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Hospitalization burden heavy after advanced cancer diagnosis
Patients with advanced cancer face a heavy burden of hospitalization in the year following diagnosis, study data showed.
Researchers recommended efforts to reduce hospitalization for patients who faced the greatest burden and improving access to palliative care.
“Ideally, the care of individuals with advanced cancer whose disease is incurable should balance prolongation of survival and maximization of the quality of remaining life,” Robin L. Whitney, PhD, of University of California, San Francisco-Fresno, and colleagues wrote. “Hospitalization and other aggressive medical interventions can work against these goals and are increasingly recognized as poor-quality cancer care. Taken together, the high cost of, and excessive variability in, inpatient cancer care suggest that interventions to reduce unnecessary hospitalizations may reduce costs and improve quality of life in this population.”
Whitney and colleagues used the California Cancer Registry to identify patients diagnosed with advanced colorectal, breast, pancreatic or non-small cell lung cancer between 2009 and 2012 (n = 25,032). The researchers calculated hospitalization rates and used Poisson regression to model rehospitalization in the year following diagnosis, accounting for survival.
Nearly three-quarters (71%) of patients were hospitalized in the year after diagnosis. Most hospitalizations (64%) originated in the emergency department. Sixteen percent of patients were hospitalized at least three times.
Certain factors appeared significantly associated with rehospitalization, including black non-Hispanic race (IRR = 1.29; 95% CI, 1.17-1.42), Hispanic ethnicity (IRR = 1.11; 95% CI, 1.03-1.2), public health insurance (IRR = 1.37; 95% CI, 1.23-1.47) and no insurance (IRR = 1.17; 95% CI, 1.02-1.35). Patients who fell into lower socioeconomic quintiles (IRRs, 1.09-1.29) and those with comorbidities (IRRs, 1.13-1.59) also appeared more likely to be rehospitalized.
Compared with colorectal cancer, patients with pancreatic cancer (IRR = 2.07; 95% CI, 1.95-2.2) and NSCLC (IRR = 1.69; 95% CI, 1.54-1.86) appeared more likely to be re-hospitalized.
“Future efforts to reduce avoidable hospitalizations might focus on subgroups at higher risk, including individuals with advanced pancreatic, lung, or colorectal cancer, younger age at diagnosis, public insurance and multiple comorbidities, as well as patients who identify themselves as men and as black or Hispanic,” the researchers wrote. “Policy efforts might include improvements in access to outpatient palliative care and tests of payment models that reduce financial incentives to provide care in the inpatient setting.” – by Andy Polhamus
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Rates of hospitalization are notoriously high for patients with advanced cancer. Although a breakdown into “preventable” and “unpreventable” would be interesting and useful, it is not feasible, as no standardized criteria for defining a “preventable” hospitalization for a patient with cancer exist.
High-quality evidence demonstrating the ability of early palliative care to reduce hospitalization and improve overall quality of care is readily available. Yet it remains underutilized in patients with advanced cancer. In reality, our health care system is not equipped to provide all patients with advanced cancer with outpatient palliative care. How, then, can we improve the use of early palliative care and subsequently reduce hospitalizations?
This article hints at two options.
First, although we know patients with advanced cancer are at high risk for hospitalization, defining a more granular subgroup at particularly high risk may be feasible. This article confirms insights previously reported elsewhere: Some variables that may be useful in creating a predictive model for hospitalization risk include gender, comorbidity, ethnicity, type of insurance, age, socioeconomic status, and cancer type. If outpatient palliative care cannot be available for all, perhaps such a model could help target its use for those most in need.
Second, financial incentives may prove useful in increasing outpatient palliative care use. In a fee-for-service model, improved reimbursement for both primary and specialty palliative care would be helpful. As our health system moves away from fee-for-service to value-based care models — such as the CMS Oncology Care Model — the value proposition of early palliative care will speak for itself.
This article reports the results of a retrospective cohort study conducted within two linked data sets with the aims of evaluating hospitalization rates for patients with advanced cancer, as well as the effect of individual- and hospital-related factors on rehospitalization rates. “Advanced cancer” was defined as metastatic cancer for solid malignancies, with the addition of stage IIIB NSCLC and stage III pancreatic cancer.
The authors focused on hospitalizations beginning on the day of cancer diagnosis and extending to one-year after diagnosis. Among this cohort, 71% of 25,032 total patients experienced at least one hospitalization and 16.1% experienced three or more. A majority (64.1%) of admissions originated from the ED, and the proportion of admissions originating from the ED was higher at for-profit hospitals (68%) than not-for-profit (63.4%) or public hospitals (35.2%). The proportion of hospitalizations originating from the ED also appeared higher at hospitals without outpatient palliative care programs than at hospitals with them (65.9% vs. 59.6%). Discharge from a for-profit hospital was associated with a 33% greater relative rate of rehospitalization, and discharges from hospitals with outpatient palliative care programs with a 10% lower rate.
Multiple patient- and disease-related factors were associated with increased relative rates of rehospitalization, including comorbid conditions (13% higher rate with one condition, 59% higher rate with two or more), African American or Hispanic race/ethnicity (29% and 11% higher), government-issued or no health insurance (37% and 17% higher). Pancreatic cancer and NSCLC were associated with higher relative rates of rehospitalization, and prostate and breast cancer with lower rates.
This data illuminates an important source aspect of the medical burden experienced in the first year following the diagnosis of advanced cancer and identifies outpatient palliative care as a possible mitigating factor. This also serves to identify several possible foci for future interventions directed at improving rehospitalization rates, including medically complex or underserved patients and perhaps even the payment models that unwittingly incentivize inpatient medical care.