More than half of ED visits among patients with cancer ‘potentially preventable’
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More than half of ED visits between 2012 and 2019 among adults with cancer potentially could have been prevented, according to study results published in JAMA Network Open.
The findings also showed a significant increase in the number of potentially preventable ED visits among these patients during the period, which may be partially explained by factors such as uncontrolled pain and highlight the need for evidence-based interventions to better manage cancer treatment complications, researchers concluded.
Rationale and methods
Patients with cancer frequently experience a range of symptoms and adverse effects associated with cancer and its treatments that necessitate use of health care services, Amir Alishahi Tabriz, MD, PhD, MPH, assistant member of the department of health outcomes and behavior at Moffitt Cancer Center, told Healio.
“While many of these symptoms can be managed in an outpatient setting, some patients may require emergency medical attention and hospitalization,” Tabriz said. “However, the ED is not the optimal environment for patients with cancer, as it increases the risk for complications and incurs higher costs compared with other health care settings.”
To address this problem, many health care organizations and payers have implemented policies aimed at reducing the number of ED visits and rehospitalizations among patients with cancer, Tabriz continued.
“One example of such a policy is the Centers for Medicare and Medicaid Services chemotherapy measure [OP-35] that encourages hospitals to develop interventions to reduce the number of potentially avoidable ED visits and hospitalizations,” he said. “The CMS defines a visit to the ED as potentially preventable if the primary diagnosis for the visit was anemia, nausea, fever, dehydration, neutropenia, diarrhea, pain, pneumonia, sepsis or emesis.”
Despite these efforts, little is known about the characteristics, trends and preventability of ED visits among patients with cancer, Tabriz added.
“To address this gap in knowledge, we sought to assess nationwide trends and factors associated with potentially preventable ED visits and unplanned hospitalizations among U.S. patients with cancer,” he said. “This information can help clinicians and policymakers design interventions to reduce potentially preventable use of the ED among patients with cancer and improve patient outcomes.”
The cross-sectional study included data on 35,510,014 ED visits by patients with cancer (median age, 66.2 years; 55.2% women; 73.2% white; 89.8% living in a private residence; 54.3% Medicare enrollees) included in the National Hospital Ambulatory Medical Care Survey between 2012 and 2019.
Researchers used U.S. Cancer Statistics reports to estimate new cancer cases each year.
Potentially preventable ED visits served as the primary outcome. Secondary outcomes included unplanned hospitalizations and immediacy of ED visits.
Results
More than half (51.6%) of ED visits met the CMS definition of potentially preventable, with 21.3% considered high acuity.
Researchers observed a 73.6% increase in potentially preventable ED visits, from 1,851,692 to 3,214,276, with pain (36.9%) as the most common reason for these visits. Moreover, results showed a 101.8% increase in the percentage of patients who visited an ED because of pain between 2012 and 2019.
More than one-quarter (28.9%) of ED visits resulted in unplanned hospitalizations, which did not appear to significantly change during the study period (32.2% in 2012 vs. 26.6% in 2019).
Researchers observed a positive associations between residing in a nursing home and having a potentially preventable ED visit (OR = 1.73; 95% CI, 1.25-2.41), and the presence of more than one comorbidity and having an unplanned hospitalization (OR = 1.82; 95% CI, 1.43-2.32).
Implications
Cancer care programs must develop innovative solutions to manage cancer-associated symptoms and complications in the outpatient setting, Tabriz told Healio.
“Pain management should be a primary focus, as it was the most common presenting symptom among patients who visited the ED,” he said. “Oncologists can play a vital role in providing effective pain management while avoiding unnecessary ED visits and hospitalizations. The development and implementation of new pain management interventions, such as early palliative care referral, can help improve quality of life and reduce risk for opioid abuse.”
Identifying patients at risk for uncontrolled pain and taking steps to address it can help prevent acute care visits and reduce the overall burden on EDs, Tabriz continued.
“The value of potentially avoidable ED visits and unplanned hospital admissions as quality indicators depends on the ability to identify the proportion of potentially avoidable readmissions accurately,” he said. “Further research is necessary to validate various methodologies, such as the CMS approach, in determining potentially preventable ED visits. Once a clear definition is established, the next step would be to create and validate interventions aimed at reducing these visits. This could include implementing a tool to assess the risk for preventable ED visits and hospitalizations or implementing remote symptom management programs.”
Preventing unnecessary ED visits among patients with cancer is a laudable goal, according to an accompanying editorial by Erek S. Majka, MD, palliative medicine physician in Las Vegas, and N. Seth Trueger, MD, MPH, researcher in the department of emergency medicine at Northwestern University Feinberg School of Medicine.
“We need to continue to adapt our approach to value-based care as we learn more about how well-intentioned payment models affect patients and health systems, and continue to modify our metrics by accounting for patient heterogeneity and improved risk adjustment, minimizing gaming by systems with resources and de facto penalties for those who provide care to the most vulnerable,” the editorial authors wrote. “The goal is not to eliminate ED visits for their own sake; rather, the goal is better care of patients with cancer, and secondarily, in a manner that is cost-effective.”
References:
- Majka ES, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2022.53797.
- Tabriz AA, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2022.50423.
For more information:
Amir Alishahi Tabriz, MD, PhD, MPH, can be reached at amir.alishahi@moffitt.org.
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