Justin E. Bekelman, MD
Emergency department (ED) visits and subsequent hospitalizations are a major source of healthcare resource utilization and costs among patients with cancer and may compromise quality of care and patient satisfaction. Emerging evidence suggests that many of these visits may be preventable, with such strategies as cancer-specific urgent care services; standardized clinical pathways for symptom management; education of patients, healthcare providers, and healthcare organizations; and tailored quality initiatives.
“For patients receiving active treatment for cancer, unplanned hospitalizations and ED visits are a very debilitating burden for them and the providers,” said Justin E. Bekelman, MD, an associate professor in the Radiation Oncology and Medical Ethics and Health Policy departments of the Perelman School of Medicine and a senior fellow in the Leonard Davis Institute for Health Economics, both at the Penn Medicine Abramson Cancer Center in Philadelphia. “If our aim is to improve the quality of cancer care that our health systems deliver, a key aspect is to make the experience of receiving cancer treatment as stable as possible, which means doing our best to reduce any unplanned emergency event that a patient might experience.”
Trends and Costs of Acute Care Visits
ED visits and subsequent hospitalizations are relatively common among patients with cancer undergoing active treatment, with the most common causes including febrile neutropenia, infection, pain, fever, and dyspnea.1
An analysis of ED usage patterns by adults (≥18 years) in the United States during a 7-year period found that 4.2% of visits were made by a patient with a cancer-related complication and that these visits were more likely to result in hospital admissions than those not related to cancer (59.7% vs 16.3%, respectively; P
In terms of tumor types, visits related to breast, prostate, or lung cancers were most frequent; in terms of complications, pneumonia, chest pain, and urinary tract infections were most commonly reported (Figure
In another perspective, an executive research briefing from the Advisory Board Oncology Roundtable showed that 56% of Medicare patients who received chemotherapy visited the ED each year, and 63% of these visits resulted in a hospitalization.3
Multiple factors drive the high rates of ED utilization. Some experts suggest that the increased size of the aging population and development of new treatment strategies that improve survival have increased the number of patients experiencing related adverse effects (AEs) that lead to an ED visit. Mikkael A. Sekeres, MD, MS, professor of medicine and director of the Leukemia Program at Cleveland Clinic in Ohio, noted that the shift in receiving cancer therapies in the outpatient setting, versus in the inpatient setting, may increase ED utilization because the AEs occur at home rather than in the hospital. Nonclinical factors, such as changes in socioeconomic status, insurance coverage, and psychological or behavioral factors over time have likely also contributed to high ED utilization, according to Laura E. Panattoni, PhD, a scientist at the Hutchinson Institute for Cancer Outcomes Research in Seattle, Washington.