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Guidelines needed to reduce unnecessary hospitalizations for older adults with cancer
An analysis of older individuals who presented to the ED showed those with cancer appeared more likely to be admitted to the hospital, whereas those who were cancer free were more likely to be observed or released home.
“There may be opportunities to develop guidelines and standards for emergency department staff to manage certain conditions for patients with cancer in observation status, and to reserve hospital resources for those who need it most,” Adam Klotz, MD, physician in the department of medicine at Memorial Sloan Kettering Cancer Center, and colleagues wrote.
The use of observation status for patients with cancer who present to the ED has not been well described.
Klotz and colleagues assessed use of observation status among a cohort of 302,366 Medicare beneficiaries aged 66 years and older identified through the SEER database. Half of the analyzed individuals had cancer.
Investigators compared the ratio of observation unit use to inpatient admission between patients with cancer and without, as well as among patients diagnosed with breast, colon, lung or prostate cancers.
Results showed observation status was used less frequently among those with cancer (43 per 1,000 inpatient admissions) than those without cancer (69 per 1,000 inpatient admissions). Observation rates were higher for individuals with either breast cancer or prostate cancer than those with colon cancer or lung cancer.
HemOnc Today spoke with Klotz about how this study came about, what the researchers found, and what he believes should be done to change standard practice for older individuals with cancer who present to hospital emergency rooms.
Question: What prompted this study?
Answer: As the clinical volume at Memorial Sloan Kettering Cancer Center continues to grow, inpatient bed constraints have become an institutional priority. Much like other health care centers across the country, we would like to reduce the need for inpatient hospitalization when it is safe, cost-effective and in our patients’ best interests to do so. One possibility we chose to explore was the expansion of observational care for older patients with cancer, which has not been well defined.
Q: What did you find?
A : Older adults with cancer appeared less likely to be placed in an observational setting compared with a matched cohort of older adults without cancer. When we dug deeper, we found that the oldest adults and those who were the sickest also tended to not be placed into the observational setting.
Q: Did the findings surprise you?
A: Physicians usually do what is safest when confronted with an uncertain situation. However, it was quite interesting that — in subgroup analysis — patients with breast or prostate cancers were slightly more likely to be placed in an observational care setting than patients with colorectal or lung cancers. This is due, perhaps, to the nature of treating breast cancer in the adjuvant setting, in which patients have a relatively low burden of disease, and they also have acute side effects of chemotherapy that are likely to resolve quickly. These patients can be expected to have a relatively short emergency room stay. Similarly, patients with prostate cancer can have a long indolent clinical course, and the reason for their ED visit may not have been cancer related.
Q: Can you describe the importance of these findings from the angles of patient quality of life, health care costs and hospital resources?
A: In general, the more time a patient spends at home, away from the hospital, the better their quality of life. From an economic perspective, observational care has been shown to be more cost-effective than hospital admission for a variety of clinical conditions seen in the ED. Finally, as hospitals face increasing inpatient bed constraints, observational care allows this valuable resource to be allocated to those individuals who need it most acutely.
Q: What do you believe should be done to change standard practice for this patient population when they present to hospital emergency rooms?
A: If there are more clearly defined clinical scenarios in which observational care is acknowledged to be safe and effective for this population, then we can try to move the practice of emergency room physicians in that direction. Right now, an individual clinician relies on his or her prior experience and level of comfort in this situation. There needs to be more evidence-based guidelines for specific clinical conditions that will lead to greater observational care use in this setting, and specifically in this patient population.
Q: Is additional research on this topic planned?
A: NCI has facilitated the creation of a research consortium known as the Comprehensive Oncologic Emergencies Research Network. This research network, comprised of academic and community hospitals, is charged with describing the use of emergency care by patients with cancer and developing evidence-based management strategies that improve cancer outcomes. This is essentially a group of physicians from across the country who have recognized that there are many knowledge gaps in how to best treat emergencies among patients with cancer. Being able to pool our experiences, analyze outcomes, and formulate and answer research questions will help to create evidence-based treatment algorithms and protocols that could lead to better comfort in the general setting for treating patients with oncologic emergencies.
Q: Is there anything else that you would like to mention?
A: The number of people with cancer, including older adults, is increasing and the nature of how we treat cancer is forever changing. There are so many incredibly exciting new therapeutic developments during the past few years. This means we will start to see patients with new side effects from new treatments, and we will have to quickly learn how to take care of them. Clearly, the one-size-fits-all approach to cancer care in the hospital is no longer appropriate or cost-effective, and it is not what our patients want. – by Jennifer Southall
Reference:
Lipitz-Snyderman A, et al. J Natl Compr Canc Netw. 2017;doi:10.6004/jnccn.2017.0160.
For more information:
Adam Klotz, MD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: klotza@mskcc.org.
Disclosure: Klotz reports no relevant financial disclosures.