Avoidable Hospitalizations and Emergency Department Visits Driving Up Costs of Cancer Care

VBCC - November 2014, Vol 5, No 9 - Economics of Cancer Care
Kate O’Rourke

Boston, MA—Two studies presented at the 2014 ASCO Quality Care Symposium show that patients with cancer have high rates of hospitalizations that are deemed avoidable, as well as high rates of emergency department visits. Clearly, strategies are needed to increase the value of cancer care for patients and for the healthcare system.

“We all agree that patients want the highest quality of life during the cancer continuum. Our obligation is to invoke the right treatment at the right time. We know that hospitalizations and emergency room visits are inevitable, but we can develop a care system that obviates the need for many of them,” said Lowell E. Schnipper, MD, Clinical Director, Beth Israel Deaconess Medical Center Cancer Center, Boston. Dr Schnipper served as the discussant of the 2 studies.

Emergency Department Visits
The first study from researchers at the University of California, Davis, compared the use of the emergency department by cancer survivors, patients with other chronic conditions, and individuals without chronic conditions.

Survivorship was defined as from the time of the cancer diagnosis through the rest of life. Few studies have examined cancer survivors’ use of the emergency department. The researchers analyzed data from the 2008-2011 Medical Expenditure Panel Survey (MEPS) and MEPS Experiences with Cancer Survivorship Supplement. MEPS is one of the most complete sources of data on healthcare cost, utilization, and health insurance coverage.

The study included 5217 cancer survivors, 29,617 patients with chronic conditions, and 27,759 individuals with no chronic conditions. The annual rate of any emergency department visit was 18.6% among cancer survivors, 15.5% in patients with chronic conditions, and 9% in individuals with no chronic conditions; the average number of visits was 1.5, 1.4, and 1.3, respectively. Undergoing active cancer treatment had no influence on the emergency department visit rate.

“As a group, cancer survivors had substantially more emergency department visits and number of visits among those who had any visits,” said lead investigator of the study Rebecca S. Lash, RN, MSN, MPP, a PhD candidate at the University of California, Davis, in Sacramento. “However, these visits were not adjusted for a number of things such as age, gender, insurance status, which did vary by group. Importantly, 85% of cancer survivors reported at least one other chronic condition.”

Compared with patients without chronic conditions, the odds of any emergency department use were higher in cancer survivors and those with chronic conditions. Other factors that predicted higher emergency department use included:

  • Having more than 1 chronic condition
  • Public insurance rather than private insurance
  • Less than a college education.
These factors have also been identified in other studies. The average annual expenditures were similar for patients with cancer ($1406), individuals with no chronic conditions ($1406), and patients with other chronic conditions ($1553). On the surface, said Ms Lash, these numbers may be surprising, but if you dig deeper, they are not.

“In MEPS, when a patient is admitted to the hospital, expenditures get wrapped up into their admission expenditures, and they are not included in MEPS emergency department expenditures,” said Ms Lash. So, the data show “people who went to the emergency room and got discharged. When you consider that, you wouldn’t expect the groups to vary much. We are probably vastly underestimating the expenditures. Oncology patients are a group likely to be admitted to a hospital. I would point out, however, that $1500 is a lot of money for an episode of care that doesn’t result in an admission.”

Avoidable Cancer-Related Hospitalizations
The second study focused on the rate of potentially avoidable hospitalizations in patients with a solid tumor who were admitted to Brigham and Women’s Hospital in Boston and had ≥2 outpatient cancer-related visits to Dana-Farber Cancer Institute in the 6 months before hospitalization.

The researchers interviewed the outpatient oncologist, inpatient attending physician, and an inpatient resident/physician assistant, asking them whether on the day of admission, the patient could have been safely and effectively managed as an outpatient rather than an inpatient, and was the hospitalization preventable with different medical management during the 30 days before admission.

Of 103 hospitalizations, 21% were rated as potentially avoidable by 2 clinicians, and 28% were deemed potentially avoidable by 1 clinician. Only 2% of hospitalizations were rated avoidable by all 3 clinicians. Hospitalizations were more likely to be perceived as avoidable when psychosocial factors contributed to the reason for hospitalization (odds ratio, 2.9; 95% confidence interval, 1.2-7.3).

The most common psychosocial factors contributing to hospitalization were depression/anxiety and inadequate home support. The median length of stay was shorter for potentially avoidable hospitalizations than for other hospitalizations—2 versus 4 days.

“There are potentially avoidable hospitalizations out there, and we really ought to believe that we can do something about those,” said Gabriel A. Brooks, MD, a medical oncologist at Dana-Farber Cancer Institute, who presented the study.

“Some potential interventions that strike me as valuable to reduce avoidable hospitalizations would be early integration of palliative and psycho­social care and more robust outpatient acute care systems.” Dr Brooks said that better identification of patients at risk for chemotherapy toxicity and chemotherapy-related hospitalization may also help.

Improving Quality Care
Dr Schnipper pointed out that studies have shown that early palliative care can help reduce hospitalizations and emergency department visits. A Canadian study, for example, showed that early palliative care for patients with cancer and other conditions reduced hospitalizations by roughly 33% and reduced emergency department visits by 25% (Seow H, et al. BMJ. 2014;348:g3496).

Dr Schnipper also believes that oncology medical homes, by providing better care, could help keep patients out of the emergency department and the hospital. A recent study demonstrated that oncology medical homes can reduce emergency department visits and hospital admissions by 50% (Sprandio JD, et al. J Oncol Pract. 2013; 9:130-132).

Related Items
Whole-Brain Radiotherapy for Brain Metastases Is Cost-Effective
Rosemary Frei, MSc
VBCC - October 2015, Vol 6, No 9 published on October 17, 2015 in Economics of Cancer Care
Current Practice Least Cost-Effective Option in Prostate Cancer Management
Meg Barbor, MPH
VBCC - October 2015, Vol 6, No 9 published on October 17, 2015 in Economics of Cancer Care
Patients with Cancer Eager to Discuss Costs of Care with Their Oncologists
Laura Morgan
VBCC - September 2015, Vol 6, No 8 published on September 17, 2015 in Economics of Cancer Care
Care Pathway for NSCLC Cuts Chemotherapy Cost
Wayne Kuznar
VBCC - August 2015, Vol 6, No 7 published on August 18, 2015 in Economics of Cancer Care
Dissecting the Cost of Targeted Therapies in Oncology
Dana Taylor
VBCC - August 2015, Vol 6, No 7 published on August 18, 2015 in Economics of Cancer Care
Site of Service Significantly Impacts Cost of Chemotherapy
Dana Taylor
VBCC - August 2015, Vol 6, No 7 published on August 18, 2015 in Economics of Cancer Care
Assessing the Cost-Effectiveness of Necitumumab in Squamous-Cell Lung Cancer
Dana Taylor
VBCC - August 2015, Vol 6, No 7 published on August 18, 2015 in Economics of Cancer Care
Increasing Use of Value Analysis Committees in US Hospitals: Implications for Healthcare Providers and Manufacturers
Laura Morgan
VBCC - June 2015, Vol 6, No 5 published on June 22, 2015 in Economics of Cancer Care
The New PC-SAF Instrument: A Patient-Reported Outcome Tool for Identifying the Symptoms of Pancreatic Cancer
Laura Morgan
VBCC - June 2015, Vol 6, No 5 published on June 22, 2015 in Economics of Cancer Care
Value of Cancer Care for Most Tumors Lower in United States than in Western Europe
Rosemary Frei, MSc
VBCC - May 2015, Vol 6, No 4 published on May 14, 2015 in Economics of Cancer Care
Last modified: November 21, 2014
  • Rheumatology Practice Management
  • American Health & Drug Benefits
  • Value-Based Cancer Care
  • Value-Based Care in Myeloma
  • Value-Based Care in Neurology