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.
The location of the practice could also play a role in whether a patient goes to the ED, according to Michael K. Keng, MD, an assistant professor of medicine in the Division of Hematology/Oncology at University of Virginia School of Medicine in Charlottesville. “We are a large academic center, and we feel comfortable with taking care of very sick patients that otherwise would need to go to the ED in a more rural type of setting,” said Keng. “Patients who live in a rural setting that doesn’t have a large hospital or cancer center support are often shunted to the EDs more quickly.”
High rates of ED utilization compromise quality of care and patient satisfaction. ED clinicians and staff often do not have oncology-specific training or care coordination protocols with the cancer care teams. Additionally, patients may have long delays in care in the ED, and immunocompromised patients are at high risk for infection in the ED or hospital.
Furthermore, ED visits and hospitalizations also lead to significant healthcare costs. An analysis of Medicare patients with advanced cancer showed that acute hospital care accounted for 48% of medical spending,4
and the actuarial firm Milliman estimated that a chemotherapy-related ED visit costs 0 on average and ,000 if the visit results in hospitalization.5
Figure. Snapshot OF Emergency Department Visits by Patients With Cancer2
Preventability of ED Visits
Emerging data suggest that many ED visits for symptoms inadequately controlled in the outpatient setting are preventable. Using symptoms identified as preventable by the CMS and symptoms targeted by patient-reported outcome tools, researchers from Fred Hutchinson Cancer Research Center studied patterns of ED use among patients with cancer in 13 counties in western Washington treated during a 4-year period. In all, 27% of approximately 5800 adults with cancer (≥18 years) visited the ED within 1 year of their diagnosis for symptoms that did not result in hospital admission.6
Investigators estimated that as many as 53% of the 2400 ED visits these patients made could have been avoided.6 When the definition of potentially preventable visits was expanded to include common symptoms associated with chronic health conditions, the proportion of potentially preventable visits increased. The authors also showed a median cost of 47 for potentially preventable cancer-related visits and estimated that 18% of ED costs resulted from inadequate cancer and chronic disease management.
“Unplanned ED visits negatively impact the patient experience and are costly for patients, families, and the healthcare system,” said Panattoni, lead author of the study. “In our community setting, where many cancer patients visit EDs that are not affiliated with their cancer provider, the ED physician may not have access to the patient electronic record, which can result in duplicative testing, extra time spent in the ED for the patient, and poor care coordination.”
CMS Measure Aims to Reduce Preventable ED Visits
To address the quality of care for patients receiving chemotherapy and encourage performance improvement in the outpatient setting, CMS is proposing to add an oncology measure to its Hospital Outpatient Quality Reporting Program that will be effective in 2020.7 The measure, OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, focuses on patients with cancer (excluding leukemia) who receive hospital-based outpatient chemotherapy and have an inpatient admission or ED visit within 30 days for 1 of 10 conditions believed to be preventable causes of ED visits and hospitalizations (Table
The measure will consist of scores for inpatient admission and ED visit rates, based on the hospital’s current and expected inpatient admissions and ED visits and national observed rates on inpatient admissions and ED visits, respectively.
“I think it’s terrific that CMS is including an important quality measure for oncology patients,” said Bekelman. “They’re lining up a process that could definitely [have an] impact on reducing unplanned acute care for Medicare beneficiaries.”
Although Panattoni agreed that the measure allows researchers to quantify the prevalence and cost implications of potentially preventable ED and inpatient visits, she cautioned about the limitations with using claims data to measure these visits. “The hope is that the CMS measure does not influence coding practices, and in the worst-case scenario, incentivize miscoding,” she said.
Keng, who began studying ED usage patterns several years ago when he was at Cleveland Clinic in Ohio, also expressed concern that it may discourage physicians from sending patients to the ED when they have a true emergency. “There are very appropriate reasons for [patients] to go to the ED,” he said. “I hope that CMS sees that if you’re appropriately using the ED, you won’t be penalized. I’m afraid that some physicians may try to treat the patients in the outpatient setting unsafely to avoid those penalties, or they may want to directly admit patients to the hospital to avoid ED use.”
Table. 10 Oncologic Symptoms for Outpatient Care7
Strategies for Reducing Preventable ED Visits
Cancer-Specific Urgent Care Services
As part of a larger effort to improve patientcentered quality of care, hospital systems and oncology practices have begun to offer cancer-specific urgent care centers. Johns Hopkins Hospital in Baltimore, Maryland, implemented a system in which patients call the center’s hotline before coming into the clinic. If nurses are unable to assist the patients over the phone, they instruct them to come into the center. This system decreased the average number of hospitalizations among a group of patients with cancer by 50%.8
The University of Texas Southwestern Medical Center in Dallas also opened a cancer urgent care center when providers recognized that their ED was not fully equipped to treat the sores, fevers, dehydration, and nausea associated with chemotherapy. At the center, patients are managed by physician assistants who are familiar with chemotherapy-induced AEs and can easily contact the patient’s oncologist for further instructions. Patients can also bypass the ED and be admitted to the hospital directly from the center if necessary.
“It results in lower costs, but really it’s about better care, keeping patients at home and not in the hospitals,” said Thomas Froehlich, MD, medical director of the center’s cancer clinics in an interview with The Baltimore Sun
Some cancer centers have opened urgent care facilities within their outpatient clinic, which improves the ease of coordinating urgent care needs and treatment schedules. The Penn Medicine Abramson Cancer Center recently opened the Oncology Evaluation Center, which serves as an urgent care facility specifically for patients with cancer and is staffed by oncologists and nurse practitioners who have extensive experience with managing common complications of cancer treatment.
Standardized Clinical Pathways for Symptom Management
Standardized clinical pathways, which include outpatient symptom management and phone triage systems, supportive care incorporated into standardized disease management pathways, and ED symptom management pathways, reduce unwanted variation in the management of cancer-related symptoms and, in turn, may reduce the need for unplanned acute care, according to Bekelman.
“When we reduce that variability and go to a standardized approach, we believe that we will not only reduce unplanned acute care, but also reduce the burden of hospitalization and ED visits and the financial burden of care that is unnecessary,” said Bekelman. “I think the ED has to be a last resort, but unfortunately in today’s world of cancer management, the ED ends up being the place [patients] go to because they don’t have other options for acute care as an outpatient.”
The concept of standardized care pathways has been explored in some settings for more than a decade. Consultants in Medical Oncology and Hematology, a community-based practice in the Philadelphia suburbs that has embraced value-based care models, developed customized symptom management protocols for dehydration, diarrhea, insomnia, and delayed chemotherapy-induced nausea and vomiting (CINV).
Starting in 2004, these protocols were followed by nurses (during business hours) and on-call physicians (after hours). After 5 years, the percentage of patients directed to the ED as a result of a clinical call decreased by almost 60%.10
The care patients received also improved; for example, standardized prevention of delayed CINV decreased posttreatment nausea and lowered prescriptions for drugs to control it.
Education of Patients and the Healthcare Team
Education of all involved parties, from the patients to the healthcare team to the healthcare organization, is critical for reducing ED visits, according to Keng. “The patient needs to be educated on what their cancer is, what is the treatment plan, and what are the treatment- related [AEs],” he said. “They need to know what to recognize early so that they don’t present too late and necessitate an ED visit and hospital admission.” He also noted that the multiple healthcare providers involved in patient care, including pharmacists, nurses, and ancillary therapists, need to be up to date on the available treatment options and associated AEs to prepare and help patients through their treatments.
Regular evaluation of the reasons for preventable ED visits and hospital readmissions within a healthcare organization is also important to identify areas for improvement in the specific healthcare setting, according to Keng. He discussed a large community practice in south Florida that had a high rate of ED admissions during office hours. Further analysis revealed that many patients were visiting the ED because of a lack of appointments and availability in the outpatient setting.
The American Society of Clinical Oncology’s Quality Improvement Program implemented an initiative project for this practice that developed a protocol for telephone operators to handle calls at the patient access center, where trained staff assessed the severity of patient symptoms and identified when an ED referral was necessary. In addition, a triage nurse was hired to provide consultation services and appointment times were added to care for walk-in patients at the participating practices. In the first 4 months of implementation, the protocol decreased the use of ED services by 60%.11
“Those are simple steps that could be applied to different organizations throughout the United States,” said Keng. “When you educate a practice with quality improvement principles, they can be applied to many different avenues to decrease ED visits.”
Quality Initiatives for Improved Care in the ED
Many life-threatening conditions associated with cancer necessitate an ED visit, yet patients may not receive the emergent treatment they need. Sekeres, Keng, and their colleagues at Cleveland Clinic started a quality initiative project to reduce time to antibiotic administration for patients with febrile neutropenia in the ED. After meeting with physicians, nurses, and pharmacists in the emergency medicine and oncology departments, along with infectious disease physicians, the researchers found that the definition of febrile neutropenia varied among practice settings and that it was being triaged at a level similar to the common cold. “We showed them data on the mortality rate of patients with fever and neutropenia and said that it [should be] similar to triaging for stroke and heart attack,” said Sekeres.
The intervention re-triaged the condition, standardized the definition of febrile neutropenia, redirected patients to an isolated waiting area, gave patients cards that informed ED staff of their health condition, and made antibiotics available in the ED. After 12 months, time with antibiotic administration was significantly shorter and hospital length of stay tended to decrease compared with historical controls, changes that Sekeres said were maintained after completion of the study.12
Although the quality initiative was center-specific, Sekeres and Keng indicated that such strategies could be implemented in other EDs. Indeed, similar solutions have been enacted at the University of Virginia and several other hospitals in the Virginia area, according to Keng.
“Although it was tailored to the Cleveland Clinic, these steps are very logical and can be done very easily at another healthcare institution,” said Keng. “If this works, this is just one aspect of how to reduce patient mortality or morbidity once [patients] are in the ED. If we find a good way to reduce ED resource utilization, it could definitely be widespread.”
Overall, experts agree that education of patients and healthcare staff, along with regular evaluation of patient outcomes and hospital data, is critical for improving the value of care for patients with cancer by minimizing preventable ED visits and improving care in the ED for emergent complications. “The major theme is education all around,” said Keng.
- Vandyk AD, Harrison MB, Macartney G, Ross-White A, Stacey D. Emergency department visits for symptoms experienced by oncology patients: a systematic review. Support Care Cancer. 2012;20(8):1589-99. doi: 10.1007/s00520-012-1459-y.
- Rivera DR, Gallicchio L, Brown J, Liu B, Kyriacou DN, Shelburne N. Trends in adult cancer–related emergency department utilization an analysis of data from the nationwide emergency department sample. JAMA Oncol. 2017;3(10):e172450. doi: 10.1001/jamaoncol.2017.2450.
- Saulet D. How to keep your cancer patients out of the ED: three practices to improve urgent care. Advisory Board website. advisory.com/research/oncology-roundtable/briefs/2018/how-to-keep-your-cancer-patients-out-of-the-ed. Published January 2, 2018. Accessed March 19, 2018.
- Brooks GA, Li L, Uno H, Hassett MJ, Landon BE, Schrag D. Acute hospital care is the chief driver of regional spending variation in Medicare patients with advanced cancer. Health Aff (Millwood). 2014;33(10):1793-800. doi: 10.1377/hlthaff.2014.0280.
- Fitch K, Pyenson B. Cancer patients receiving chemotherapy: opportunity for better management [client report]. New York, NY: Milliman, Inc; March 30, 2010; milliman.com/uploadedFiles/insight/research/health-rr/cancer-patients-receiving-chemotherapy.pdf. Accessed March 19, 2018.
- Panattoni LE, Fedorenko CR, Kreizenbeck KL, Greenlee S, et al. The role of chronic disease in the costs of potentially preventable emergency department use during treatment: a regional study. Presented at: 2017 American Society of Clinical Oncology Annual Meeting; June 2-6, 2017; Chicago, IL. Abstract 6505. meetinglibrary.asco.org/record/150305/abstract.
- Miller B. CMS proposes outcomes-based quality measure for outpatient cancer care. Advisory Board website. advisory.com/research/oncology-roundtable/oncology-rounds/2016/08/cms-outcomes-based-quality-measure. Published August 17, 2016. Accessed March 19, 2018.
- Why Johns Hopkins opened an urgent care center—just for cancer patients. Advisory Board website. advisory.com/daily-briefing/2016/12/01/cancer-patient-urgent-care. Published December 1, 2016. Accessed March 19, 2018.
- Cohn M. Hopkins expands urgent care to cancer patients. The Baltimore Sun. November 25, 2016. baltimoresun.com/health/bs-hs-cancer-urgent-care-20161122-story.html. Accessed March 19, 2018.
- Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Community Oncol. 2010;7(12):565-572. mdedge.com/sites/default/files/jso-archives/Elsevier/co/journal/articles/0712565.pdf. Accessed April 9, 2018.
- Hunis B, Alencar AJ, Castrellon AB, et al. Making steps to decrease emergency room visits in patients with cancer: our experience after participating in the ASCO Quality Training Program. Presented at: 2016 ASCO Quality Care Symposium; February 26-27, 2016; Phoenix, AZ. Abstract 51. meetinglibrary.asco.org/record/121629/abstract.
- Keng MK, Thallner EA, Elson P, et al. Reducing time to antibiotic administration for febrile neutropenia in the emergency department. J Oncol Pract. 2015;11(6):450-455. doi: 10.1200/JOP.2014.002733.