Factors Associated with Emergency Department Utilization and Admission in Patients with Colorectal Cancer

Evaluating the Oncology-Related Education Needs of Emergency Nurses

INTRODUCTION

Treatment for patients with cancer in the emergency department ranges from treating life-threatening emergencies to symptom management or issues unrelated to their cancer, but for which cancer and its treatment may be complicating factors. Nurses are expected to manage the care of this population and be aware of risk factors for complications that may be unique to cancer patients. To date, education for emergency nurses regarding oncologic emergencies and the care for patients with cancer has been limited.

METHODS

We conducted a cross-sectional needs assessment to establish emergency nurses' educational needs (knowledge, skills, and attitudes) related to the care of patients with cancer and to evaluate if there are different educational needs for emergency nurses associated with the care of the cancer patient by practice setting type.

RESULTS

Of 237 nurses surveyed, only 28% of nurse respondents indicated receiving any cancer-specific education or training. Overall, scores on a knowledge assessment were relatively low (mean 53%; range 9.5-85.7%; SD 13%). Nurses reported variable confidence and skills, with the weakest areas being in the triage of complications and oncologic emergencies, assessment of complications related to cancer treatment, and end-of-life conversations. Nearly all of the respondents (97%) indicated a need for oncologic education for emergency nurses with moderate-high priority in relation to other educational needs.

DISCUSSION

Our findings suggest that emergency nurses need a stronger foundation of the knowledge and skills required to care for patients with cancer. Results from this study can inform future curriculum development efforts.

Understanding the Extent of Polypharmacy and its Association With Health Service Utilization Among Persons With Cancer and Multimorbidity: A Population-Based Retrospective Cohort Study in Ontario, Canada

Background: Cancer often co-occurs with other chronic conditions, which may result in polypharmacy. Polypharmacy is associated with adverse outcomes, including increased health service utilization. Objectives: This study examines the overall prevalence of polypharmacy (5 or more medications) among adults with cancer and multimorbidity, as well as the association of both minor polypharmacy (5-9 medications) and hyper-polypharmacy (10 or more medications) on high use of emergency room visits and hospitalizations, while controlling for age, sex, and type and stage of cancer. Methods: This retrospective longitudinal study used linked health administrative databases and included persons 18 years and older diagnosed with cancer between April 2010 and March 2013 in Ontario, Canada. Data on the number of health service utilizations at or above the 90th percentile (high users), was collected up to March 2014 and multivariate logistic regression was used to determine the impact of polypharmacy. Results: The prevalence of polypharmacy was 46% prior to cancer diagnosis, and 57% one year after diagnosis. Polypharmacy prior to and after cancer diagnosis increased with the level of multimorbidity, increasing age, but did not differ by sex. It was also highest in persons with lung cancer (52.4%) and those diagnosed with stage 4 cancer (51.3%). Minor polypharmacy increased the odds of being a high user of emergency rooms (1.16; 99% CI: 1.09-1.24) and hospitalizations (1.03; 0.98-1.09) and the odds of high use was greater with hyper-polypharmacy (1.41; 1.33-1.51) and (1.23; 1.17-1.29) respectively. Conclusion: Polypharmacy is highly prevalent and is associated with high health service utilization among adults with cancer and multimorbidity.

Frailty and medical financial hardship among older adults with cancer in the United States

Background

Little is known about the association between frailty level and medical financial hardship among older adults with cancer. This study aims to describe the prevalence of frailty and to identify its association with medical financial hardship among older cancer survivors in the United States.

Methods

The National Health Interview Survey (NHIS; 2019-2020) was used to identify older cancer survivors (n = 3,919). Both the five-item (Fatigue, Resistance, Ambulation, Illnesses, and Low weight-for-height) FRAIL and the three-domain (Material, Psychological, and Behavioral) medical financial hardship questions were constructed based on the NHIS questionnaire. Multivariable logistic models were used to identify the frailty level associated with financial hardship and its intensity.

Results

A total of 1,583 (40.3%) older individuals with cancer were robust, 1,421 (35.9%) were pre-frail, and 915 (23.8%) were frail. Compared with robust cancer survivors in adjusted analyses, frail cancer survivors were more likely to report issues with material domain (odds ratio (OR) = 3.19, 95%CI: 2.16-4.69; p < 0.001), psychological domain (OR = 1.47, 95%CI: 1.15-1.88; p < 0.001), or behavioral domain (ORs ranged from 2.19 to 2.90, all with p < 0.050), and greater intensities of financial hardship.

Conclusion

Both pre-frail and frailty statuses are common in the elderly cancer survivor population, and frail cancer survivors are vulnerable to three-domain financial hardships as compared with robust cancer survivors. Ongoing attention to frailty highlights the healthy aging of older survivors, and efforts to targeted interventions should address geriatric vulnerabilities during cancer survivorship.

Retrospective study of cancer patients' predictive factors of care in a large, Hungarian tertiary care centre

OBJECTIVES

To identify predictive factors of multiple emergency department (ED) visits, hospitalisation and potentially preventable ED visits made by patients with cancer in a Hungarian tertiary care centre.

DESIGN

Observational, retrospective study.

SETTING

A large, public tertiary hospital, in Somogy County, Hungary, with a level 3 emergency and trauma centre and a dedicated cancer centre.

PARTICIPANTS

Patients above 18 years with a cancer diagnosis (International Classification of Diseases, 10th Revision codes of C0000-C9670) who visited the ED in 2018, who had received their diagnosis of cancer within 5 years of their first ED visit in 2018 or received their diagnosis of cancer latest within the study year. Cases diagnosed with cancer at the ED (new cancer diagnosis-related ED visits) were also included, constituting 7.9% of visits.

PRIMARY OUTCOME MEASURES

Demographic and clinical characteristics were collected and the predictors of multiple (≥2) ED visits within the study year, admission to inpatient care following the ED visit (hospitalisation), potentially preventable ED visits and death within 36 months were determined.

RESULTS

2383 ED visits made by 1512 patients with cancer were registered. Predictive factors of multiple (≥2) ED visits were residing in a nursing home (OR 3.09, 95% CI 1.88 to 5.07) and prior hospice care (OR 1.87, 95% CI 1.05 to 3.31). Predictive factors for hospitalisation following an ED visit included a new cancer diagnosis-related visit (OR 1.86, 95% CI 1.30 to 2.66) and complaint of dyspnoea (OR 1.61, 95% CI 1.22 to 2.12).

CONCLUSIONS

Being a resident of a nursing home and receiving prior hospice care significantly increased the odds of multiple ED visits, while new cancer-related ED visits independently increased the odds of hospitalisation of patients with cancer. This is the first study to report these associations from a Central-Eastern European country. Our study may shed light on the specific challenges of EDs in general and particularly faced by countries in the region.

Cancer-related emergency and urgent care: expanding the research agenda

Purpose of review

Cancer-related emergency department (ED) visits often result in higher hospital admission rates than non-cancer visits. It has been estimated many of these costly hospital admissions can be prevented, yet urgent care clinics and EDs lack cancer-specific care resources to support the needs of this complex population. Implementing effective approaches across different care settings and populations to minimize ED and urgent care visits improves oncologic complication management, and coordinating follow-up care will be particularly important as the population of cancer patients and survivors continues to increase. The National Cancer Institute (NCI) and the Office of Emergency Care (OECR) convened a workshop in December 2021, “Cancer-related Emergency and Urgent Care: Prevention, Management, and Care Coordination” to highlight progress, knowledge gaps, and research opportunities. This report describes the current landscape of cancer-related urgent and emergency care and includes research recommendations from workshop participants to decrease the risk of oncologic complications, improve their management, and enhance coordination of care.

Recent findings

Since 2014, NCI and OECR have collaborated to support research in cancer-related emergency care. Workshop participants recommended a number of promising research opportunities, as well as key considerations for designing and conducting research in this area. Opportunities included better characterizing unscheduled care services, identifying those at higher risk for such care, developing care delivery models to minimize unplanned events and enhance their care, recognizing cancer prevention and screening opportunities in the ED, improving management of specific cancer-related presentations, and conducting goals of care conversations.

Summary

Significant progress has been made over the past 7 years with the creation of the Comprehensive Oncologic Emergency Research Network, broad involvement of the emergency medicine and oncology communities, establishing a proof-of-concept observational study, and NCI and OECR’s efforts to support this area of research. However, critical gaps remain.

Recognizing the emergency department’s role in oncologic care: a review of the literature on unplanned acute care

Background

The global prevalence of cancer is rapidly increasing and will increase the acute care needs of patients with cancer, including emergency department (ED) care. Patients with cancer present to the ED across the cancer care continuum from diagnosis through treatment, survivorship, and end-of-life. This article describes the characteristics and determinants of ED visits, as well as challenges in the effort to define preventable ED visits in this population.

Findings

The most recent population-based estimates suggest 4% of all ED visits are cancer-related and roughly two thirds of these ED visits result in hospitalization—a 4-fold higher ED hospitalization rate than the general population. Approximately 44% of cancer patients visit the ED within 1 year of diagnosis, and more often have repeat ED visits within a short time frame, though there is substantial variability across cancer types. Similar patterns of cancer-related ED use are observed internationally across a range of different national payment and health system settings. ED use for patients with cancer likely reflects a complex interaction of individual and contextual factors—including provider behavior, health system characteristics, and health policies—that warrants greater attention in the literature.

Conclusions

Given the amount and complexity of cancer care delivered in the emergency setting, future research is recommended to examine specific symptoms associated with cancer-related ED visits, the contextual determinants of ED use, and definitions of preventable ED use specific to patients with cancer.

Racial Disparities in Diabetes-Related Emergency Department Visits and Hospitalizations Among Cancer Survivors

PURPOSE

Black and Hispanic individuals with diabetes receive less recommended diabetes care after cancer diagnosis than non-Hispanic Whites (NHW). We sought to determine whether racial/ethnic minorities with diabetes and cancer were at increased risk of diabetes-related emergency department (ED) visits and hospitalizations compared with NHW.

METHODS

Using SEER cancer registry data linked to Medicare claims from 2006 to 2014, we included Medicare beneficiaries age 66+ years diagnosed with incident nonmetastatic breast, prostate, or colorectal cancer between 2007 and 2012 who had diabetes. Our primary outcome was any diabetes-related ED visit or hospitalization 366-731 days after cancer diagnosis. Using Fine-Gray subdistribution hazard models, we examined whether risk of ED visits or hospitalizations was higher for racial/ethnic minorities compared with NHW.

RESULTS

We included 40,059 beneficiaries with mean age 75.5 years (standard deviation 6.3), 45.6% were women, and 28.9% were non-White. Overall, 825 (2.1%) had an ED visit and 3,324 (8.3%) had a hospitalization related to diabetes in the 366-731 days after cancer diagnosis. Compared with NHW, Black individuals were more likely to have ED visits (2.9% v 2.0%; P < .0001) and hospitalizations (11.7% v 7.8%; P < .0001). Adjusting for potential confounders, Black (adjusted hazard ratio, 1.22; 95% CI, 1.12 to 1.35) individuals had a higher risk of any ED visit or hospitalization compared with NHW.

CONCLUSION

Black individuals with diabetes and cancer were at increased risk for diabetes-related ED visits and hospitalizations in the second year after cancer diagnosis compared with NHW even after accounting for confounders.

Expenditures in Young Adults with Hodgkin Lymphoma: NCI-designated Comprehensive Cancer Centers vs. Other Sites

BACKGROUND

Outcomes among Hodgkin Lymphoma (HL) patients diagnosed between 22 and 39 years are worse than among those diagnosed <21 years, and have not seen the same improvement over time. Treatment at an NCI-designated Comprehensive Cancer Center (CCC) mitigates outcome disparities, but may be associated with higher expenditures.

METHODS

We examined cancer-related expenditures among 22-39 year-old HL patients diagnosed between 2001-2016 using de-identified administrative claims data (OptumLabs® Data Warehouse) (CCC: n=1,154; non-CCC: n=643). Adjusting for sociodemographics, clinical characteristics and months enrolled, multivariable general linear models modeled average monthly health-plan paid (HPP) expenditures, and incidence rate ratios compared CCC/non-CCC monthly visit rates.

RESULTS

In the year following diagnosis, CCC patients had higher HPP-expenditures ($12,869 vs. $10,688, p=0.001), driven by higher monthly rates of CCC non-treatment outpatient hospital visits (p=0.001) and per-visit expenditures for outpatient hospital chemotherapy ($632 vs. $259); higher CCC inpatient expenditures ($1,813 vs. $1,091, p=0.001) were driven by 3.1-times higher rates of chemotherapy admissions (p=0.001). Out-of-pocket expenditures were comparable (p=0.3).

CONCLUSIONS

Young adults with Hodgkin lymphoma at CCCs saw higher health plan expenditures, but comparable out-of-pocket expenditures. Drivers of CCC expenditures included outpatient hospital utilization (monthly rates of non-therapy visits and per-visit expenditures for chemotherapy).

IMPACT

Higher HPP-expenditures at CCCs in the year following HL diagnosis likely reflect differences in facility structure and comprehensive care. For young adults, it is plausible to consider incentivizing CCC care to achieve superior outcomes while developing approaches to achieve long-term savings.

Unplanned emergency department visits and hospital admissions of older adults under treatment for cancer in the ambulatory/community setting

PURPOSE

This study aims to identify the incidence and risk/protective factors for (1) unplanned emergency department (ED) visits and hospital admissions (HA) and (2) nausea/vomiting/dehydration (NVD) at time of treatment in older adults under treatment for cancer.

MATERIALS AND METHODS

This is a exploratory retrospective cohort study of adults (60 and older) with cancer. Adults were included if they had a new cancer diagnosis and were being treated with chemotherapy. Study outcomes included the number of ED visits and HA (cycles 1-4) and NVD at the time of receiving chemotherapy (cycles 2-4). Repeated measures, Poisson regression was used to obtain risk ratios with 95% confidence intervals for independent predictors of outcomes.

RESULTS

Of 402 study participants, 20% experienced an ED visit, and 18% experienced a HA. Common reasons for ED visits were pain (23.5%) and NVD (20.4%). Common reasons for HA were infection (34.4%) and NVD (22.2%). Multivariate analysis showed risk factors for ED visits included chemotherapy cycle 1, having esophageal cancer, being treated with ≥ 3 chemotherapy agents, and increasing levels of functional impairment. Risk factors for HA included chemotherapy cycle 1, increasing levels of functional impairment, intravenous fluids between treatment, and being prescribed antiemetics for home use. Predictors of NVD at time of chemotherapy treatment included Hispanic ethnicity, insurance status, cancer type, chemotherapy emetic potent, treatment frequency, intravenous fluids between cycles, and number of home antiemetics.

CONCLUSION

Unplanned ED visits and HA occur in older adults under treatment for cancer due to numerous treatment-related side effects. Helping older adults identify and manage side effects early may reduce the number of unplanned admissions.

Expenditures among young adults with acute lymphoblastic leukemia by site of care

BACKGROUND

Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures.

METHODS

Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled.

RESULTS

Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable.

CONCLUSIONS

Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings.

LAY SUMMARY

Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.

What are the predictors of emergency department utilization and readmission following extremity bone sarcoma resection?

INTRODUCTION

Treatment for bone sarcomas are large undertakings. Emergency department (ED) visits and unplanned hospital readmissions are a potential target for cost containment. The purpose of this study was to evaluate the risk factors for ED visits and unplanned readmissions following extremity bone sarcoma surgery.

METHODS

Data from Optum Labs Data Warehouse, a national administrative claims database, was analyzed to identify patients with extremity bone sarcomas from 2006 to 2017. Multivariable logistic regression was used to identify factors associated with ED visits and readmissions.

RESULTS

Of 1390 (743 males, 647 female) adult patients, 137 (12%) visited the ED and 245 (18%) were readmitted within 30 days of discharge. The most common indication for ED visits (n = 63, 45.9%) and readmission (n = 119, 48.5%) were complications of surgery. Length of stay >10 days was associated with ED utilization (OR, 1.83; P = .01) and readmission (OR, 4.47; P < .001).

CONCLUSION

One in ten patients will use the ED, and one in five patients will be readmitted to the hospital within 30 days of discharge following extremity bone sarcoma surgery. Length of stay was associated with ED visits and readmission. These patients could be targeted with alternative management strategies in the outpatient setting with early clinical follow-up to minimize readmission.

Statistical tools used for analyses of frequent users of emergency department: a scoping review

OBJECTIVE

Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user.

METHODS

We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis.

RESULTS

We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used.

CONCLUSIONS

This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.