Do Patient-Reported Symptoms Predict Emergency Department Visits in Cancer Patients? A Population-Based Analysis

Investigation of the reasons and frequency of oncology patients over the age of 65 who apply to the emergency department

PURPOSE

This study aims to investigate frequency and causes of emergency department visits among oncology patients aged 65 and older.

METHOD

In this cross-sectional, descriptive and comparative study, data were collected a questionnaire form from a single emergency deparment of a university hospital in İzmir, West Turkey between January 2022 and July 2022. Data were analyzed by using IBM SPSS Statistics 25 software.

RESULTS

A total 125 patients were included in the study. The most common causes of patients to the emergency derparment were infection, pain, nausea-vomiting, and dyspnea. A significant difference was found between the reason for the patient's emergency department visit and their knowledge of when to seek medical help (p < 0.05).

CONCLUSION

The recurrent visits of cancer patients to emergency departments suggest an inadequacy of comprehensive information available to both patients and their caregivers concerning the pursuit of emergency medical intervention.

Analyzing temporal patterns in frequent emergency department visits among oncology patients using semantic similarity measures

PURPOSE

Patients with cancer face complex challenges that often lead them to seek care in emergency departments (EDs) for acute symptoms and complications. While previous studies have examined preventable ED visits by patients with cancer, less attention has focused on frequent ED use in this population. This study aimed to explore the temporal visit patterns of frequent ED users with cancer.

METHODS

This retrospective study analyzed ED visit records from 10 large hospitals (five urban, five rural) in Illinois from 2018 to 2019. Adult frequent ED users, defined as those with four or more visits in a year, were classified as cancer or non-cancer users based on cancer-related diagnoses in their first four visits. The Wu-Palmer method was used to calculate semantic similarity between diagnoses.

RESULTS

Of the 98,246 frequent ED users, 18.2 % had at least one cancer-related visit. Cancer patients made up 21.7 % of frequent users in urban EDs and 7.6 % in rural EDs. Cancer patients had slightly higher proximity scores than non-cancer patients. Patients with central nervous system malignancies had the highest median proximity score, while breast cancer patients had a lower score. In both urban and rural EDs, cancer patients had significantly higher proximity scores than non-cancer patients, with the difference being more pronounced in urban EDs.

CONCLUSION

Frequent ED visits by oncology patients are more likely to be for similar reasons compared to non-cancer frequent users. These findings highlight the need for targeted care coordination for oncology patients who frequently visit the ED, potentially reducing repeat visits through improved outpatient management. Understanding the distinct patterns of ED utilization among cancer patients could help prioritize resource allocation and care pathways.

Prognostic impact of patient-reported symptoms in multiple myeloma

ABSTRACT

Patient-reported outcomes (PROs) are associated with treatment outcomes in multiple myeloma (MM) in the clinical trial setting. However, most PRO tools are time consuming, which hinders use in routine practice. Our institution incorporated a "Hematology Patient-Reported Symptom Screen" (HPRSS), a 3-item questionnaire for fatigue, pain, and quality of life (QOL). The main objective of this study was to evaluate the impact of these symptoms on progression-free survival (PFS) and overall survival (OS) in a real-world cohort of patients with newly diagnosed MM. This retrospective study included patients with MM diagnosed between April 2011 and December 2017, seen at Mayo Clinic (Rochester, MN), who completed the HPRSS. Patients rated their symptoms on a scale from 0 to 10. Clinically relevant symptoms were defined as scores ≥5 for pain and fatigue, and ≤5 for QOL. At diagnosis, 735 patients had scores for all domains. The median follow-up was 8.1 years. Age was associated with increased odds of fatigue and decreased QOL. Female sex and comorbidities were associated with fatigue and pain. Higher disease stage, anemia, lytic lesions, and increased plasma cell burden were associated with fatigue, pain, and decreased QOL. Clinically relevant fatigue, pain, and decreased QOL were associated with decreased PFS and OS. On multivariate analysis including age, International Staging System III, high-risk cytogenetics, and postinduction transplantation, fatigue and decreased QOL were independently associated with decreased OS. A composite HPRSS score stratified patients into 3 groups with distinct OS. Patient-reported symptoms are prognostic in patients with newly diagnosed MM. The prognostic values of fatigue and decreased QOL are independent of age, disease stage, and transplant status.

The Economic Cost of Nursing Care of Palliative Patients in the Emergency Department

(1) Background: The economic cost of nursing care to palliative patients in avoidable hospital admission is unknown. (2) Methods: An observational, retrospective, and analytical study was used encompassing the economic cost of nursing care in a general hospital emergency department that uses descriptive and inferential statistical analysis. (3) Results: We have a sample of 273 palliative patients in preventable hospital admissions (76.3%, CI 95%: 71.7-80.8), deceased, in 2019. With a median of 84 years, about 80% were admitted home after 5 h of complaints, mainly due to respiratory symptoms. Patients remained for approximately 24 h in the emergency department, totaling a median of EUR 180.98 in nursing care costs per admission. (4) Conclusions: It was evident that with the knowledge obtained about palliative economic nursing costs, we could increase results, manage resources, and consolidate PC integration in health systems, as this study proved. This study was not registered.

Symptoms, Symptom Profiles, and Healthcare Utilization in Patients with Hematologic Malignancies: A Retrospective Observational Cohort Study and Latent Class Analysis

Symptom burden is known to be high in patients with hematologic malignancies and can adversely impact patients' quality of life. The aims of this retrospective observational cohort study were to explore symptoms in patients with hematologic malignancies, including during the last year of life, to explore symptom profiles in patients with hematologic malignancies, and to explore associations among symptoms/symptom profiles and demographic, clinical, and treatment-related variables. Symptom prevalence and severity and symptom profiles were explored in patients with hematologic malignancies who completed patient-reported outcome measures (n = 6136) between October 2019 and April 2020. Emergency department visits and hospital admissions during the study period were reviewed. Chart audits were undertaken for patients who died within a year of completing patient-reported outcome measures (n = 432) to explore symptoms and healthcare utilization in the last year of life. Patients with hematologic malignancies in this study reported multiple symptoms co-occurring, with more than 50% of patients reporting four or more symptoms. Classes of co-occurring symptoms (symptom profiles) were associated with demographic and clinical factors as well as with healthcare utilization, particularly emergency department visits. The most reported symptoms were tiredness, impaired well-being, and drowsiness. The findings emphasize the need for more supports for patients with hematologic malignancies, particularly for symptom management.

Identifying the palliative care needs of frail, older, housebound patients in the community: A cross-sectional study

BACKGROUND

The early introduction of palliative care can have a positive impact on the quality of life of patients suffering from life-limiting diseases. However, the palliative care needs of older, frail, housebound patients are still mostly unknown, as is the impact of frailty on the importance of these needs.

OBJECTIVES

To identify the palliative care needs of frail, older, housebound patients in the community.

METHODS

We conducted a cross-sectional observational study. This study took place in a single primary care center and included patients who were ≥65 years old, housebound, followed by the Geriatric Community Unit of the Geneva University Hospitals.

RESULTS

Seventy-one patients completed the study. Most patients were female (56.9%), and mean age (SD) was 81.1 (±7.9). The Edmonton Symptom Assessment Scale mean (SD) score was higher in frail patients as opposed to vulnerable patients for tiredness (p = 0.016), drowsiness (p = 0.0196), loss of appetite (p = 0.0124), and impaired feeling of well-being (p = 0.0132). There was no difference in spiritual well-being, measured by the spiritual scale subgroup of the Functional Assessment of the Chronic Illness Therapy-Spiritual Well-Being scale (FACIT-sp) between frail and vulnerable participants, although scores in both groups were low. Caregivers were mainly spouses (45%) and daughters (27.5%) with a mean (SD) age of 70.7 (±13.6). The overall carer-burden measured by the Mini-Zarit was low.

SIGNIFICANCE OF RESULTS

Older, frail, housebound patients have specific needs that differ from non-frail patients and should guide future palliative care provision. How and when palliative care should be provided to this population remains to be determined.

Brain Metastasis in the Emergency Department: Epidemiology, Presentation, Investigations, and Management

Brain metastases (BMs) are the most prevalent type of cerebral tumor, significantly affecting survival. In adults, lung cancer, breast cancer, and melanoma are the primary cancers associated with BMs. Symptoms often result from brain compression, and patients may present to the emergency department (ED) with life-threatening conditions. The goal of treatment of BMs is to maximize survival and quality of life by choosing the least toxic therapy. Surgical resection followed by cavity radiation or definitive stereotactic radiosurgery remains the standard approach, depending on the patient's condition. Conversely, whole brain radiation therapy is becoming more limited to cases with multiple inoperable BMs and is less frequently used for postoperative control. BMs often signal advanced systemic disease, and patients usually present to the ED with poorly controlled symptoms, justifying hospitalization. Over half of patients with BMs in the ED are admitted, making effective ED-based management a challenge. This article reviews the epidemiology, clinical manifestations, and current treatment options of patients with BMs. Additionally, it provides an overview of ED management and highlights the challenges faced in this setting. An improved understanding of the reasons for potentially avoidable hospitalizations in cancer patients with BMs is needed and could help emergency physicians distinguish patients who can be safely discharged from those who require observation or hospitalization.

End-of-Life Symptom Burden among Patients with Cancer Who Were Provided Medical Assistance in Dying (MAID): A Longitudinal Propensity-Score-Matched Cohort Study

Cancer is the primary underlying condition for most Canadians who are provided Medical Assistance in Dying (MAID). However, it is unknown whether cancer patients who are provided MAID experience disproportionally higher symptom burden compared to those who are not provided MAID. Thus, we used a propensity-score-matched cohort design to evaluate longitudinal symptom trajectories over the last 12 months of patients' lives, comparing cancer patients in Alberta who were and were not provided MAID. We utilized routinely collected retrospective Patient-Reported Outcomes (PROs) data from the Edmonton Symptom Assessment System (ESAS-r) reported by Albertans with cancer who died between July 2017 and January 2019. The data were analyzed using mixed-effect models for repeated measures to compare differences in symptom trajectories between the cohorts over time. Both cohorts experienced increasing severity in all symptoms in the year prior to death (β from 0.086 to 0.231, p ≤ .001 to .002). Those in the MAID cohort reported significantly greater anxiety (β = -0.831, p = .044) and greater lack of appetite (β = -0.934, p = .039) compared to those in the non-MAID cohort. The majority (65.8%) of patients who received MAID submitted their request for MAID within one month of their death. Overall, the MAID patients did not experience disproportionally higher symptom burden. These results emphasize opportunities to address patient suffering for all patients with cancer through routine collection of PROs as well as targeted and early palliative approaches to care.

Development of a claims-based risk-scoring model to predict emergency department visits in older patients receiving anti-neoplastic therapy

This study developed and validated a risk-scoring model, with a particular emphasis on medication-related factors, to predict emergency department (ED) visits among older Korean adults (aged 65 and older) undergoing anti-neoplastic therapy. Utilizing national claims data, we constructed two cohorts: the development cohort (2016-2018) with 34,642 patients and validation cohort (2019) with 10,902 patients. The model included a comprehensive set of predictors: demographics, cancer type, comorbid conditions, ED visit history, and medication use variables. We employed the least absolute shrinkage and selection operator (LASSO) regression to refine and select the most relevant predictors. Out of 120 predictor variables, 12 were integral to the final model, including seven related to medication use. The model demonstrated acceptable predictive performance in the validation cohort with a C-statistic of 0.76 (95% CI 0.74-0.77), indicating reasonable calibration. This risk-scoring model, after further clinical validation, has the potential to assist healthcare providers in the effective management and care of older patients receiving anti-neoplastic therapy.

Patient-Reported Outcome-Based Prediction for Postdischarge Complications after Lung Surgery

BACKGROUND

Patients undergoing lung tumor surgery may experience various complications after discharge from the hospital. Using patient-reported outcomes (PROs), this study attempted to identify relevant indicators of postdischarge complications after lung tumor surgery and develop a predictive nomogram model to evaluate the risk for individual patients.

METHODS

Patients who underwent lung tumor surgery between December 2021 and June 2022 were included in this study. PROs were assessed using the Perioperative Symptom Assessment for Lung Surgery scale and were assessed preoperatively at baseline, on postoperative day 1 (POD1) 1 to POD4, and then weekly until the fourth week. A random forest machine learning prediction model was built to rank the importance of each PRO score of patients on POD1 to POD4. We then selected the top 10 variables in terms of importance for the multivariable logistic regression analysis. Finally, a nomogram was developed.

RESULTS

PROs, including coughing (POD3 and POD4), daily activity (POD1), and pain (POD1 and POD2), were associated with postdischarge complications in patients undergoing lung tumor surgery. The predictive model showed good performance in estimating the risk of postdischarge complications, with an area under the curve of 0.833 (95% confidence interval: 0.753-0.912), while maintaining good calibration and clinical value.

CONCLUSION

We found that PRO scores on POD1 to POD4 were associated with postdischarge complications after lung tumor surgery, and we developed a helpful nomogram model to predict the risk of postdischarge complications.

Age-related differences in symptom distress among patients with cancer

INTRODUCTION

Differences in symptom distress among older (age 65-74) and very old (age 75+) patients with cancer, compared to younger patients, remain to be well explored. These differences are important to understand given the heterogeneity of older populations and may have implications for age-appropriate symptom detection and management.

MATERIALS AND METHODS

We examined routinely collected Edmonton Symptom Assessment System Revised (ESAS-r) scores from 9,143 patients age 40+ initiating chemotherapy for solid malignancies at a single academic cancer centre, between September 2011 and May 2019. We used multivariable logistic regression models to determine associations between the most common symptoms and age group (ages 40-64, 65-74, 75-84, and 85+), cancer site, clinical stage, sex, and income levels. We focused our findings on patients with the five most common cancers, breast (n = 1,532), prostate (n = 923), lung (n = 889), pancreatic (n = 429), and colorectal (n = 368), prior to receiving treatment.

RESULTS

Within our sample, 58.0% were age 40-64, 27.3% age 65-74, 11.8% age 75-84, and 2.9% age 85+. Among the nine symptoms in the ESAS-r (anxiety, depression, tiredness, wellbeing, nausea, pain, drowsiness, appetite, and shortness of breath), the most common symptoms overall were anxiety (moderate-severe scores [ESAS-r 4 or higher] were reported by 33.8% of patients), lack of well-being (38.3%), and tiredness (38.3%). Older age was associated with lower odds of moderate/severe anxiety (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.73-0.90 for age 65-74; OR 0.81, 95%CI 0.70-0.93 for age 75-84; OR 0.62, 95%CI 0.47-0.82 for age 85+; referent is 40-64-year-olds for all analyses), and increased odds of tiredness (OR 1.00, 95%CI 0.90-1.11 for age 65-74; OR 1.19, 95%CI 1.04-1.37 for age 75-84; and OR 1.34, 95%CI 1.04-1.72 for age 85+). Advanced stage, female sex, and lower income levels were associated with higher odds of moderate/severe tiredness, anxiety, and lack of well-being in adjusted models. Patients with pancreatic and lung cancers reported worse scores for these three symptoms than patients with other cancers.

DISCUSSION

Older age was associated with differences in symptom experiences such as increased tiredness and reduced anxiety. Supportive care interventions and future research should focus on addressing these symptoms to improve patient quality of life.

Efficacy of a Patient Education Session for Cancer Patients Receiving Immunotherapy

OBJECTIVES

Our research questions include: What are gaps in cancer patients' knowledge about immunotherapy? What is the efficacy of an education session in improving cancer patients' knowledge about immunotherapy and reducing inappropriate emergency department (ED) visits?

DATA SOURCES

From July 2020 to September 2021, we invited cancer patients receiving immunotherapy to participate in a one-on-one patient education session and pre-test/post-test surveys. The patient education session included an oral presentation following National Comprehensive Cancer Network guidelines, video on immunotherapy mechanisms of action, and review of written materials and alert cards. The surveys assessed patient knowledge of immunotherapies' mechanisms of action, adverse effects and their management, and health literacy. Survey data were paired with data abstracted from the electronic health record on patient ED utilization and demographic characteristics.

CONCLUSION

Before the education session, knowledge gaps about immunotherapy included understanding the medical term "itis," side effects of immunotherapy, and treatment for side effects of immunotherapy. Overall, the education session significantly improved cancer patients' knowledge about immunotherapy. The education session addressed knowledge gaps by significantly increasing patients' knowledge of immunotherapy mechanisms of action, recognition of side effects, and ability to define the medical term "itis". Because our sample had low inappropriate ED utilization, we could not assess the impact of the education session on inappropriate ED utilization.

IMPLICATIONS FOR NURSING PRACTICE

A multicomponent strategy for patient education was effective in improving overall knowledge uptake, especially among patients who initially had the least knowledge. Future studies should continue to explore whether patient education decreases inappropriate ED utilization.

Telemedicine Use for Oncology Clinic Visits at a Large Medical Center During the Onset of COVID-19

Introduction: The COVID-19 pandemic created an unprecedented surge toward telemedicine. This project investigated oncology clinic telemedicine utilization across the Vanderbilt University Medical Center (VUMC) from January to October 2020. Poorer prognosis and care of oncology patients is expected to be associated with increased emergency department (ED) visits. Methods: January to October 2020 clinic visits were identified from the VUMC's Electronic Data Warehouse (EDW). Oncology patients were identified by ICD-10 code and their EDW ED visit data were extracted. Joinpoint piecewise linear regression evaluated trends in tele-oncology visits. VUMC ED visits were compared for patients who did versus did not use telemedicine for oncology clinic visits. A Welch's two-tailed t-test investigated differences in ED visits/patient between these cohorts (α < 0.05). Results: A sharp increase in tele-oncology clinic visits from January to April 2020 (Monthly Percent Change = 396.26%) was followed by a steady decrease from April to October 2020 (Monthly Percent Change = -20.93%). The difference between these two trends was significant (p < 0.002). Of 18 cancer sites, breast cancers had the highest proportion (29.04%) of tele-oncology visits. There was no significant difference in January to October 2020 ED usage for oncology patients who did (0.40 ED visits/patient) versus did not (0.38 ED visits/patient) utilize telemedicine (p = 0.69). A total of 9.64% of oncology clinic visits from January to October 2020 were telemedicine visits, just below the 13.0% institutional average. Discussion: At the VUMC, tele-oncology spiked in March and April 2020 before decreasing from April to October 2020. Breast cancer clinics were most likely to use tele-oncology. Telemedicine use was not associated with increased ED visits for oncology patients, suggesting telemedicine as an alternative for routine oncology clinics. Oncology clinic telemedicine usage was 18th-highest among 33 specialties at our institutions, and among the lowest of nonsurgical specialties.

Nurse-led emergency department avoidance model of care for patients receiving cancer therapy in the ambulatory setting: a health service improvement initiative

AIMS

The Symptom and Urgent Review Clinic was a service improvement initiative, which consisted of the implementation and evaluation of a nurse-led emergency department (ED) avoidance model of care. The clinic was developed for patients experiencing symptoms associated with systemic anti-cancer therapy in ambulatory cancer settings.

METHODS

The clinic was implemented in four health services in Melbourne, Australia across a six-month period in 2018. Evaluation was by prospective data collection of the frequency and characteristics of patients who used the service, pre- and post-survey of patient reported experience, and a post-implementation survey of clinician engagement and experience.

RESULTS

There were 3095 patient encounters in the six-month implementation period; 136 patients were directly admitted to inpatient healthcare services after clinic utilization. Of patients who contacted SURC (n = 2174), a quarter (n = 553) stated they would have otherwise presented to the emergency department and 51% (n = 1108) reported they would have otherwise called the Day Oncology Unit. After implementation, more patients reported having a dedicated point of contact (OR 14.3; 95% CI 5.8-37.7) and ease of contacting the nurse (OR 5.5; 95% CI 2.6-12.1). Clinician reported experience and engagement with the clinic was highly favorable.

CONCLUSION

The nurse-led emergency department avoidance model of care addressed a gap in service delivery, while optimizing service utilization by reducing ED presentations. Patients reported improved levels of satisfaction with ease of access to a dedicated nurse and advice provided.

Symptom Burden and Survival in Patients Receiving Outpatient and Home-Based Palliative Care

Background: Symptom burden assessment with the Edmonton Symptom Assessment System (ESAS) has been widely studied among patients in outpatient palliative care (OPC), but fewer reports in home-based palliative care (HBPC), and none has assessed the prognostic value of ESAS scores in HBPC. Methods: This retrospective cohort study compares symptom burden and its prognostic value in adult patients receiving OPC and HBPC services between January 1, 2019, and June 30, 2021. Results: Patients completed the ESAS at the first OPC consultation (n = 4086) and at admission to HBPC (n = 4087). OPC patients were younger, more likely to have cancer, less likely to have had a recent hospitalization, and had higher adjusted median ESAS scores (28.1 vs. 22.9) compared with HBPC patients (all p < 0.001). ESAS was prognostic of survival in both settings (Hazard ratio 1.18-1.64, p < 0.01). Conclusion: Symptom burden is an independent prognosticator of survival in HBPC and OPC in this community-based setting.

Optimal care of people with brain cancer in the emergency department: A cross-sectional survey of outpatient perceptions

Objective

People diagnosed with brain cancer commonly present to the emergency department (ED). There is uncertainty about essential components and processes of optimal care from the perspective of consumers, and few guidelines exist to inform practice. This study examined the perceptions of outpatients and their support persons regarding what constitutes optimal care for people with brain cancer presenting to the ED.

Methods

A cross sectional descriptive survey study was undertaken. Participants included adults attending hospital outpatient clinics (n ​= ​181, 60% of eligible participants). Participants completed a survey assessing perceptions of optimal care for brain cancer patients presenting to emergency department and socio-demographic characteristics.

Results

The survey items endorsed as 'essential' by participants included that the emergency department team help patients: 'understand signs and symptoms to watch out for' (51%); 'understand the next steps in care and why' (48%); 'understand if their medical condition suggests it is likely they will die in hospital' (47%); 'ask patients if they have a substitute decision maker and want that person told they are in the emergency department' (44%); 'understand the purpose of tests and procedures' (41%).

Conclusions

Symptom management, effective communication and supported decision-making should be prioritised by ED teams. Further research to establish the views of those affected by brain cancer about essential care delivered in the ED setting, and to compare these views with the quality of care that is actually delivered, is warranted.

Machine learning models for 180-day mortality prediction of patients with advanced cancer using patient-reported symptom data

PURPOSE

The objective of the current study was to develop and test the performances of different ML algorithms which were trained using patient-reported symptom severity data to predict mortality within 180 days for patients with advanced cancer.

METHODS

We randomly selected 630 of 689 patients with advanced cancer at our institution who completed symptom PRO measures as part of routine care between 2009 and 2020. Using clinical, demographic, and PRO data, we trained and tested four ML algorithms: generalized regression with elastic net regularization (GLM), extreme gradient boosting (XGBoost) trees, support vector machines (SVM), and a single hidden layer neural network (NNET). We assessed the performance of algorithms individually as well as part of an unweighted voting ensemble on the hold-out testing sample. Performance was assessed using area under the receiver-operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The starting cohort of 630 patients was randomly partitioned into training (n = 504) and testing (n = 126) samples. Of the four ML models, the XGBoost algorithm demonstrated the best performance for 180-day mortality prediction in testing data (AUROC = 0.69, sensitivity = 0.68, specificity = 0.62, PPV = 0.66, NPV = 0.64). Ensemble of all algorithms performed worst (AUROC = 0.65, sensitivity = 0.65, specificity = 0.62, PPV = 0.65, NPV = 0.62). Of individual PRO symptoms, shortness of breath emerged as the variable of highest impact on the XGBoost 180-mortality prediction (1-AUROC = 0.30).

CONCLUSION

Our findings support ML models driven by patient-reported symptom severity as accurate predictors of short-term mortality in patients with advanced cancer, highlighting the opportunity to integrate these models prospectively into future studies of goal-concordant care.

Patient-Reported Symptom Complexity and Acute Care Utilization Among Patients With Cancer: A Population-Based Study Using a Novel Symptom Complexity Algorithm and Observational Data

BACKGROUND

Patients with cancer in Canada are often effectively managed in ambulatory settings; however, patients with unmanaged or complex symptoms may turn to the emergency department (ED) for additional support. These unplanned visits can be costly to the healthcare system and distressing for patients. This study used a novel patient-reported outcomes (PROs)-derived symptom complexity algorithm to understand characteristics of patients who use acute care, which may help clinicians identify patients who would benefit from additional support.

PATIENTS AND METHODS

This retrospective observational cohort study used population-based linked administrative healthcare data. All patients with cancer in Alberta, Canada, who completed at least one PRO symptom-reporting questionnaire between October 1, 2019, and April 1, 2020, were included. The algorithm used ratings of 9 symptoms to assign a complexity score of low, medium, or high. Multivariable binary logistic regressions were used to evaluate factors associated with a higher likelihood of having an ED visit or hospital admission (HA) within 7 days of completing a PRO questionnaire.

RESULTS

Of the 29,133 patients in the cohort, 738 had an ED visit and 452 had an HA within 7 days of completing the PRO questionnaire. Patients with high symptom complexity had significantly higher odds of having an ED visit (OR, 3.10; 95% CI, 2.59-3.70) or HA (OR, 4.20; 95% CI, 3.36-5.26) compared with low complexity patients, controlling for demographic covariates.

CONCLUSIONS

Given that patients with higher symptom complexity scores were more likely to use acute care, clinicians should monitor these more complex patients closely, because they may benefit from additional support or symptom management in ambulatory settings. A symptom complexity algorithm can help clinicians easily identify patients who may require additional support. Using an algorithm to guide care can enhance patient experiences, while reducing use of acute care services and the accompanying cost and burden.

Graphical user interface design to improve understanding of the patient-reported outcome symptom response

BACKGROUND

Symptom monitoring application (SMA) has clinical benefits to cancer patients but patients experience difficulties in using it. Few studies have identified which types of graphical user interface (GUI) are preferred by cancer patients for using the SMA.

METHODS

This is a cross-sectional study aimed to identify preferred GUI among cancer patients to use SMA. Total of 199 patients were asked to evaluate 8 types of GUIs combining text, icon, illustration, and colors using mixed-methods. Subgroup analyses were performed according to age and gender.

RESULTS

The mean age of the patients was 57 and 42.5% was male. The most preferred GUI was "Text + Icon + Color" (mean = 4.43), followed by "Text + Icon" (mean = 4.39). Older patients (≥ 60 years) preferred "Text + Icon" than younger patients (p for interaction < 0.01). Simple and intuitive text and icons were the most useful GUI for cancer patients to use the SMA.

CONCLUSION

Simple and intuitive text and icons were the most useful GUI for cancer patients to use the SMA. Researchers need to be careful when applying realistic face drawings to cancer symptom monitoring applications because they can recall negative images of cancer.

Machine Learning Model of Emergency Department Use for Patients Undergoing Treatment for Head and Neck Cancer Using Comprehensive Multifactor Electronic Health Records

PURPOSE

To use a hybrid method, combining statistical profiling, machine learning (ML), and clinical evaluation to predict emergency department (ED) visits among patients with head and neck cancer undergoing radiotherapy.

MATERIALS AND METHODS

Patients with head and neck cancer treated with radiation therapy from 2015 to 2019 were identified using electronic health record data. Records from 60 days before 90 days after treatment were analyzed. Statistical profiling and ML were used to create a predictive model for ED visits during or after radiation therapy. A comprehensive set of variables were studied. Multiple ML models were developed including extreme gradient-boosted decision tree and generalized logistic regression with comparison of multiple predictive performance metrics.

RESULTS

Of the 1,355 patients studied, 13% had an ED visit during or after treatment. Our hybrid methodology enabled evidence-based winnowing of candidate features from 141 to 11 with clinically applicable, evidence-based thresholds. Extreme gradient boosting had the highest area under the curve (0.81 ± 0.06) with a sensitivity of 0.89 ± 0.10 and exceeded generalized logistic regression (area under the curve 0.64 ± 0.02). Significant predictors of ED visits during treatment included increasingly complex opioid use, number of prior ED visits, tumor volume, rate of change of blood urea nitrogen, total bilirubin, body mass index, and distance from hospital.

CONCLUSION

Our approach combining bootstrapped statistical profiling and ML importance analysis supported integration of clinician input to identify a distilled set of phenotypical characteristics for developing ML models predicting which patients undergoing head and neck cancer radiation therapy were at risk for ED visits.

Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality

BACKGROUND

We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer.

METHODS

This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized.

RESULTS

Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01).

CONCLUSION

Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.

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.

Psychological Evaluation of Patients With Cancer Presenting to the Emergency Department With Pain: Independent Predictors of Worse Pain Severity, Interference, and Higher Hourly Opioid Administration

PURPOSE

Pain is a common complaint in patients with cancer presenting to the emergency department (ED). This prospective study evaluated whether biopsychosocial factors could help predict cancer patients with risk of higher pain severity, pain interference, and opioid consumption.

METHODS

Patients with cancer presenting to the ED with a complaint of moderate-severe pain (≥ 4/10-numeric rating scale) completed validated self-report measures assessing sociodemographics, cancer-related treatments, pain severity and interference, medication use, and psychological symptoms (depression, anxiety, pain catastrophizing, and sleep disturbance). Opioids administered and subsequent hospitalization were abstracted. Univariable and multivariable regression analyses assessed factors associated with pain-related outcomes.

RESULTS

Participants (n = 175) presented with a variety of cancer types, with 76% having metastatic disease and 42% reporting current outpatient opioid use. Higher pain catastrophizing, lower depressive symptoms, lower income, outpatient opioid use, and historical chronic pain were independently associated with worse pain (P ≤ .05). Higher pain catastrophizing, anxiety, sleep disturbance, outpatient opioid use, and education were independently associated with worse pain interference (P ≤ .05). The sole independent predictor of ED opioid administration was outpatient opioid use. Patients taking outpatient opioids were younger, had lower health literacy, worse pain catastrophizing, sleep disturbance, depression/anxiety, and greater rates of metastatic cancer and cancer-related surgery (P ≤ .05).

CONCLUSION

Biopsychosocial factors, particularly pain catastrophizing, remained significantly associated with worse pain outcomes for patients with cancer in the ED even after controlling for demographic and clinical variables. Patient outpatient opioid use was independently associated with worse pain, interference, and greater opioid administration, identifying this as a marker for who may benefit most from adjuvant pharmacologic and behavioral interventions.

Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study

INTRODUCTION

Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer.

MATERIALS AND METHODS

Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017.

RESULTS

Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics.

DISCUSSION

We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.

Systematic self-reporting of patients’ symptoms: improving oncologic care and patients’ satisfaction

Background:

In recent years, there has been a growing interest to enhance patients’ symptom management during routine cancer care using patient-reported outcome measures. The goal of this study is to analyse patients’ responses to the Edmonton Symptom Assessment System (ESAS) to determine whether patient-reported outcomes could help characterise those patients with the highest supportive care needs and symptom burden in order to help provide targeted support for patients.

Methods:

In this study, we analysed ESAS questionnaire responses completed by patients as part of their routine care and considered part of patients’ standard of care. Statistical analyses were performed using the IBM SPSS Statistics version 26.0. Descriptive statistics are used to summarise patient demographics, disease characteristics and patient-reported symptom severity and prevalence.

Results:

The overall mean age is 65.2 ± 12.8 years comprising 43.8% male and 56.2% female patients. The five common primary disease sites are breast (26.2%), haematology (21.1%), gastrointestinal (15.3%), genitourinary (12.7%) and lung (12.0%) cancers. The mean severity for each symptom is all mild (score: 1–3). The three most common reported symptoms causing distress are tiredness, poor overall wellbeing and anxiety, and the least reported symptom is nausea.

Conclusions:

Systematic self-reporting of patients’ symptoms is important to improve symptom management, timely facilitation of appropriate intervention, patient experience, and patient and family satisfaction. The awareness of disease site, gender and age-related symptom variations should help in the design and provision of appropriate symptom-directed, tumour-specific and patient-focused interventions to meet patients’ immediate needs.

Understanding the Symptoms and Concerns of Adolescents and Young Adults with Cancer in Alberta: A Comparative Cohort Study Using Patient-Reported Outcomes

Purpose: Adolescents and young adults (AYAs) with cancer are in a unique situation due to their age and developmental stage in life and may have different symptoms and concerns than older patients. Patient-Reported Outcomes (PROs) questionnaires, routinely used in Alberta, can help identify the distinct needs of AYAs. We aimed to compare PROs data for AYAs and older adults (OAs) to better understand how the concerns of AYAs differ, which is key to providing individualized care and creating targeted programming and system-level change. Methods: Retrospective data were collected for two patient cohorts who completed at least one PROs questionnaire between October 1, 2019 and April 1, 2020. The AYA cohort was aged 18-39, and the OA cohort was aged 40 and older. Symptoms were compared using mean scores and multiple linear regression, and concerns were compared using counts and multivariate negative binomial regression. Results: AYAs had significantly higher mean scores on depression and anxiety, compared to OAs, and lower mean scores for most physical symptoms. They indicated significantly more concerns in the Emotional and Social/Family/Spiritual domains, and were over three times more likely to indicate Work/School as a concern. Conclusion: AYAs with cancer have distinct concerns that should be addressed to ensure comprehensive, quality cancer care for this population. PROs data are useful in identifying needs and facilitating evidence-based, data-driven change at all levels of the health care system.

Chief complaints of patients with cancer who visit the emergency department over their oncologist's outpatient clinic in South Korea

Background

There have been several reports of patients with cancer visiting the Emergency Department (ED) rather than the outpatient department of their oncologist. In this study, we aimed to analyze the chief complaints, visit time, and time spent in the ED between study groups of patients with cancer visiting the ED. This finding will help medical staff provide better care for patients with cancer and reduce time spent in the ED.

Methods

A total of 787 patients with cancer visited the Regional Emergency Medical Center between January 1, 2020, and December 31, 2020. After the exclusion criterion such as patients who were transferred to the ED with a referral issued slip, patients who were pregnant women or minors under the age of 18 were applied, data from 607 patients with cancer were collected retrospectively from electronic medical records at the hospital. The participating patients with cancer were divided into two groups: 1) ED group—those who were cared for by the ED physician and 2) Referral group—those who were referred to their oncologist for hospitalization.

Results

We found that 40% of the total patients with cancer included in the study visited the ED with a chief complaint of pain. It was observed that the highest frequency of visits to the ED was around noon during clinic hours. The length of ED stay was 169 and 566 min for the ED and referral groups, respectively.

Conclusion

It would be more beneficial for patients with cancer visiting the ED to be quickly discharged from the ED physician’s active care for their symptoms. This usage of ED services will reduce unnecessary waiting time.

Symptom Burden and Complexity in the Last 12 Months of Life among Cancer Patients Choosing Medical Assistance in Dying (MAID) in Alberta, Canada

Background: In 2019, cancer patients comprised over 65% of all individuals who requested and received Medical Assistance in Dying (MAID) in Canada. This descriptive study sought to understand the self-reported symptom burden and complexity of cancer patients in the 12 months prior to receiving MAID in Alberta. Methods: Between July 2017 and January 2019, 337 cancer patients received MAID in Alberta. Patient characteristics were descriptively analyzed. As such, 193 patients (57.3%) completed at least one routine symptom-reporting questionnaire in their last year of life. Mixed effects models and generalized estimating equations were utilized to examine the trajectories of individual symptoms and overall symptom complexity within the cohort over this time. Results: The results revealed that all nine self-reported symptoms, and the overall symptom complexity of the cohort, increased as patients’ MAID provision date approached, particularly in the last 3 months of life. While less than 20% of patients experienced high symptom complexity 12 months prior to MAID, this increased to 60% in the month of MAID provision. Conclusions: Cancer patients in this cohort experienced increased symptom burden and complexity leading up to their death. These findings could serve as a flag to clinicians to closely monitor advanced cancer patients’ symptoms, and provide appropriate support and interventions as needed.

Comparison of the Management and Short-Term Outcomes between Patients with Advanced Cancer and Other End-of-Life Conditions Presenting to Two Canadian Emergency Departments

Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March-August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.

Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy

BACKGROUND AND PURPOSE

The study objective was to determine whether longitudinal changes in patient-reported outcomes (PROs) were associated with survival among early-stage, non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiation therapy (SBRT).

MATERIALS AND METHODS

Data were obtained from January 2015 through March 2020. We ran a joint probability model to assess the relationship between time-to-death, and longitudinal PRO measurements. PROs were measured through the Edmonton Symptom Assessment Scale (ESAS). We controlled for other covariates likely to affect symptom burden and survival including stage, tumor diameter, comorbidities, gender, race/ethnicity, relationship status, age, and smoking status.

RESULTS

The sample included 510 early-stage NSCLC patients undergoing SBRT. The median age was 73.8 (range: 46.3-94.6). The survival component of the joint model demonstrates that longitudinal changes in ESAS scores are significantly associated with worse survival (HR: 1.04; 95% CI: 1.02-1.05). This finding suggests a one-unit increase in ESAS score increased probability of death by 4%. Other factors significantly associated with worse survival included older age (HR: 1.04; 95% CI: 1.03-1.05), larger tumor diameter (HR: 1.21; 95% CI: 1.01-1.46), male gender (HR: 1.87; 95% CI: 1.36-2.57), and current smoking status (HR: 2.39; 95% CI: 1.25-4.56).

CONCLUSION

PROs are increasingly being collected as a part of routine care delivery to improve symptom management. Healthcare systems can integrate these data with other real-world data to predict patient outcomes, such as survival. Capturing longitudinal PROs-in addition to PROs at diagnosis-may add prognostic value for estimating survival among early-stage NSCLC patients undergoing SBRT.

Symptom Burden Is Associated with Increased Emergency Department Utilization among Patients with Cirrhosis

Background: Patients with cirrhosis have significant morbidity and mortality, as well as substantial symptom burden. Objective: We investigated the relationship between symptom burden and inpatient health care utilization among patients with cirrhosis. Methods: Adult patients with cirrhosis being evaluated for or awaiting liver transplantation at an academic institution in the United States completed the Edmonton Symptom Assessment Scale (ESAS), a validated symptom evaluation tool with total scores ranging from 0 to 90. The outcomes of interest were emergency department (ED) visits, nonelective hospitalizations, hospital days, intensive care unit (ICU) admissions, and 30-day readmissions within 6 months. Adjusted incidence rate ratios (IRRs) were used to examine the relationship between ESAS scores and outcomes. Results: Of 233 patients (43% female, median age 61), the median total ESAS score was 16 (interquartile range 6-30). Higher total scores on the ESAS were associated with increased ED visits, hospitalizations, hospital days, and ICU days (all p < 0.04). After adjusting for age, gender, and Model for End-Stage Liver Disease-sodium, ESAS total score remained an independent predictor of ED visits (IRR 1.05, confidence interval [95% CI] 1.00-1.10, p = 0.03). Multivariate ESAS subscale analyses revealed that the physical symptom score was associated with ED visits (IRR 1.09, 95% CI 1.02-1.16, p = 0.01), but the psychological symptom score was not (IRR 1.03, 95% CI 1.00-1.08, p = 0.15). Conclusions: Patient-reported symptoms, particularly physical symptoms, are independently associated with ED visits among patients with cirrhosis being considered for liver transplantation. Further research is needed to examine whether addressing symptoms more aggressively, such as with palliative care co-management, could decrease ED utilization in this population.

Emergency department visits and inpatient hospitalizations among older patients with brain metastases: a dual population- and institution-level analysis

Background

Older patients with brain metastases (BrM) commonly experience symptoms that prompt acute medical evaluation. We characterized emergency department (ED) visits and inpatient hospitalizations in this population.

Methods

We identified 17 789 and 361 Medicare enrollees diagnosed with BrM using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2010-2016) and an institutional database (2007-2016), respectively. Predictors of ED visits and hospitalizations were assessed using Poisson regression.

Results

The institutional cohort averaged 3.3 ED visits/1.9 hospitalizations per person-year, with intracranial disease being the most common reason for presentation/admission. SEER-Medicare patients averaged 2.8 ED visits/2.0 hospitalizations per person-year. For patients with synchronous BrM (N = 7834), adjusted risk factors for ED utilization and hospitalization, respectively, included: male sex (rate ratio [RR] = 1.15 [95% CI = 1.09-1.22], P < .001; RR = 1.21 [95% CI = 1.13-1.29], P < .001); African American vs white race (RR = 1.30 [95% CI = 1.18-1.42], P < .001; RR = 1.25 [95% CI = 1.13-1.39], P < .001); unmarried status (RR = 1.07 [95% CI = 1.01-1.14], P = .02; RR = 1.09 [95% CI = 1.02-1.17], P = .01); Charlson comorbidity score >2 (RR = 1.27 [95% CI = 1.17-1.37], P < .001; RR = 1.36 [95% CI = 1.24-1.49], P < .001); and receipt of non-stereotactic vs stereotactic radiation (RR = 1.44 [95% CI = 1.34-1.55, P < .001; RR = 1.49 [95% CI = 1.37-1.62, P < .001). For patients with metachronous BrM (N = 9955), ED visits and hospitalizations were more common after vs before BrM diagnosis (2.6 vs 1.2 ED visits per person-year; 1.8 vs 0.9 hospitalizations per person-year, respectively; RR = 2.24 [95% CI = 2.15-2.33], P < .001; RR = 2.06 [95% CI = 1.98-2.15], P < .001, respectively).

Conclusions

Older patients with BrM commonly receive hospital-level care secondary to intracranial disease, especially in select subpopulations. Enhanced care coordination, closer outpatient follow-up, and patient navigator programs seem warranted for this population.

A Computational Framework to Analyze the Associations Between Symptoms and Cancer Patient Attributes Post Chemotherapy Using EHR Data

Patients with cancer, such as breast and colorectal cancer, often experience different symptoms post-chemotherapy. The symptoms could be fatigue, gastrointestinal (nausea, vomiting, lack of appetite), psychoneurological symptoms (depressive symptoms, anxiety), or other types. Previous research focused on understanding the symptoms using survey data. In this research, we propose to utilize the data within the Electronic Health Record (EHR). A computational framework is developed to use a natural language processing (NLP) pipeline to extract the clinician-documented symptoms from clinical notes. Then, a patient clustering method is based on the symptom severity levels to group the patient in clusters. The association rule mining is used to analyze the associations between symptoms and patient attributes (smoking history, number of comorbidities, diabetes status, age at diagnosis) in the patient clusters. The results show that the various symptom types and severity levels have different associations between breast and colorectal cancers and different timeframes post-chemotherapy. The results also show that patients with breast or colorectal cancers, who smoke and have severe fatigue, likely have severe gastrointestinal symptoms six months after the chemotherapy. Our framework can be generalized to analyze symptoms or symptom clusters of other chronic diseases where symptom management is critical.

Discrepancy in the perception of symptoms among patients and healthcare providers after lung cancer surgery

PURPOSE

Patients who undergo surgery for lung cancer experience a variety of symptoms, such as pain and coughing, which interfere with their postoperative daily functions. However, there may be differences between the perception of symptoms among healthcare providers and patients. This study aimed to investigate patients' experiences after lung cancer surgery and analyze whether the perception of postoperative symptoms among the healthcare providers differed from that reported by patients.

METHODS

Semi-structured qualitative interviews involving 39 patients who underwent lung cancer surgery at the Sichuan Cancer Hospital were conducted between November 2018 and October 2019. In addition, 22 healthcare providers from the Department of Thoracic Surgery at the hospital answered open-ended questions about their perception of symptoms related to lung cancer surgery. The types and frequencies of symptoms reported by the patients and healthcare providers were compared.

RESULTS

The most frequent patient-reported symptoms were pain (967 times, 39 patients, 100%), coughing (904 times, 37 patients, 94.87%), shortness of breath (491 times, 35 patients, 89.74%), Disturbed sleep (412 times, 34 patients, 87.18%), and interference while walking (347 times, 36 patients, 92.31%). Of the patient-reported symptoms, the first four were perceived by the healthcare providers, while they interpreted interference while walking as fatigue.

CONCLUSION

Although the healthcare providers and patients had a certain consensus on the main symptoms, there were differences in perception. Healthcare providers need to pay more attention to postoperative interference while walking.

Emergency department visits among people with cancer: Frequency, symptoms, and characteristics

OBJECTIVE

People with cancer are increasingly more likely to visit an emergency department for acute care than the general population. They often have long wait times and more exposure to infection and receive treatment from staff less experienced with cancer-related problems. Our objective was to examine emergency department (ED) visits among people with cancer to understand how often and why they seek care.

METHODS

We conducted a retrospective study of ED visits using the National Syndromic Surveillance Program BioSense Platform. Cancer reported during an ED visit was identified using International Classification of Diseases, Tenth Revision codes for any cancer type, including bladder, breast, cervical, colorectal, kidney, liver, lung, ovary, pancreas, prostate, or uterine cancers. Symptoms prompting the visit were identified for people with cancer who visited EDs in the United States from June 2017 to May 2018 in ≈4500 facilities, including 3000 EDs in 46 states and the District of Columbia (66% of all ED visits during a 1-year period).

RESULTS

Of 97 million ED visits examined, 710,297 (0.8%) were among people with cancer. Percentages were higher among women (50.1%) than men (49.5%) and among adults aged ≥65 years (53.6%) than among those ≤64 years (45.7%). The most common presenting symptoms were pain (19.1%); gastrointestinal (13.8%), respiratory (11.5%), and neurologic (5.3%) complaints; fever (4.9%); injury (4.1%); and bleeding (2.4%). Symptom prevalence differed significantly by cancer type.

CONCLUSIONS

The Centers for Medicare & Medicaid Services encourages efforts to reduce acute care visits among people with cancer. We characterized almost 70% of ED visits among this population.

Predictors of Urgent Cancer Care Clinic and Emergency Department Visits for Individuals Diagnosed with Cancer

In 2013, CancerCare Manitoba (CCMB) launched an urgent cancer care clinic (UCC) to meet the needs of individuals diagnosed with cancer experiencing acute complications of cancer or its treatment. This retrospective cohort study compared the characteristics of individuals diagnosed with cancer that visited the UCC to those who visited an emergency department (ED) and determined predictors of use. Multivariable logistic mixed models were run to predict an individual’s likelihood of visiting the UCC or an ED. Scaled Brier scores were calculated to determine how greatly each predictor impacted UCC or ED use. We found that UCC visits increased up to 4 months after eligibility to visit and then decreased. ED visits were highest immediately after eligibility and then decreased. The median number of hours between triage and discharge was 2 h for UCC visits and 9 h for ED visits. Chemotherapy had the strongest association with UCC visits, whereas ED visits prior to diagnosis had the strongest association with ED visits. Variables related to socioeconomic status were less strongly associated with UCC or ED visits. Future studies would be beneficial to planning service delivery and improving clinical outcomes and patient satisfaction.

A Machine Learning Model Approach to Risk-Stratify Patients With Gastrointestinal Cancer for Hospitalization and Mortality Outcomes

PURPOSE

Patients with gastrointestinal (GI) cancer frequently experience unplanned hospitalizations, but predictive tools to identify high-risk patients are lacking. We developed a machine learning model to identify high-risk patients.

METHODS AND MATERIALS

In the study, 1341 consecutive patients undergoing GI (abdominal or pelvic) radiation treatment (RT) from March 2016 to July 2018 (derivation) and July 2018 to January 2019 (validation) were assessed for unplanned hospitalizations within 30 days of finishing RT. In the derivation cohort of 663 abdominal and 427 pelvic RT patients, a machine learning approach derived random forest, gradient boosted decision tree, and logistic regression models to predict 30-day unplanned hospitalizations. Model performance was assessed using area under the receiver operating characteristic curve (AUC) and prospectively validated in 161 abdominal and 90 pelvic RT patients using Mann-Whitney rank-sum test. Highest quintile of risk for hospitalization was defined as "high-risk" and the remainder "low-risk." Hospitalizations for high- versus low-risk patients were compared using Pearson's χ² test and survival using Kaplan-Meier log-rank test.

RESULTS

Overall, 13% and 11% of patients receiving abdominal and pelvic RT experienced 30-day unplanned hospitalization. In the derivation phase, gradient boosted decision tree cross-validation yielded AUC = 0.823 (abdominal patients) and random forest yielded AUC = 0.776 (pelvic patients). In the validation phase, these models yielded AUC = 0.749 and 0.764, respectively (P < .001 and P = .002). Validation models discriminated high- versus low-risk patients: in abdominal RT patients, frequency of hospitalization was 39% versus 9% in high- versus low-risk groups (P < .001) and 6-month survival was 67% versus 92% (P = .001). In pelvic RT patients, frequency of hospitalization was 33% versus 8% (P = .002) and survival was 86% versus 92% (P = .15) in high- versus low-risk patients.

CONCLUSIONS

In patients with GI cancer undergoing RT as part of multimodality treatment, machine learning models for 30-day unplanned hospitalization discriminated high- versus low-risk patients. Future applications will test utility of models to prompt interventions to decrease hospitalizations and adverse outcomes.

I'm here because I was told to come: a study of cancer patients' reasons for attending the emergency department

OBJECTIVES

Patients with cancer are seen frequently in emergency departments (EDs). It has been proposed that many of these visits are preventable, but the patient perspective has not been well-studied.

METHODS

We conducted structured interviews with a convenience sample of patients who presented to a single ED with a cancer-related complaint. We asked standardized questions regarding patient predisposing characteristics, enabling factors (e.g., access to support), and perceived need for care. We compared the reported perceived need with the evaluated need by ED healthcare providers. Themes were identified using descriptive content analysis.

RESULTS

Forty-five patients completed interviews, of whom 30 (67%) were admitted to hospital. The most frequent reasons for seeking ED care were pain (includes abdominal) (33%), fever (11%), and weakness (11%). The majority (77%) did not make the decision to go to the ED alone: healthcare providers (40%, most commonly oncologists) and caregivers (36%) were the reported decision-makers in these cases. The majority (73%) felt their ED visit was not preventable. Themes of an alternative oncological setting for tests, improved community services, and both earlier medication management and referral to specialist care were identified from patients who reported their visit was avoidable. Congruence between (patient) perceived need and evaluated need was high (96%).

CONCLUSIONS

The minority of patients made the decision to seek ED care by themselves. While the majority did not believe emergency care was avoidable, those who did had cogent suggestions to that end. Patient's assessments of their own need had high agreement with ED providers' evaluations.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BACKGROUND

Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies.

PURPOSE

To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency.

METHODS

This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period.

RESULTS

The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital.

CONCLUSION

Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration

PROBLEM STATEMENT

This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy.

DESIGN

This study used a two-phase, qualitatively driven, mixed-methods descriptive design.

DATA SOURCES

11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls.

ANALYSIS

Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis.

FINDINGS

Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy.

IMPLICATIONS FOR PRACTICE

Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

Longitudinal Symptom Burden Trajectories in a Population-Based Cohort of Women with Metastatic Breast Cancer: A Group-Based Trajectory Modeling Analysis

Understanding the symptom burden trajectory for metastatic breast cancer patients can enable the provision of appropriate supportive care for symptom management. The aim of this study was to describe the longitudinal trajectories of symptom burden for metastatic breast cancer patients at the population-level. A cohort of 995 metastatic breast cancer patients with 16,146 Edmonton Symptom Assessment System (ESAS) assessments was constructed using linked population-level health administrative databases. The patient-reported ESAS total symptom distress score (TSDS) was studied over time using group-based trajectory modeling, and covariate influences on trajectory patterns were examined. Cohort patients experienced symptom burden that could be divided into six distinct trajectories. Patients experiencing a higher baseline TSDS were likely to be classified into trajectory groups with high, uncontrolled TSDS within the study follow-up period (χ2 (1, N = 995) = 136.25, p < 0.001). Compared to patients classified in the group trajectory with the highest relative TSDS (Group 6), patients classified in the lowest relative TSDS trajectory group (Group 1) were more likely to not have comorbidities (97.34% (for Groups 1-3) vs. 91.82% (for Group 6); p < 0.05), more likely to receive chemotherapy (86.52% vs. 80.50%; p < 0.05), and less likely to receive palliative care (52.81% vs. 79.25%; p < 0.0001). Receiving radiotherapy was a significant predictor of how symptom burden was experienced in all identified groups. Overall, metastatic breast cancer patients follow heterogeneous symptom burden trajectories over time, with some experiencing a higher, uncontrolled symptom burden. Understanding trajectories can assist in establishing risk-stratified care pathways for patients.

Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study

PURPOSE

To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population.

METHODS

This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering.

RESULTS

There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero.

CONCLUSION

ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.

Association Between Preoperative Patient-Reported Symptoms and Postoperative Outcomes in Rectal Cancer Patients: A Retrospective Cohort Study

BACKGROUND

Rectal cancer patients undergoing preoperative radiotherapy experience a significant symptom burden. However, it is unknown whether symptoms during radiotherapy may portend adverse postoperative outcomes and healthcare utilization.

METHODS

A retrospective cohort study was performed of rectal cancer patients undergoing neoadjuvant radiotherapy and proctectomy in Ontario from 2007 to 2014. The primary outcome was a complicated postoperative course-a dichotomous variable created as a composite of postoperative mortality, major morbidity, or hospital readmission. Patient-reported Edmonton Symptom Assessment System (ESAS) scores, collected routinely at outpatient provincial cancer center visits, were linked to administrative healthcare databases. The receiver-operating characteristic analysis was used to compare ESAS scoring approaches and to stratify patients into low versus high symptom score groups. Multivariable regression models were constructed to evaluate associations between preoperative symptom scores and postoperative outcomes.

RESULTS

1455 rectal cancer patients underwent sequential radiotherapy and proctectomy during the study period and recorded symptom assessments. Patients with high preoperative symptom scores were significantly more likely to experience a complicated postoperative course (OR 1.55, 95% CI 1.23-1.95). High preoperative ESAS scores were also associated with the secondary outcomes of emergency department visits (OR 1.34, 95% CI 1.08-1.66) and longer length of stay (IRR 1.23, 95% CI 1.04-1.45).

CONCLUSIONS

Rectal cancer patients reporting elevated symptom scores during neoadjuvant radiotherapy have increased odds of experiencing a complicated postoperative course. Preoperative patient-reported outcome screening may be a useful tool to identify at-risk patients and to efficiently direct perioperative supportive care.

Selecting, implementing and evaluating patient-reported outcome measures for routine clinical use in cancer: the Cancer Care Ontario approach

BACKGROUND

The use of Patient-Reported Outcome Measures (PROMs) in routine clinical care can help ensure symptoms are identified, acknowledged and addressed. In 2007, the provincial cancer agency, Cancer Care Ontario, began to implement routine symptom screening with the Edmonton Symptom Assessment System (ESAS) for ambulatory cancer patients. Having had a decade of experience with ESAS, the program developed a strategic interest in implementing new and/or additional measures. This article describes the development of a streamlined PROM selection and implementation evaluation process with core considerations.

METHODS

Development of the PROM selection and implementation evaluation process involved analysis of quantitative and qualitative data as well as consensus building through a multi-stakeholder workshop. Core PROM selection considerations were developed through a literature scan, review and refinement by a panel of methodological experts and patient advisors, and testing via a test case. Core PROM implementation evaluation considerations were developed through analysis of PROM evaluation frameworks, and review and refinement by a committee of provincial implementation leads.

RESULTS

Core PROM selection considerations were identified under three overarching themes: symptom coverage, usability and psychometric properties. The symptom coverage category assesses each PROM to determine how well the PROM items address the most prevalent and burdensome symptoms in the target patient population. The usability category aims to assess each measure on characteristics key to successful implementation in the clinical setting. The psychometric properties category assesses each PROM to ensure the data collected is credible, meaningful and interpretable. A scoring system was developed to rate PROM performance by assigning a grade of "weak", "average" or "good" for each category. The process results in a summary matrix which illustrates the overall assessment of each PROM. Implementation evaluation considerations were identified under three overarching concepts: acceptability, outcomes, and sustainability. A consensus building exercise resulted in the further identification of patient, provider, and clinic specific indicators for each consideration.

CONCLUSION

To address the need for a systematic, evidence-based approach to selection, implementation and evaluation of PROMs in the clinical setting, Cancer Care Ontario defined a process with embedded core considerations to facilitate decision-making and encourage standardization.

Symptom Evolution in Patients with Esophageal and Gastric Cancer Receiving Palliative Chemotherapy: A Population-Based Study

INTRODUCTION

Palliative chemotherapy (PC) is associated with a modest survival benefit in patients with incurable esophageal and gastric cancer; however, changes in symptom profile during treatment are not well described. Understanding the trajectory of symptoms during treatment may lead to improved care and facilitate shared decision making. In this study, we address this knowledge gap among all patients receiving PC in the Canadian province of Ontario.

METHODS

Patients diagnosed with incurable esophageal and gastric cancer who received PC from 2012 to 2017 were identified from the Ontario Cancer Registry. Patients with one or more recorded Edmonton Symptom Assessment System (ESAS) scores in the 12 months following cancer diagnosis were included. The ESAS includes scores from 0 to 10 in nine domains (anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and lack of well-being). Symptom severity is categorized as none-mild (≤ 3), moderate (4-6), or severe (7-10). We focused on potentially modifiable symptoms, i.e. nausea, pain, and anxiety/depression. Logistic regression was used to identify factors associated with moderate-severe ESAS scores in these domains. Among those patients with serial ESAS scores (at 8 ± 2 and 12 ± 2 weeks) receiving chemotherapy, we describe changes during treatment (decrease by ≥ 1 = improved; - 1 > 0 > 1 = unchanged; increase by ≥ 1 = deteriorated).

RESULTS

The cohort included 1900 patients who received PC, of whom 79% (1497/1900) had one or more recorded ESAS scores. In multivariate analysis, younger patients were more likely to have moderate-severe scores in nausea (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.23-2.90 [p < 0.01] in patients aged 41-50 years compared with patients aged ≥ 71 years) and pain (OR 1.88, 95% CI 1.36-2.60 [p < 0.01] in patients aged 51-60 years compared with patients aged ≥ 71 years). Compared with males, females were more likely to report moderate-severe scores in anxiety/depression (OR 1.58, 95% CI 1.21-2.08 [p < 0.01]). At 8 ± 2 weeks from PC initiation, symptom scores were unchanged in 19-42% of patients, improved in 30-51% of patients, and deteriorated in 17-35% of patients. The greatest change in symptom burden was observed for appetite (51% improvement) and anxiety/depression (35% deterioration). Similar trends were observed at 12 ± 2 weeks.

CONCLUSIONS

In this large, population-based study, we observed that younger patients were more likely to report moderate-severe symptoms in pain and nausea, and females were more likely to report moderate-severe symptoms in anxiety/depression. Anxiety/depression symptoms become increasingly problematic for a substantial proportion of patients receiving PC. Supportive care efforts to mitigate these symptoms in routine practice are needed.

Prediction of breast cancer-related outcomes with the Edmonton Symptom Assessment Scale: A literature review

PURPOSE

The Edmonton Symptom Assessment Scale (ESAS) is a validated tool used in patients with varied cancer diagnoses to measure patient symptoms. The present manuscript will review the literature assessing the ability of the ESAS to predict patient-related outcomes in breast cancer patients.

METHODS

A literature search was conducted of Cochrane Central Register of Controlled Trials databases, Ovid MEDLINE, and Embase for English articles that investigated the use of predictive modelling with the ESAS in the breast cancer population. Study type, publication year, sample size, patient demographics, predicted outcomes, and strongest predictive factors/symptoms were summarized for each study.

RESULTS

A total of nine articles were included in this review. Five articles used the ESAS in predictive models to determine patient time to death. ESAS was also used to predict emergency department visits, determine symptoms associated with decreased quality of life, and generate a Health Utility Score. Lack of appetite was the most common ESAS symptom, as it was reported in five studies to be associated with decreased survival. In four of the nine articles, an additional survey investigating physical functioning was used in combination with ESAS to strengthen the predictive models.

CONCLUSIONS

Included studies support the use of ESAS in predictive models, particularly for predicting survival. Using the ESAS as a predictive tool allows for more accurate time to death predictions, potentially improving symptom management and preventing overtreatment of palliative patients near the end of life.

Testing Symptom Severity Thresholds and Potential Alerts for Clinical Intervention in Patients With Cancer Undergoing Chemotherapy

PURPOSE

Symptom monitoring is attracting attention as a way to improve adherence to cancer therapy, reduce treatment-related toxicities, and possibly improve overall survival. How reporting thresholds affect symptom alert generation and clinical outcomes is poorly understood.

PATIENTS AND METHODS

We analyzed data from 38 US health care institutions collected for the prospective Eastern Cooperative Oncology Group-American College of Radiology Imaging Network E2Z02 Symptom Outcomes and Practice Patterns study. Participants were outpatients receiving chemotherapy for breast (n = 642), colorectal (n = 486), or lung cancer (n = 340) who rated symptom severity using the MD Anderson Symptom Inventory at 2 assessment points 1 month apart. Percentages of patients with pain, dyspnea, fatigue, or distress at different thresholds (score of 4-7 on a 0-10 scale) were compared. The percentage of patients whose performance status had worsened at follow-up was used to estimate risk for missing clinically important symptom data by using higher severity thresholds.

RESULTS

At the guideline-recommended threshold of ≥ 4, suprathreshold rates were 60% for any of the 4 symptoms at the initial survey; performance status worsened at follow-up for 27% of all patients with any symptom rated ≥ 4 at the initiate survey. When the threshold was increased to ≥ 7, approximately half of patients (51%) with worsened performance status were not identified.

CONCLUSION

The burden to clinicians from an alert threshold of ≥ 4 (per many current guidelines) would be substantial. However, setting higher alert thresholds may miss a large percentage of patients who need clinical intervention. These results may inform resource planning when implementing electronic symptom screening at an institutional or practice level.

Comparing an Artificial Neural Network to Logistic Regression for Predicting ED Visit Risk Among Patients With Cancer: A Population-Based Cohort Study

CONTEXT

Prior work using symptom burden to predict emergency department (ED) visits among patients with cancer has used traditional statistical methods such as logistic regression (LR). Machine learning approaches for prediction, such as artificial neural networks (ANNs), are gaining attention but are yet to be commonly applied in practice.

OBJECTIVES

We will compare an artificial neural network with logistic regression for predicting ED visit risk among patients with cancer.

METHODS

This was a population-based study of patients diagnosed with cancer between 2007 and 2015 in Ontario, Canada. After splitting the cohort into training and test sets, an ANN model and a LR model were developed on the training cohort to predict the risk of an ED visit within seven days after an assessment of symptom burden. The predictive performance of each risk model was assessed on the test cohort and compared with respect to area under the curve and calibration.

RESULTS

The training cohort consisted of 170,092 patients undergoing 1,015,125 symptom assessments, and the remaining 42,523 patients undergoing 252,169 symptom assessments were set aside as the test cohort. Both models performed similarly with respect to specificity (ANN 67.0%; LR 67.3%) and accuracy (ANN 67.1%; LR 67.2%), and only minor improvement was found with respect to sensitivity (ANN 68.9%; LR 67.1%), discrimination (ANN 74.3%; LR 73.7%), and calibration under the ANN model compared with the LR model. The most notable improvement in calibration was found among patients in the highest ED visit risk percentile.

CONCLUSION

Although both models were similar in predictive performance using our data, ANNs have an important role in prediction because of their flexible structure and data-driven distribution-free benefits and should thus be considered as a potential modeling approach when developing a prediction tool.