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Tiutan T, Wallins JS, Brown S, Gonen M, Korenstein D. Prognostic value of procalcitonin in cancer patients with coronavirus disease 2019. Clin Chem Lab Med 2023; 61:339-348. [PMID: 36367353 PMCID: PMC9747503 DOI: 10.1515/cclm-2022-0366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Many biomarkers have been studied to assist in the risk stratification and prognostication of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Procalcitonin (PCT), a circulating precursor of the hormone calcitonin, has been studied with mixed results as a predictor of severe coronavirus disease 2019 (COVID-19) in the general population; however, to date, no studies have focused on the utility of PCT in predicting disease severity and death from COVID-19 in the cancer population. METHODS We conducted a retrospective study of cancer patients hospitalized with COVID-19 at a comprehensive cancer center over a 10-month period who had PCT recorded on admission. We assessed associations between variables of clinical interest and the primary outcomes of progression of COVID-19 and death during or within 30 days of hospitalization using univariable and multivariable logistic regression. RESULTS The study included 209 unique patients. In the univariate analysis, elevated PCT on admission was associated with higher odds of progression of COVID-19 or death (Odds ratio [OR] 1.40, 95% CI 1.08-1.93) and mortality alone (OR 1.53, 95% CI 1.17-2.11). In multivariate regression, PCT remained significantly associated with progression or death after holding chronic kidney disease (CKD) status constant (OR 1.40, 95% CI: 1.08, 1.93, p=0.003). Similarly, the association of PCT and death remained significant after adjusting for age (OR 1.54, 95% CI: 1.17-2.15). CONCLUSIONS In hospitalized COVID-19 patients with underlying cancer, initial PCT levels on admission may be associated with prognosis, involving higher odds of progression of COVID-19 and/or mortality.
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Affiliation(s)
- Timothy Tiutan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Samantha Brown
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Cancer-related emergency and urgent care: expanding the research agenda. EMERGENCY CANCER CARE 2022; 1:4. [PMID: 35844668 PMCID: PMC9194780 DOI: 10.1186/s44201-022-00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/23/2022] [Indexed: 11/17/2022]
Abstract
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.
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3
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The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain. Curr Oncol Rep 2022; 24:595-602. [PMID: 35192121 DOI: 10.1007/s11912-022-01245-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.
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4
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Chaftari P, Lipe DN, Wattana MK, Qdaisat A, Krishnamani PP, Thomas J, Elsayem AF, Sandoval M. Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center. JCO Oncol Pract 2021; 18:e574-e585. [PMID: 34905410 PMCID: PMC9014449 DOI: 10.1200/op.21.00478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. Outcomes of patients placed in an emergency department observation unit of a comprehensive cancer center
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Affiliation(s)
- Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Demis N Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monica K Wattana
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jomol Thomas
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed F Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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5
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Zhuang Q, Chan JSE, See LKY, Chiang J, Suhaimi SR, Chua TWL, Venkataraman A. Characteristics of unplanned hospitalisations among cancer patients in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:882-891. [PMID: 34985100 DOI: 10.47102/annals-acadmedsg.2021212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Cancer is a pervasive global problem with significant healthcare utilisation and cost. Emergency departments (EDs) see large numbers of patients with oncologic emergencies and act as "gate-keepers" to subsequent hospital admissions. A proportion of such hospital admissions are rapidly discharged within 2 days and may be potentially avoidable. METHODS Over a 6-month period, we conducted a retrospective audit of active cancer patients presenting to the ED with subsequent admission to the Department of Medical Oncology. Our aims were to identify independent factors associated with a length of stay ≤2 days; and characterise the clinical and resource needs of these short admissions. RESULTS Among all medical oncology admissions, 24.4% were discharged within 2 days. Compared to longer stayers, patients with short admissions were significantly younger (P=0.010), had lower National Early Warning Scores (NEWS) (P=0.006), and had a lower proportion of gastrointestinal and hepatobiliary cancers (P=0.005). Among short admissions, common presenting medical problems were infections (n=144, 36.3%), pain (n=116, 29.2%), gastrointestinal complaints (n=85, 21.4%) and respiratory complaints (n=76, 19.1%). These admissions required investigations and treatments already available at the ED. CONCLUSION Short admissions have low resource needs and may be managed in the ED. This may help save valuable inpatient bed-days and reduce overall healthcare costs.
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Affiliation(s)
- Qingyuan Zhuang
- Division of Supportive and Palliative Care, National Cancer Centre, Singapore
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6
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Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
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Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
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7
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Gould Rothberg BE, Canavan ME, Mun S, Sedghi T, Carafeno T, Raucci M, Dest V, Sinanis N, Gross CP, Adelson KB. Impact of a Dedicated Cancer Urgent Care Center on Acute Care Utilization. JCO Oncol Pract 2021; 18:e129-e136. [PMID: 34383579 DOI: 10.1200/op.21.00183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Acute care imposes a significant burden on patients and cancer care costs. We examined whether an advanced practice provider-driven, cancer-specific urgent care center embedded within a large tertiary academic center decreased acute care use among oncology patients on active therapy. MATERIALS AND METHODS We conducted a quasi-experimental study anchored around the Oncology Extended Care Clinic (OECC) opening date. We evaluated two parallel 4-month periods: a post-OECC period that followed a 5-month run-in phase, and the identical calendar period 1 year earlier. Our primary outcomes included all emergency department (ED) presentations and hospital admissions during the 3-month window following the index provider visit. We used Poisson models to calculate absolute pre-OECC v post-OECC rate differences. RESULTS Our cohort included 2,095 patients in the pre-OECC period and 2,188 in the post-OECC period. We identified 32.6 ED visits/100 patients and 41.2 hospitalizations/100 patients in the pre-OECC period, versus 28.2 ED visits/100 patients and 26.1 hospitalizations/100 patients post-OECC. After adjusting for age, sex, race and ethnicity, and practice location, we observed a significant decrease of 4.6 ED visits/100 patients during the post-OECC period (95% CI, -8.92/100 to -0.28/100; P = .04) compared with the pre-OECC period. There was no significant association between the OECC opening and hospitalization rate (rate difference: -3.29 admissions/100 patients; 95% CI, -8.24/100 to 1.67/100; P = .19). CONCLUSION Establishing a cancer-specific urgent care center was significantly associated with a modest decrease in emergency room utilization but not with hospitalization rate. Barriers included clinic capacity, patient awareness, and physician comfort with advanced practice provider autonomy. Optimizing workflow and standardizing clinical pathways can create benchmarks useful for value-based payments.
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Affiliation(s)
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Sophia Mun
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT
| | - Tannaz Sedghi
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT
| | - Tracy Carafeno
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Maureen Raucci
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Vanna Dest
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Naralys Sinanis
- Smilow Cancer Hospital at Yale-New Haven Health, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kerin B Adelson
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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8
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Emergency Presentations of Immune Checkpoint Inhibitor-Related Endocrinopathies. J Emerg Med 2021; 61:140-146. [PMID: 33795170 DOI: 10.1016/j.jemermed.2021.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 02/06/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) are an important component of anticancer treatment, with indications across an increasing range of oncological diagnoses. ICIs are associated with a range of immune-mediated toxicities. Immune-related endocrinopathies pose a distinct challenge, given the nonspecific symptom profile and potentially life-threatening sequelae if not recognized. OBJECTIVES To determine the frequency and clinical presentations of immune-mediated endocrinopathies in patients treated with ICIs presenting as emergencies. METHODS A prospective observational cohort study was undertaken at a specialist oncology hospital in North West England from May 20, 2018 to May 19, 2020. Within the hospital, the Oncology Assessment Unit (OAU) acts as the receiving unit in which assessments are undertaken of all emergency presentations. All patients treated with ICIs presenting to the OAU were included. The primary outcome was diagnosis of an immune-mediated endocrinopathy. Length of inpatient stay, and 7- and 30-day mortality rates were examined. RESULTS During the study period, 684 patients treated with ICIs presented to the OAU. Twenty-four (3.5%) patients had an acute immune-mediated endocrinopathy, of which 17 had hypophysitis, 4 diabetes mellitus, 2 thyrotoxicosis, and 1 adrenalitis. Median length of stay for patients with hypophysitis was 1 day. No patient with an immune-mediated endocrinopathy died within 30 days of presentation. CONCLUSIONS Presentations to emergency settings with acute immune-mediated endocrinopathies are rare. Early recognition of immune-mediated toxicities is important, and particularly pertinent in ICI-related endocrinopathies, where even in life-threatening cases, the presentation can be vague and nonspecific.
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9
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McGregor BA, Vidal GA, Shah SA, Mitchell JD, Hendifar AE. Remote Oncology Care: Review of Current Technology and Future Directions. Cureus 2020; 12:e10156. [PMID: 33014652 PMCID: PMC7526951 DOI: 10.7759/cureus.10156] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cancer patients frequently develop tumor and treatment-related complications, leading to diminished quality of life, shortened survival, and overutilization of emergency department and hospital services. Outpatient oncology treatment has potential to leave cancer patients unmonitored for long periods while at risk of clinical deterioration which has been exaggerated during the COVID19 pandemic. Visits to cancer clinics and hospitals risk exposing immunocompromised patients to infectious complications. Remote patient reported outcomes monitoring systems have been developed for use in cancer treatment, showing benefits in economic and survival outcomes. While advanced devices such as pulmonary artery pressure monitors and implantable loop recorders have proven benefits in cardiovascular care, similar options do not exist for oncology. Here we review the current literature around remote patient monitoring in cancer care and propose the use of reliable devices for capturing and reporting patient symptoms and physiology.
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Affiliation(s)
| | - Gregory A Vidal
- Oncology, West Cancer Center and Research Institute and the University of Tennessee Health Science Center, Memphis, USA
| | - Sumit A Shah
- Oncology, Stanford University School of Medicine, Palo Alto, USA
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10
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Cooksley T, Gupta A, Al-Sayed T, Lorigan P. Emergency presentations in patients treated with immune checkpoint inhibitors. Eur J Cancer 2020; 130:193-197. [DOI: 10.1016/j.ejca.2020.02.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
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11
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Jairam V, Lee V, Park HS, Thomas CR, Melnick ER, Gross CP, Presley CJ, Adelson KB, Yu JB. Treatment-Related Complications of Systemic Therapy and Radiotherapy. JAMA Oncol 2020; 5:1028-1035. [PMID: 30946433 DOI: 10.1001/jamaoncol.2019.0086] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Systemic therapy and radiotherapy can be associated with acute complications that may require emergent care. However, there are limited data characterizing complications and the financial burden of cancer therapy that are treated in emergency departments (EDs) in the United States. Objectives To estimate the incidence of treatment-related complications of systemic therapy or radiotherapy, examine factors associated with inpatient admission, and investigate the overall financial burden. Design, Setting, and Participants A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was performed. Between January 2006 and December 2015, there was a weighted total of 1.3 billion ED visits; of these, 1.5 million were related to a complication of systemic therapy or radiotherapy for cancer. Data analysis was conducted from February 22 to December 23, 2018. External cause of injury codes, Clinical Classifications Software, International Classification of Diseases, Ninth Revision, Clinical Modification, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), Clinical Modification codes were used to identify patients with complications of systemic therapy or radiotherapy. Main Outcomes and Measures Patterns in treatment-related complications, patient- and hospital-related factors associated with inpatient admission, and median and total charges for treatment-related complications were the main outcomes. Results Of the 1.5 million ED visits included in the analysis, 53.2% of patients were female and mean age was 63.3 years. Treatment-related ED visits increased by a rate of 10.8% per year compared with 2.0% for overall ED visits. Among ED visits, 90.9% resulted in inpatient admission to the hospital and 4.9% resulted in death during hospitalization. Neutropenia (136 167 [8.9%]), sepsis (128 171 [8.4%]), and anemia (117 557 [7.7%]) were both the most common and costliest (neutropenia: $5.52 billion; sepsis: $11.21 billion; and anemia: $6.78 billion) complications diagnosed on presentation to EDs; sepsis (odds ratio [OR], 21.00; 95% CI, 14.61-30.20), pneumonia (OR, 9.73; 95% CI, 8.08-11.73), and acute kidney injury (OR, 9.60; 95% CI, 7.77-11.85) were associated with inpatient admission. Costs related to the top 10 most common complications totaled $38 billion and comprised 48% of the total financial burden of the study cohort. Conclusions and Relevance Emergency department visits for complications of systemic therapy or radiotherapy increased at a 5.5-fold higher rate over 10 years compared with overall ED visits. Neutropenia, sepsis, and anemia appear to be the most common complications; sepsis, pneumonia, and acute kidney injury appear to be associated with the highest rates of inpatient admission. These complications suggest that significant charges are incurred on ED visits.
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Affiliation(s)
- Vikram Jairam
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Victor Lee
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health and Science University-Knight Cancer Institute, Portland
| | - Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut
| | - Carolyn J Presley
- The James Cancer Hospital & Solove Research Institute, Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus
| | - Kerin B Adelson
- Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut.,Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
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12
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Cooksley T, Marshall W, Ahn S, Lasserson DS, Marshall E, Rice TW, Klotz A. Ambulatory emergency oncology: A key tenet of future emergency oncology care. Int J Clin Pract 2020; 74:e13436. [PMID: 31633264 DOI: 10.1111/ijcp.13436] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/16/2019] [Accepted: 10/13/2019] [Indexed: 12/19/2022] Open
Abstract
Ambulatory emergency oncology The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients' needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high-risk non-oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low-risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory-sensitive presentations.
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Affiliation(s)
- Tim Cooksley
- Department of Acute Medicine and Critical Care, The Christie, Manchester, UK
| | - Will Marshall
- Department of Acute Medicine, Manchester University Foundation Trust, Manchester, UK
| | - Shin Ahn
- Department of Emergency Medicine, Cancer Emergency Room, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Daniel S Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ernie Marshall
- Department of Medical Oncology, Clatterbridge Cancer Centre, Wirral, UK
| | - Terry W Rice
- Division of Internal Medicine, Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam Klotz
- Department of Emergency Medicine, Memorial Sloan Kettering, New York, NY, USA
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13
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Northfield S, Button E, Wyld D, Gavin NC, Nasato G, Yates P. Taking care of our own: A narrative review of cancer care services-led models of care providing emergent care to patients with cancer. Eur J Oncol Nurs 2019; 40:85-97. [PMID: 31229211 DOI: 10.1016/j.ejon.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/06/2019] [Accepted: 02/14/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To synthesise available evidence on cancer care services-led models of care in the acute care setting that aim to reduce emergency presentations and/or hospital admissions for patients with cancer. METHODS A narrative review of studies describing models of care for patients with cancer and emergent healthcare needs was undertaken. Four databases were searched using keywords to identify primary research or quality improvement articles published between January 2005-June 2017. RESULTS After a systematic search, 22 studies were included in the review. The methodological quality of the included studies was poor when assessed using the Mixed Methods Appraisal Tool. Most studies were retrospective and set in a single centre. The overarching outcomes associated with the most commonly described models of care (telephone advice services and/or unplanned care and assessment units) were improved coordination of care/continuity of care, prompt access to specialist care, reduced utilisation of emergency departments, fewer hospital admissions and reduced cost. At the time of this review, evaluation of Nurse Practitioner-led services and acute oncology services had been limited. CONCLUSIONS Findings indicate several models of care reduce emergency presentations and/or hospitalisations for those living with cancer and improve patient outcomes. What remains unclear is which underlying mechanisms reduce emergency presentations and/or hospitalisations for patients with cancer and whether successful models of care are uniquely suited to specific contexts of care or applicable across different healthcare settings. More research is needed to assist healthcare services to develop and evaluate models of care to address the emergent needs of people with cancer.
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Affiliation(s)
- Sarah Northfield
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia.
| | - Elise Button
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland, Australia
| | - David Wyld
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, St Lucia, Brisbane, Queensland, Australia
| | - Nicole Claire Gavin
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland, Australia
| | - Gillian Nasato
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
| | - Patsy Yates
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland, Australia
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14
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Daly B, Nicholas K, Gorenshteyn D, Sokolowski S, Gazit L, Adams L, Matays J, Katzen LL, Chiu YO, Xiao H, Salvaggio R, Baldwin-Medsker A, Chow K, Nelson J, Ross M, Ng KK, Zervoudakis A, Perchick W, Reidy DL, Simon BA, Wagner I. Misery Loves Company: Presenting Symptom Clusters to Urgent Care by Patients Receiving Antineoplastic Therapy. J Oncol Pract 2018; 14:e484-e495. [PMID: 30016125 DOI: 10.1200/jop.18.00199] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The Centers for Medicare & Medicaid Services (CMS) identifies suboptimal management of treatment toxicities as a care gap and proposes the measurement of hospital performance on the basis of emergency department visits for 10 common symptoms. Current management strategies do not address symptom co-occurrence. METHODS We evaluated symptom co-occurrence in three patient cohorts that presented to a cancer hospital urgent care center in 2016. We examined both the CMS-identified symptoms and an expanded clinician-identified set defined as symptoms that could be safely managed in the outpatient setting if identified early and managed proactively. The cohorts included patients who presented with a CMS-defined symptom within 30 days of treatment, patients who presented within 30 days of treatment with a symptom from the expanded set, and patients who presented with a symptom from the expanded set within 30 days of treatment start. Symptom co-occurrence was measured by Jaccard index. A community detection algorithm was used to identify symptom clusters on the basis of a random walk process, and network visualizations were used to illustrate symptom dynamics. RESULTS There were 6,429 presentations in the CMS symptom-defined cohort. The network analysis identified two distinct symptom clusters centered around pain and fever. In the expanded symptom cohort, there were 5,731 visits and six symptom clusters centered around fever, emesis/nausea, fatigue, deep vein thrombosis, pain, and ascites. For patients who newly initiated treatment, there were 1,154 visits and four symptom clusters centered around fever, nausea/emesis, fatigue, and deep vein thrombosis. CONCLUSION Uncontrolled symptoms are associated with unplanned acute care. Recognition of the complexity of symptom co-occurrence can drive improved management strategies.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Lior Gazit
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lynn Adams
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennie Matays
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Yeneat O Chiu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Han Xiao
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Judith Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mikel Ross
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth K Ng
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Diane L Reidy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett A Simon
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY
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15
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Lipitz-Snyderman A, Klotz A, Gennarelli RL, Groeger J. A Population-Based Assessment of Emergency Department Observation Status for Older Adults With Cancer. J Natl Compr Canc Netw 2017; 15:1234-1239. [PMID: 28982749 DOI: 10.6004/jnccn.2017.0160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/21/2022]
Abstract
Background: Hospitals' use of observation status for patients with cancer presenting to the emergency department (ED) is not well understood. This model of care delivery may be a viable alternative to inpatient admission for patients with cancer presenting with certain conditions. Our objective was to assess the use of observation status among Medicare beneficiaries with and without cancer. Methods: Population-based SEER-Medicare data were used to assess differences in the use of observation status between Medicare beneficiaries aged ≥66 years with and without cancer using a matched analysis (n=151,183 per cohort). We assessed the ratio of observation unit use to inpatient admission, between cancer and noncancer cohorts, and for patients diagnosed with breast, colon, lung, and prostate cancers. Poisson regression models were used to calculate observation rate estimates and 95% CIs while adjusting for selected patient characteristics. Results: When considering the volume of hospitalizations, observation status is used less frequently among beneficiaries with cancer than those without (43 vs 69 observation status visits per 1,000 inpatient admissions, respectively). The estimated observation rate per 1,000 inpatient admissions was higher for beneficiaries aged <75 years versus those aged ≥75 years, those with a Charlson comorbidity index of 0 vs 1 or ≥2, and those without a prior hospitalization versus those with ≥1 prior hospitalizations. Patients with breast and prostate cancers had higher adjusted and unadjusted observation rates per 1,000 inpatient admissions compared with those with colon and lung cancers. Conclusions: Observation status is used proportionately less for beneficiaries with cancer than those without. There may be opportunities to develop standards for ED staff to manage certain conditions for patients with cancer in observation status, and to reserve hospital resources for those who need it most.
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16
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Brooks GA, Chen EJ, Murakami MA, Giannakis M, Baugh CW, Schrag D. An ED pilot intervention to facilitate outpatient acute care for cancer patients. Am J Emerg Med 2016; 34:1934-1938. [PMID: 27412915 DOI: 10.1016/j.ajem.2016.06.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Unplanned hospitalizations are common in patients with cancer, and most hospitalizations originate in the emergency department (ED). METHODS We implemented an ED-based pilot intervention designed to reduce hospitalizations among patients with solid tumors. The intervention, piloted at a single academic medical center, involved a medical oncologist embedded in the ED during evening hours. We used a quasiexperimental preimplementation/postimplementation study design to evaluate the proportion of ED visits that resulted in inpatient hospital admission, before and after pilot implementation. General estimating equations were used to evaluate the association between the intervention and hospital admission. RESULTS There were 390 ED visits by eligible cancer patients in the preintervention period and 418 visits in the intervention period. During the intervention period, 158 (38%) of 418 ED visits were identified by the embedded oncologist during the evening intervention shift. The proportion of ED visits leading to hospitalization was 70% vs 69% in the preintervention and intervention periods (odds ratio, 0.93 [95% confidence interval, 0.69-1.24]; P= .62). There were no differences between periods in ED length of stay or subsequent use of acute care. Among patients with initial ED presentation during the operating hours of the intervention, the proportion of ED visits leading to hospitalization was 77% vs 67% in the preintervention and intervention periods (odds ratio, 0.62 [0.36-1.08]; P= .08). CONCLUSION Embedding an oncologist in the ED of an academic medical center did not significantly reduce hospital admissions. Novel approaches are needed to strengthen outpatient acute care for patients with cancer.
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Affiliation(s)
- Gabriel A Brooks
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115.
| | - Eddy J Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Mark A Murakami
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Marios Giannakis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115
| | - Deb Schrag
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115
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17
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Marsland T. Admission Versus Observation: Clinically Impactful or Just a Reimbursement Shell Game? J Oncol Pract 2015; 11:78. [DOI: 10.1200/jop.2014.002881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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