Hospitalization burden heavy after advanced cancer diagnosis

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.