospice, 118 (12.7%) were discharged to PAC, and 88 (9.4%) to hospice. Those discharged to PAC and hospice reported high rates of severe symptoms, including dyspnea, constipation, low appetite, fatigue, depression, and anxiety. Using logistic regression, patients discharged to PAC or hospice versus home without hospice were more likely to be older (odds ratio [OR], 1.03; 95% CI, 1.02 to 1.05; P < .001), live alone (OR, 1.95; 95% CI, 1.25 to 3.02; P < .003), have impaired mobility (OR, 5.08; 95% CI, 3.46 to 7.45; P < .001), longer hospital stays (OR, 1.15; 95% CI, 1.11 to 1.20; P < .001), higher Edmonton Symptom Assessment System physical symptoms (OR, 1.02; 95% CI, 1.003 to 1.032; P < .017), and higher Patient Health Questionnaire-4 depression symptoms (OR, 1.13; 95% CI, 1.01 to 1.25; P < .027). Patients discharged to hospice rather than PAC were more likely to receive palliative care consultation (OR, 4.44; 95% CI, 2.12 to 9.29; P < .001) and have shorter hospital stays (OR, 0.84; 95% CI, 0.77 to 0.91; P < .001). Patients discharged to PAC versus home had lower survival (hazard ratio, 1.53; 95% CI, 1.22 to 1.93; P < .001). Conclusion Patients with advanced cancer who were discharged to PAC facilities and hospice had substantial physical and psychological symptom burden, impaired physical function, and inferior survival compared with those discharged to home. These patients may benefit from interventions to enhance their quality of life and care.

Processes of code status transitions in hospitalized patients with advanced cancer

BACKGROUND

Although hospitalized patients with advanced cancer have a low chance of surviving cardiopulmonary resuscitation (CPR), the processes by which they change their code status from full code to do not resuscitate (DNR) are unknown.

METHODS

We conducted a mixed-methods study on a prospective cohort of hospitalized patients with advanced cancer. Two physicians used a consensus-driven medical record review to characterize processes that led to code status order transitions from full code to DNR.

RESULTS

In total, 1047 hospitalizations were reviewed among 728 patients. Admitting clinicians did not address code status in 53% of hospitalizations, resulting in code status orders of "presumed full." In total, 275 patients (26.3%) transitioned from full code to DNR, and 48.7% (134 of 275 patients) of those had an order of "presumed full" at admission; however, upon further clarification, the patients expressed that they had wished to be DNR before the hospitalization. We identified 3 additional processes leading to order transition from full code to DNR acute clinical deterioration (15.3%), discontinuation of cancer-directed therapy (17.1%), and education about the potential harms/futility of CPR (15.3%). Compared with discontinuing therapy and education, transitions because of acute clinical deterioration were associated with less patient involvement (P = .002), a shorter time to death (P < .001), and a greater likelihood of inpatient death (P = .005).

CONCLUSIONS

One-half of code status order changes among hospitalized patients with advanced cancer were because of full code orders in patients who had a preference for DNR before hospitalization. Transitions due of acute clinical deterioration were associated with less patient engagement and a higher likelihood of inpatient death. Cancer 2017;123:4895-902. © 2017 American Cancer Society.

Post-discharge transitions of care for hospitalized patients with advanced cancer

6504

Background: Patients with advanced cancer experience frequent hospitalizations and burdensome transitions of care post-discharge. We examined predictors of discharge location for patients with advanced cancer. Methods: We prospectively enrolled patients with advanced cancer with unplanned hospitalizations from 9/14 to 3/16. Upon admission, we used the Edmonton Symptom Assessment Scale and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. We used logistic regression models to identify predictors of discharge to location other than home, including post-acute care (PAC) [skilled nursing facility or long term acute care hospital] or hospice [any setting]. We used Cox regression models adjusted for clinical variables to assess the relationship between discharge location and survival. Results: Out of 932 patients, 726 (77.9%) were discharged home, 118 (12.7%) to PAC and 88 (9.4%) to hospice. Compared with patients discharged home, those discharged to PAC or hospice had higher symptom burden, including dyspnea, constipation, low appetite, drowsiness, fatigue, depression, and anxiety (all p < 0.05). Patients discharged to PAC or hospice vs. home were more likely to be older (OR 1.03, p < 0.0001), live alone (OR 1.95, 95% CI: 1.25-3.02, p < 0.003), have impaired mobility (OR 5.08, 95% CI: 3.46-7.45, p < 0.0001), longer length of stay (OR 1.15, 95% CI: 1.11-1.20, p < 0.0001), higher ESAS physical symptoms (OR 1.02, 95% CI: 1.003-1.032, p < 0.017), and higher PHQ-2 depression symptoms (OR 1.13, 95% CI: 1.01-1.25, p < 0.027). Patients discharged to hospice vs. PAC were more likely to receive palliative care consultation (OR 4.44, 95% CI: 2.12 to 9.29, p < 0.0001) and have shorter length of stay (OR 0.84, 95% CI: 0.77 to 0.91, p < 0.0001). Compared with patients discharged home, those discharged to PAC had lower survival (HR 1.53, 95% CI 1.22-1.93, p < 0.0001). Conclusions: Patients with advanced cancer discharged to PAC or hospice have substantial physical and psychological symptom burden and poor physical function. Patients discharged to PAC also have inferior survival compared with those discharged home. They may benefit from targeted interventions to improve their quality of life and care.

Symptom burden and hospital length of stay among patients with curable cancer

6579

Background: Prolonged hospital admissions are often inconsistent with patients’ preferences and incur significant costs. While patients’ symptoms may result in hospitalizations, the relationship between patients’ symptom burden and their hospital length-of-stay (LOS) has not been fully explored in patients with curable cancers. Methods: We prospectively enrolled patients with curable cancer and unplanned hospital admissions between 8/2015 and 12/2016. Within the first 5 days of admission, we assessed patients’ physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10 with higher scores indicating greater symptom burden) and psychological symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically and continuous with higher scores indicating greater distress). We created summated ESAS total and physical symptom variables. To assess the relationship between patients’ symptom burden and their hospital LOS, we used separate linear regression models adjusted for age, sex, marital status, education level, time since cancer diagnosis, and cancer type. Results: We enrolled 452 of 497 (91%) approached patients (mean age = 61.9 years; 188 [42%] female). Over half had hematologic cancers (n = 249, 55%). Mean hospital LOS was 8.3 days. Over one-tenth of patients screened positive for PHQ-4 depression (n = 74, 16%) and anxiety (n = 60, 13%) symptoms. Mean ESAS symptom scores were highest for fatigue (6.6), drowsiness (5.4), pain (4.9), and lack of appetite (4.8). In multivariable regression analysis, patients’ physical and psychological symptoms were associated with longer hospital LOS (table). Conclusions: Patients with curable cancer and unplanned hospital admissions experience a substantial symptom burden, which predicts for prolonged hospitalizations. Importantly, patients’ symptoms are modifiable risk factors that, if properly addressed, can improve care delivery and may have the potential to help decrease prolonged hospitalizations. [Table: see text]

The importance of recognizing and addressing depression in patients with advanced cancer

10050

Background: Patients with cancer often experience depression, which is associated with worse outcomes, including longer hospital length of stay (LOS). Although antidepressant medication can improve depressive symptoms in patients with cancer, it is unclear whether their use translates into better outcomes. We sought to clarify the relationship between depressive symptoms, antidepressant medication, and hospital LOS in patients with advanced cancer. Methods: We enrolled hospitalized patients with advanced cancer from 9/2014 to 4/2016 as part of a longitudinal data repository. We examined patients’ medical records to obtain information about documented depressive symptoms in the 3 months prior to admission and use of antidepressant medication at the time of admission. Using descriptive statistics, we compared differences in patient characteristics and hospital LOS across these groups. We used linear regression to examine associations and moderation effects between depressive symptoms, use of antidepressant medication, and hospital LOS. Results: Of 1,036 enrolled patients (89.9% of approached), 126 (12.2%) had documented depressive symptoms in the 3 months prior to admission and 288 (27.8%) were taking an antidepressant medication at the time of admission. Patients with depressive symptoms were more likely to be on antidepressant medication at admission than those without depressive symptoms (48.4% vs 24.9%, p < .001). Patients taking antidepressant medication were younger (62.4 vs 64.4 years, p = .026) and more likely to be female (55.2% vs 47.2%, p = .021). Depressive symptoms were associated with longer hospital LOS (7.3 vs 6.1 days, p = .036), and antidepressant medication was a moderator of this relationship. Among patients not on antidepressant medication, depressive symptoms were associated with longer hospital LOS (7.9 vs 6.1 days, p = .025), but among those on antidepressant medication, depressive symptoms were not associated with hospital LOS (6.6 vs 6.2 days, p = .588). Conclusions: Antidepressant medication moderated the relationship between depressive symptoms and longer hospital LOS. Our results support the need to recognize and address depressive symptoms in patients with advanced cancer.

Potentially avoidable hospitalizations in patients with advanced cancer

e18275

Background: Cancer patients and their clinicians often wish to avoid preventable hospital admissions, but efforts to understand the predictors of avoidable hospitalizations are lacking. We sought to examine reasons for hospital admissions in patients with advanced cancer, identify potentially avoidable hospitalizations (PAH), and explore predictors of PAH. Methods: We prospectively enrolled hospitalized patients with advanced cancer from 9/2014 - 11/2014 as part of a longitudinal data repository to define symptom burden in this population. Upon admission, we assessed patients’ symptom burden (Edmonton Symptom Assessment System [ESAS]; scored 0-10). We created a summated ESAS physical symptom variable. We used consensus-driven medical record review to identify the primary reason for each hospital admission and categorize it as PAH or not based on of an adaptation of Graham’s criteria for PAH. We used mixed multivariable logistic regression analyses to identify predictors of PAH. Results: We assessed 477 hospital admissions in 200 consecutively admitted patients (mean age = 64.6; 47% female; 67% married). Over half of admissions came through the emergency department (56%). The most common reasons for admissions were fever/infection (30%), symptoms (26%), and planned admission for chemotherapy or procedure (10%). We identified 149 (31%) as PAH. Among these PAH, 45 (30%) were readmissions due to failure of timely outpatient follow-up (within 7 days of discharge) and 44 (30%) were due to premature discharge from prior hospitalization. In a mixed logistic regression model, being married (odds ratio [OR] 0.48 [0.28-0.81]; p < 0.01) was associated with lower likelihood of PAH, while higher physical symptom burden (OR 1.02 [1.00-1.04]; p = 0.04) was associated with greater likelihood of PAH. Conclusions: We identified that a substantial proportion of hospitalizations in patients with advanced cancer are potentially avoidable, often related to failure of timely outpatient follow-up and premature hospital discharge. Our results demonstrate that patients’ symptom burden predicts PAH, thus underscoring the need to address patients’ symptoms in order to reduce preventable hospital admissions.

Code status transitions from full code to do-not-resuscitate (DNR) among hospitalized patients with advanced cancer

6592

Background: Code status discussions ensure the delivery of preference-concordant care. However, the processes by which hospitalized patients with advanced cancer change their code status from full code to DNR are unknown. Methods: We conducted a mixed-methods study on a prospective cohort of patients with advanced cancer who were hospitalized from 9/14-10/15. Two physicians used a consensus-driven medical record review to characterize processes leading to code status transitions from full code to DNR. We explored factors associated with these processes using χ2 and Kruskal-Wallis tests. Results: We reviewed 1,047 hospitalizations among 728 patients. Admitting physicians did not address code status in 52.1% of these hospitalizations, leading code status orders to be “presumed full.” 273 patients (37.5%) transitioned from full code to DNR; 132 (48.4%) of them had erroneous “presumed full” code status orders on admission. We identified three additional processes leading to transitions from full code to DNR: acute clinical deterioration (15.4%), discontinuation of cancer-directed therapy (17.2%), and hypothetical discussions regarding the futility of CPR (15.4%). Among these processes, code status transitions due to acute clinical deterioration were associated with less patient involvement, shorter time to death, and higher likelihood of inpatient death. Changes due to hypothetical discussions were more likely to involve palliative care. Conclusions: Half of code status transitions among hospitalized patients with advanced cancer were due to erroneous full code orders, underscoring a greater need to discuss patient CPR preferences. Transitions due to acute clinical deterioration were associated with less patient engagement and higher likelihood of inpatient death. [Table: see text]

Symptom burden to predict health care utilization in hospitalized patients with incurable cancer

98

Background: Patients with incurable cancer are often hospitalized and have frequent readmissions after discharge. Considering the high physical and psychological symptom burden in this population, we sought to investigate symptoms as predictors of hospital length of stay (LOS) and time to first unplanned readmission. Methods: We consecutively enrolled incurable cancer patients with unplanned hospital admissions from 9/2014-4/2016. Within the first 5 days of admission, we assessed physical (Edmonton Symptom Assessment System [ESAS]; scored 0-10) and mood symptoms (Patient Health Questionnaire 4 [PHQ-4]; scored categorically). We created summated ESAS total and physical symptom variables. To identify predictors of LOS we used linear regression and for time to readmission we used Cox regression, with all models adjusted for age, sex, marital status, comorbidity, education, cancer type and time since incurable diagnosis. Results: We enrolled 1,000 of 1,227 (81%) eligible patients (mean age = 63.4; 50% female; 66% married). Gastrointestinal (33%) and lung (18%) cancers were the most common. Mean hospital LOS was 6.2 days and 30-day readmission rate was 25%. Over half of patients reported moderate/severe fatigue, drowsiness, lack of appetite, pain and poor well-being. Over one-fourth screened positive for PHQ depression and anxiety. All physical and mood symptoms individually predicted for longer LOS. Pain, nausea, poor well-being, ESAS total, ESAS physical and PHQ anxiety predicted for shorter time to readmission. Conclusions: Hospitalized patients with incurable cancer experience a high symptom burden, which correlates with their health care utilization. Both physical and psychological symptoms predict for longer hospital LOS and shorter time to readmission. These findings can inform interventions targeting patients’ symptoms during hospital admissions in an effort to improve health care delivery and utilization. [Table: see text]

Symptom burden in hospitalized patients with advanced cancer

100

Background: Patients with advanced cancer experience high rates of both physical and psychological morbidity, but data describing patients’ symptoms during hospital admissions are lacking. We sought to describe symptom burden in hospitalized patients with incurable solid and hematologic malignancies. Methods: We prospectively enrolled patients with incurable cancers admitted to the Massachusetts General Hospital from 9/1/2014 through 5/1/2015. Within the first week of their admission, we assessed physical and psychological symptoms using the Edmonton Symptom Assessment System-revised (ESAS-r). Beginning 11/15/2015, we also administered the Patient Health Questionnaire 4 (PHQ-4), scored categorically. Results: We enrolled 457 of 547 (84%) eligible patients. Participants (mean age=63.8 years; n=231, 51% female) had the following malignancies: gastrointestinal (n=149, 33%), lung (n=77, 17%), genitourinary (n=52, 11%), breast (n=33, 7%), hematologic (n=24, 5%), and other solid tumors (n=122, 27%). Using the ESAS-r, tiredness, drowsiness, anorexia, and pain were the most common severe symptoms. Using the PHQ-4, approximately one-third of participants screened positive for depression (91/271, 34%) and anxiety (86/273, 32%). Conclusions: Hospitalized patients with incurable solid and hematologic malignancies experience substantial physical and psychological symptoms. Most patients reported at least moderate tiredness, drowsiness, anorexia and pain. Additionally, a concerning proportion reported depression and anxiety. Our data demonstrate the need for efforts to alleviate the physical symptoms experienced by this population, while also seeking to understand and address their psychological needs. [Table: see text]