Association Between Hospitals’ Risk-Adjusted Emergency Department Visits and Survival and Costs in Kidney Cancer Patients Undergoing Nephrectomy

PurposeTo estimate the association between a hospital’s risk-adjusted emergency department (ED) visit rate and its risk-adjusted mortality rate and costs among kidney cancer patients undergoing initial nephrectomy.Patients and MethodsUsing 2007-2012 Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we used logistic regression to model ED visit occurrence within 30 and 365 days for all kidney cancer patients receiving initial surgery. Our model controlled for demographics, stage, histology, systemic targeted therapy, and comorbidities. Based on model predictions, we created a ratio of actual versus predicted ED visits for hospitals to identify hospitals with higher and lower than predicted ED visit rates. We estimated the association between the hospitals’ ED visit ratio and hospitals’ risk-adjusted 365-day mortality rates, and 6- and 12-month total costs and total costs (less ED visits).ResultsIn our sample of 6078 patients, 15.5% had an ED visit within 30 days of surgery and 43.5% within 365 days. For hospitals with ≥ 11 patients, we found no statistically significant association between 30-day or 365-day risk-adjusted ED visit rate and their 365-day risk-adjusted mortality rate. Hospitals’ 30-day ED visit rates were not significantly associated with either 6- or 12-month costs. However, hospitals’ 365-day ED visit rates were significantly associated with 12-month costs, even when excluding the cost of the ED visit.ConclusionOur results suggest hospitals’ risk-adjusted ED visit rates capture a qualitatively different measure of quality than the more commonly reported mortality rates. Longer term ED visit rates are significantly associated with increased costs while 30-day ED visits are not.     

Acute Care Use by Breast Cancer Patients on Adjuvant Chemotherapy in Alberta: Demonstrating the Importance of Measurement to Improving Quality

Breast cancer patients receiving adjuvant chemotherapy are at increased risk of acute care use. The incidence of emergency department (ED) visits and hospitalizations (H) have been characterized in other provinces but never in Alberta. We conducted a retrospective population-based cohort study using administrative data of women with stage I-III breast cancer receiving adjuvant chemotherapy. Rates of ED and H use in the 180 days following chemotherapy initiation were determined, and logistic regression was performed to identify risk factors. We found that 47% of women receiving adjuvant chemotherapy experienced ED or H, which compared favourably to other provinces. However, Alberta had the highest rate of febrile neutropenia-related ED visits, and among the highest chemotherapy-related ED visits. The incidence of acute care use increased over time, and there were significant institutional differences despite operating under a single provincial healthcare system. Our study demonstrates the need for systematic measurement and the importance of quality improvement programs to address this gap.     

Predictors of Urgent Cancer Care Clinic and Emergency Department Visits for Individuals Diagnosed with Cancer

In 2013, CancerCare Manitoba (CCMB) launched an urgent cancer care clinic (UCC) to meet the needs of individuals diagnosed with cancer experiencing acute complications of cancer or its treatment. This retrospective cohort study compared the characteristics of individuals diagnosed with cancer that visited the UCC to those who visited an emergency department (ED) and determined predictors of use. Multivariable logistic mixed models were run to predict an individual’s likelihood of visiting the UCC or an ED. Scaled Brier scores were calculated to determine how greatly each predictor impacted UCC or ED use. We found that UCC visits increased up to 4 months after eligibility to visit and then decreased. ED visits were highest immediately after eligibility and then decreased. The median number of hours between triage and discharge was 2 h for UCC visits and 9 h for ED visits. Chemotherapy had the strongest association with UCC visits, whereas ED visits prior to diagnosis had the strongest association with ED visits. Variables related to socioeconomic status were less strongly associated with UCC or ED visits. Future studies would be beneficial to planning service delivery and improving clinical outcomes and patient satisfaction.     

Evidence for racial/ethnic disparities in emergency department visits following breast cancer surgery among women in California: a population-based study

Purpose

Racial/ethnic disparities in breast cancer outcomes may be related to quality of care and reflected in emergency department (ED) visits following primary treatment. We examined racial/ethnic variation in ED visits following breast cancer surgery.

Methods

Using linked data from the California Cancer Registry and California Office of Statewide Health Planning and Development, we identified 151,229 women diagnosed with stage 0-III breast cancer between 2005 and 2013 who received surgical treatment. Differences in odds of having at least one breast cancer-related ED visit within 90 days post-surgery were estimated with logistic regression controlling for clinical and sociodemographic variables. Secondary analyses examined health care-related moderators of disparities.

Results

Hispanics and non-Hispanic (NH) Blacks had an increased likelihood of having an ED visit within 90 days of surgery compared to NH Whites [OR?=?1.11 (1.04–1.18), p?=?0.0016; OR?=?1.38 (1.27–1.50), p?<?0.0001, respectively]; the likelihood was reduced in Asian/Pacific Islanders [aOR?=?0.77 (0.71–0.84), p?<?0.0001]. Medicaid and Medicare (vs. commercial insurance) increased the likelihood of ED visit for NH Whites, and to a lesser degree for Hispanics and NH Blacks (p?<?0.0001 for interaction). Receipt of surgery at an NCI-designated Comprehensive Cancer Center or at a for-profit (vs. non-profit) hospital was associated with reduced likelihood of ED visits for all groups.

Conclusion

Racial/ethnic disparities in ED visits following breast cancer surgery persist after controlling for clinical and sociodemographic variables. Improving quality of care following breast cancer surgery could improve outcomes for all groups.

     

Lung Cancer Pre-Diagnostic Pathways from First Presentation to Specialist Referral

Background: Lung cancer is often diagnosed at a late stage with high associated mortality. Timely diagnosis depends on timely referral to a respiratory specialist; however, in Canada, little is known about how patients move through primary care to get to a respiratory specialist. Accordingly, we aimed to identify and describe lung cancer pre-diagnostic pathways in primary care from first presentation to referral. Methods: In this retrospective cohort study, patients with primary lung cancer were recruited using consecutive sampling (n = 50) from a lung cancer center in Montréal, Québec. Data on healthcare service utilization in primary care were collected from chart reviews and structured patient interviews and analyzed using latent class analysis to identify groups of patients with similar pre-diagnostic pathways. Each group was described based on patient- and tumor-related characteristics and the sequence of utilization activities. Results: 68% of the patients followed a pathway where family physician (FP) visits were dominant (“FP-centric”) and 32% followed a pathway where walk-in clinic and emergency department (ED) visits were dominant (“ED-centric”). Time to referral in the FP group was double that of the ED group (45 days (IQR: 12–111) vs. 22 (IQR: 5–69)) with more advanced disease (65% vs. 50%). In the FP group, 29% of the patients saw their FP three times or more before being referred and 41% had an ED visit. Conclusions: Our findings may reflect the challenge of diagnosing lung cancer in primary care, missed opportunities for earlier diagnosis, and a lack of integration between primary and specialist care.     

Emergency admission for cancer: a matter of survival?

The objective of this study was to compare the pre-hospital health care process, clinical characteristics at admission and survival of patients with a digestive tract cancer first admitted to hospital either electively or via the emergency department. The study involved cross-sectional analysis of information elicited through personal interview and prospective follow-up. The setting was a 450-bed public teaching hospital primarily serving a low-income area of Barcelona, Catalonia, Spain. Two hundred and forty-eight symptomatic patients were studied, who had cancer of the oesophagus (n = 31), stomach (n = 70), colon (n = 82) and rectum (n = 65). The main outcome measures were stage, type and intention of treatment and time elapsed from admission to surgery; the relative risk of death was calculated using Cox''s regression. There were 161 (65%) patients admitted via the emergency department and 87 (35%) electively. The type of physician seen at the first pre-hospital visit had more often been a general practitioner in the emergency than in the elective group (89% vs 75%, P < 0.01). Emergency patients had seen a lower number of physicians from symptom onset until admission, but two-thirds had made repeated visits to a primary care physician. Emergency patients were less likely to have a localized tumour and a diagnosis of cancer at admission, and surgery as the initial treatment. Median survival was 30 months for elective patients and 8 months for emergency patients (P < 0.001), and the relative risk of death (RR) was 1.83 (95% confidence interval, CI, 1.32-2.54). After adjustment for strong prognostic factors, emergency patients continued to experience a significant excess risk (RR = 1.58; CI 1.10-2.27). In conclusion, in digestive tract cancers, admission to hospital via the emergency department is a clinically important marker of a poorer prognosis. Emergency departments can only partly counterbalance deficiencies in the effectiveness of and integration among the different levels of the health system.     

Study of hormone refractory prostate cancer: hospital care and palliative care resource use at a VA medical center

Palliative care plays a central role in the management of hormone refractory prostate cancer patients (HRPC), yet little is known about palliative care resource use. Computerized medical records of a retrospective cohort of 89 consecutive HRPC patients seen at a VA medical center from 1994 to 1999 were reviewed for hospital and palliative care resource use in the last 6 months of life. There were 51 Caucasian and 38 African American patients; 95% of patients were admitted to the hospital for symptom management (median of 2 admissions); 98% visited clinics (median 19 visits); 35% went to the emergency room (median of 1 visit); 60% died in the hospital (median length of last hospitalization of 22 days); 49% received palliative radiation; 52% used rehabilitation; 57% received blood transfusion (median 2 units). Thirty-five patients (40%) received hospice care (median stay 35 days). The most frequently prescribed medications included opioids (90%), laxatives (89%), H2-blockers (57%), antiemetics (55%), diuretics (49%), and corticosteroids (43%). The prevalence of patients receiving opioids, as well as the dose of opioids increased over time. There was no difference in categories of palliative care resource use or survival by race. The median survival for all patients was 13 months. The results begin to highlight the extent of care and resources needed by patients with end-stage HRPC. This information will be of importance in planning palliative care for patients with HRPC and in designing future prospective studies.     

Health care utilization and mortality among elderly patients with myelodysplastic syndromes

BackgroundMortality in patients with myelodysplastic syndromes (MDS) is high, and patients are likely to require hospitalizations, emergency department (ED) visits, and transfusions. The relationships between these events and the MDS complications of anemia, neutropenia, and thrombocytopenia are not well understood.Patients and methodsA total of 1864 patients registered in the United States’ Surveillance Epidemiology and End Results (SEER) program and aged ≥66 years old when diagnosed with MDS in 2001 or 2002 were included. Medicare claims were used to identify MDS complications and utilization (hospitalizations, ED visits, and transfusions) until death or the end of 2005. Mortality was based on SEER data. Kaplan–Meier incidence rates were estimated and multivariable Cox models were used to study the association between complications and outcomes.ResultsThe 3-year incidence of anemia, neutropenia, and thrombocytopenia was 81%, 25%, and 41%, and the incidence of hospitalization, ED visit, and transfusion was 62%, 42%, and 45%, respectively. Median survival time was 22 months. Cytopenia complications were significantly associated with each of these outcomes.ConclusionsAll types of cytopenia are common among patients with MDS and are risk factors for high rates of health care utilization and mortality. Management of the complications of MDS may improve patient outcomes.     

It’s who you know: patient-sharing,quality, and costs of cancer survivorship care

Purpose

Cancer survivors frequently receive care from a large number of physicians, creating challenges for coordination. We sought to explore whether cancer survivors whose providers have more patients in common (e.g., shared patients) tend to have higher quality and lower cost care.

Methods

We performed a retrospective cohort study of 8,661 patients diagnosed with loco-regional breast, prostate, or colorectal cancer. We examined survivorship care from days 366 to 1,095 following their cancer diagnosis. Our primary independent variable was “care density,” a novel metric of the extent to which a patient’s providers share patients with one another. Our outcome measures were health care utilization, quality metrics, and costs.

Results

In adjusted analyses, we found that patients with high care density—indicating high levels of patient-sharing among their providers—had significantly lower rates of hospitalization (OR 0.87, 95 % CI 0.75–1.00) and higher odds of an eye examination for diabetes (OR 1.31, 95 % CI 1.03–1.66) compared to patients with low care density. High care density was not associated with emergency department visits, avoidable outcomes, lipid profile following an angina diagnosis, or odds of glycosylated hemoglobin testing for diabetes. Patients with high care density had significantly lower total costs of care over 24 months (beta coefficient ?$2,116, 95 % CI ?$3,107 to ?$1,125) along with lower inpatient and outpatient costs.

Conclusion

Cancer survivors treated by physicians who share more patients with one another tend to have some higher aspects of quality and lower cost care.

Implications of cancer survivors

If validated, care density may be a useful indicator for monitoring care coordination among cancer survivors and potentially targeting interventions that seek to improve care delivery.     

Cancer-associated neutropenic fever: clinical outcome and economic costs of emergency department care

Purpose. Febrile neutropenia (FN) is a common, costly, and potentially fatal complication in oncology. While FN in the inpatient setting has been extensively studied, only one study has evaluated emergency department (ED) care for FN cancer patients. That study found that 96% of patients survived the complication. We evaluated clinical and economic outcomes for cancer patients with chemotherapy-associated FN treated in an ED. Methods. ED records for consecutive oncology patients with FN were reviewed for information on death, intensive care unit (ICU) use, blood cultures, and costs. Results. Forty-eight patients (n = 57 visits) were evaluated. Six patients died from FN (12%) and four received ICU care within 2 weeks and survived (8%). Blood cultures were positive for 37% of the ED visits. The median ED time was 3.3 hours. In 91% of visits, i.v. antibiotics were administered in the ED, ordered at a median of 1.7 hours from triage (interquartile range [IQR], 1.2-2.8 hours). All patients with death or ICU in 2 weeks and all but one patient with positive blood cultures received antibiotics. The median per patient ED costs were $1,455 (IQR, $1,300-$1,579)-42.4% for hospital/nursing, 23.5% for radiology, 20.8% for physician services, 10.9% for diagnostic tests, and 2.4% for antibiotics. Conclusions. Cancer patients with FN in this sample presenting to the ED frequently had no identified source of infection. One third of the patients had positive ED blood cultures and one fifth died or required ICU care within 2 weeks. Costs of ED care were similar to the cost of a single day of inpatient care. Disclosure of potential conflicts of interest is found at the end of this article.     

Integration of Oncology and Palliative Care,a Forgotten Indicator: Shared Decision‐Making

A review article addressing the integration of oncology and palliative care is missing an important indicator: shared decision-making in patient care between oncologists and the palliative care team.Hui et al. [1] have published a review article addressing the integration of oncology and palliative care (PC). As described by the authors, integration is a heterogeneously defined concept, but since PC improves quality of life, quality of end-of-life care, satisfaction, costs of care, and survival, parameters to identify and improve integration are needed. This review identified 38 indicators related to structure and processes of clinical programs, education, research, and administration that could help define and measure integration. But we believe that the authors have missed one important indicator.In a case series study of metastatic cancer patients previously treated with chemotherapy, we studied the quality of end-of-life care [2] based on indicators such as location of death, number of emergency room visits in last month of life, and chemotherapy administration in last 14 days of life [3, 4]. In our study, PC team intervention, even when early, had no impact on indicators. Only patients’ case discussions at the dedicated weekly onco-palliative meetings independently decreased the odds of receiving chemotherapy in the last 14 days of life (odds ratio: 0.5; 95% confidence interval: 0.2–0.9) and of dying in an acute care setting (odds ratio: 0.3; 95% confidence interval: 0.1–0.5).In our opinion, this indicator is only partially captured by two indicators described in the review: communication, cooperation, and coordination between PC and oncology services (indicator 13); and involvement of PC in multidisciplinary tumor boards/patient care rounds (indicator 14). We propose that shared decision-making in patient care between oncologists and the PC team should be considered an indicator of integration of oncology and palliative care.     

Cardiovascular and Metabolic Toxicity of Abiraterone in Castration-resistant Prostate Cancer: Post-marketing Experience

IntroductionAbiraterone improves survival in metastatic castration-resistant prostate cancer (mCRPC) but may result in the development or worsening of comorbid conditions. We assessed the course of these conditions in patients receiving abiraterone in clinical practice and compared outcomes with those in clinical trials.Materials and MethodsMedical records of patients with mCRPC who started abiraterone at an academic institution between 2012 and 2015 were reviewed for emergency department (ED) visits, hospitalizations, and the development and/or worsening of key comorbid conditions while on abiraterone. Patient characteristics and adverse events were compared with those from clinical trials.ResultsIn a cohort of 174 patients, 28% experienced either the development or worsening of a comorbid disease; 8% required an ED visit or hospitalization owing to known adverse effects of abiraterone. Increasing age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.17), higher prostate-specific antigen at initiation of treatment (OR, 1.68; 95% CI, 1.18-2.47), preexisting uncontrolled hypertension (OR, 7.61; 95% CI, 1.22-38.70), congestive heart failure (OR, 7.61; 95% CI, 1.22-38.70), and cardiac arrhythmias (OR, 4.73; 95% CI, 1.39-15.12) were associated with increased odds of an ED visit or hospitalization owing to known adverse effects of abiraterone. The rate of discontinuation (6%) was similar to 1 phase III trial that demonstrated the drug’s efficacy in chemotherapy-naive patients.ConclusionFew patients discontinued abiraterone owing to toxicity; however, the fact that over one-quarter of patients experienced the development or worsening of cardiovascular and metabolic diseases warrants development of team-based approaches to the management of these comorbid conditions.     

Identifying potential indicators of the quality of end-of-life cancer care from administrative data.

PURPOSE: To explore potential indicators of the quality of end-of-life services for cancer patients that could be monitored using existing administrative data. METHODS: Quality indicators were identified and assessed by literature review for proposed indicators, focus groups with cancer patients and family members to assess candidate indicators and generate new ideas, and an expert panel ranking the meaningfulness and importance of each potential indicator using a modified Delphi approach. RESULTS: There were three major concepts of poor quality of end-of-life cancer care that could be examined using currently-available administrative data (such as Medicare claims): institution of new anticancer therapies or continuation of ongoing treatments very near death; a high number of emergency room visits, inpatient hospital admissions, or intensive care unit days near the end of life; and a high proportion of patients never enrolled in hospice, only admitted in the last few days of life, or dying in an acute-care setting. Concepts such as access to psychosocial and other multidisciplinary services and pain and symptom control are important and may eventually be feasible, but they cannot currently be applied in most data systems. Indicators based on limiting the use of treatments with low probability of benefit or indicators based on economic efficiency were not acceptable to patients, family members, or physicians. CONCLUSION: Several promising claims-based quality indicators were identified that, if found to be valid and reliable within data systems, could be useful in identifying health-care systems in need of improving end-of-life services.     

The impact of failure to achieve symptom control after resection of functional neuroendocrine tumors: An 8-institution study from the US Neuroendocrine Tumor Study Group

Palliative care (PC) seeks to improve the quality of life for patients facing serious illness. Several oncology organizations have guidelines about PC, reflecting the need to integrate PC into standard oncology care. Many surgical patients do not receive PC despite the need for these services and established surgical PC competencies. Recent educational and research efforts reveal increased appreciation of the need and benefit of integrating PC services with cancer care in general, and surgical care, specifically.     

Prevalence of Cancer Visits by Physician Specialty, 1997–2006

Understanding the prevalence of cancer-related visits by physician specialty may help target educational and quality improvement initiatives. Using the 1997–2006 National Ambulatory Medical Care Survey, adult ambulatory visits (N = 161,278) were classified by cancer diagnosis and patients’ characteristics and compared with physician specialty. The prevalence of cancer visits within each specialty varied from 0% to 62%. Aside from hematology/oncology (hem/onc) specialties, nine surgical specialties and four medical specialties had more than 1% cancer visits. Cancer patients with private insurance or Medicaid coverage were less likely to see hem/onc specialists compared to Medicare patients. Whereas hem/onc specialists primarily see cancer patients, general surgeons and primary care physicians provide a large amount of cancer services, particularly to underinsured patients. Thus, when trying to contact cancer patients or their physicians, health administrators, researchers, and practitioners should consider targeting general surgeons and primary care physicians in addition to hem/onc specialists.     

Assessing the Impact of the COVID-19 Pandemic on Emergency Department Use for Patients Undergoing Cancer-Directed Surgeries

Emergency department (ED) use is a concern for surgery patients, physicians and health administrators particularly during a pandemic. The objective of this study was to assess the impact of the pandemic on ED use following cancer-directed surgeries. This is a retrospective cohort study of patients undergoing cancer-directed surgeries comparing ED use from 7 January 2018 to 14 March 2020 (pre-pandemic) and 15 March 2020 to 27 June 2020 (pandemic) in Ontario, Canada. Logistic regression models were used to (1) determine the association between pandemic vs. pre-pandemic periods and the odds of an ED visit within 30 days after discharge from hospital for surgery and (2) to assess the odds of an ED visit being of high acuity (level 1 and 2 as per the Canadian Triage and Acuity Scale). Of our cohort of 499,008 cancer-directed surgeries, 468,879 occurred during the pre-pandemic period and 30,129 occurred during the pandemic period. Even though there was a substantial decrease in the general population ED rates, after covariate adjustment, there was no significant decrease in ED use among surgical patients (OR 1.002, 95% CI 0.957–1.048). However, the adjusted odds of an ED visit being of high acuity was 23% higher among surgeries occurring during the pandemic (OR 1.23, 95% CI 1.14–1.33). Although ED visits in the general population decreased substantially during the pandemic, the rate of ED visits did not decrease among those receiving cancer-directed surgery. Moreover, those presenting in the ED post-operatively during the pandemic had significantly higher levels of acuity.     

Relative Incidence of Emergency Department Visits After Treatment for Prostate Cancer With Radiation Therapy or Radical Prostatectomy

PurposeSide effect profiles play an important role in treatment decisions for localized prostate cancer. Emergency department (ED) visits, which may be due to side effects from treatment, can be measured in real-world, structured, electronic health record (EHR) data. The goal of this study was to determine whether treatments for localized prostate cancer are associated with ED visits, as a measure of side effects, using EHR data.Methods and MaterialsWe used a self-controlled case series study design, including patients treated at an urban academic medical center with radiation therapy (RT) or radical prostatectomy (RP) for prostate cancer between 2011 and 2020 who had visits documented for ≥6 months before and after treatment and ≥1 ED visit. We estimated relative incidences (RI) of ED visits, comparing incidence in the exposed and unexposed periods, with the exposed period being between start of treatment and 1 month after completion, and the unexposed period consisting of all other documented time.ResultsAmong men who had at least 1 ED visit and after adjusting for age, there were higher rates of ED visits after RP (RI, 20.4; 95% confidence interval [CI], 15.4-27.0; P < .001), RT overall (RI, 2.4; CI, 1.7-3.4; P < .001), intensity modulated radiation therapy with high dose-rate brachytherapy (RI, 3.4; CI, 1.7-6.8; P < .001) or stereotactic body radiation therapy boost (RI, 7.1; CI, 3.4-14.8; P < .001), and high dose rate brachytherapy alone (RI, 16.3; CI, 7.2-36.9; P < .001) compared with unexposed time. The number needed to harm to result in an ED visit was less for RP (17; CI, 13-23) than RT overall (43; CI, 25-126), but varied by RT modality.ConclusionsIn summary, relative rates of ED visits vary by treatment type, suggesting differing severities of side effects. These data may aid in selecting treatments and demonstrate the feasibility of using the self-controlled case series study design on ED visits in real-world, structured EHR data to better understand side effects of treatment.