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Study reveals five strategies to help patients with cancer reduce emergency department visits
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Researchers from University of Pennsylvania identified five strategies for reducing unnecessary ED or hospital visits for patients with cancer.
Nathan R. Handley, MD, a hematology oncology fellow in Penn’s Perelman School of Medicine, and colleagues conducted a PubMed search for articles published between 2000 and 2017 relating to ED visits, hospitalizations and hospitalizations within 30 days.
They also reviewed guidelines published by professional health care organizations.
Investigators determined five strategies can help reduce these visits: identifying patients at high risk for unplanned acute care; enhancing access and care coordination among health professionals; standardizing clinical pathways for symptom management; developing urgent cancer care tactics, and employing early palliative care.
HemOnc Today spoke with Handley about these five practices, the role oncologists can play in reducing unnecessary hospitalizations, and the broader implications of these findings.
Question: Can you elaborate on the five best practices you identified?
Answer: They came out of a review of the literature. I have been talking with experts in the field around the country. A lot of people have been thinking about this for the last couple of years, but not a lot of publications have really consolidated them. Identifying patients at high risk of acute care is simply a matter of figuring out who is most likely to have an ED visit. Access and care coordination is about ensuring patients can get in touch with who they need to get in touch with to avoid an unnecessary ED visit or hospitalization. The third approach, standardizing clinical pathways, is largely symptom management. We talk a lot about clinical pathways in medicine. This is more of a focus on the specific symptoms that drive a patient to the ED. The fourth is developing urgent cancer care tactics. When people do need to be seen urgently, we need to let them know how do that without sending them to the hospital. The final approach is encouraging palliative care early in the process.
Q: What do you mean by early?
A: One of the biggest studies to really put early palliative care on the radar of oncologists was done by Temel and colleagues. The study, published in 2010 in The New England Journal of Medicine, showed patients with late-stage lung cancer who were referred to palliative care within 8 weeks of their diagnosis did better overall. They had longer OS, and they also had better symptom management.
Q: Whose responsibility is it to understand these five practices and execute them? Is it the oncologist, the patient or both?
A: It is a combination of both. Thinking about one practice that has done a good job of this, their approach is that, during the first new patient visit, they are clear about the expectations for who to call and when to make a call in the event of some real or perceived emergency. This ends up being a joint partnership between the patient and the provider as opposed to a one-sided approach. Of course, the provider knows what the best procedure is, but they also have to be aware of what to do if and when the patient calls. They have to understand whether they should bring the patient in quickly or if the situation can be managed over the phone. It’s most important that the patient understands that the ED is not necessarily the right place to go every time.
Q: What role does patient anxiety about their diagnosis — and the uncertainty they feel when they experience an unusual symptom or pain — play in excess ED visits?
A: When something is happening to the patient that is related to cancer, there can be a lot of uncertainty. Figuring out what a symptom means can be very disconcerting for a patient. They often just don’t know if it means something really bad is going to happen, or if it’s just the natural course of the disease. When there is this kind of unknown, the final common pathway for many people is to go to the ED because they know they are going to see a doctor there. That’s just part of our culture. The objective is to re-educate patients that the ED is not necessarily the best place for these patients to go or to handle these situations. The best place to get care is where you’re known most, and that’s usually not by a doctor you’re just meeting in the ED. Early proactive education about what to expect from the disease can remove some of the uncertainty with some of these symptoms. Sometimes the uncertainty is the worst part. Patients just don’t know what’s normal and what’s not. Setting those expectations can go a long way in providing some relief from that anxiety.
Q: Could you talk more broadly about why ED visits are such a part of our culture, and how patients with all chronic diseases can reduce these visits?
A : Cancer is a microcosm of health care in America. All these strategies that we talk about in cancer care are generalizable beyond cancer care. One of the studies we talk about in our study was done by a group in Texas that used predictive analytics to determine which patients with heart failure are most likely to present at the ED. They can target resources toward those patients. We can learn from this. What it comes down to in cancer care — and in health care in general — is that we are becoming more interested in value-based care. These five strategies are essentially value-based care approaches. We are figuring out who needs the care and how it can be delivered to the right person at the right time in the right place — whether that’s the ED, an urgent care center or at home. That’s not cancer specific. That is generalizable.
Q: What has the reaction been to your study?
A: It’s generally been positive. A lot of practices in oncology are working on these things and thinking about them. They are interested in keeping patients out of the hospital unnecessarily. It has become a point of focus for a lot of other specialties, as well. People are excited and hopeful that we can get better. Not that things are really bad, but we always want to get better and do right by our patients. – by Rob Volansky
References:
Handley NR, et al. J Oncol Pract. 2018;doi:10.1200/JOP.17.00081.
Temel JS, et al. N Engl J Med. 2010;doi:10.1056/NEJMoa1000678.
For more information:
Nathan R. Handley, MD, can be reached at Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104-6218; email: nathan.handley@uphs.upenn.edu.
Disclosure: Handley reports no relevant financial disclosures.