Hospital Emergency Department Practices for Treating Older Adults With Cancer

Key Points

  • After adjusting for patient characteristics, the researchers determined that there were only 43 observation status visits per 1,000 inpatient admissions among patients with cancer vs 69 per 1,000 among the cancer-free group.
  • Cancer-free patients with prior inpatient admission were still more likely to be placed on observation status than those with cancer but without prior hospitalizations.

A new study published by Lipitz-Snyderman et al in JNCCN–Journal of the National Comprehensive Cancer Network found that among patients presenting to the emergency department, those with cancer, especially those aged 75 years or older, are more likely to be admitted to the hospital—and less likely to be observed and released home—than those without cancer. That’s despite the fact that inpatient admission is not always the best treatment option available. Observation status is often preferable, because it minimizes patients' exposure to the inconvenience and risk of a hospital admission, while also reserving hospital resources for those who need it most.

“Observation status allows for additional time to be certain that a patient's clinical status is stabilized and that the correct diagnosis has been made, providing the treating staff, patient, and caregiver with a greater feeling of security upon discharge,” explained study coauthor Jeffrey Groeger, MD, Chief of the Urgent Care Service at Memorial Sloan Kettering Cancer Center (MSK). “Not all acutely ill patients in the emergency department will ultimately require inpatient admission prior to safe discharge. Patients in observation status should be suitable for rapid discharge once symptoms resolve or diagnoses are confirmed.”

Study Findings

The research focused on Medicare beneficiaries aged 66 and older. Allison Lipitz-Snyderman, PhD, first author on the study and Assistant Attending Outcomes Research Scientist at MSK, and her team analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for a total of 151,193 patients with cancer, matched to a demographically similar control group. Those with cancer had been diagnosed with breast, colon, lung, or prostate cancer between 2006 and 2008.

After adjusting for patient characteristics, the researchers determined that there were only 43 observation status visits per 1,000 inpatient admissions among patients with cancer vs 69 per 1,000 among the cancer-free group. In fact, cancer-free patients with prior inpatient admission were still more likely to be placed on observation status than those with cancer but without prior hospitalizations.

Dr. Lipitz-Snyderman recommends more research to determine where there are opportunities to develop standards for emergency department staff to treat older patients with cancer optimally.

“By implementing a set of standards and treatment protocols for addressing specific clinical conditions, we can increase the systematic use of observation status for patients with cancer,” said Dr. Groeger. “Some examples include the management of pain, nausea, vomiting, diarrhea, constipation, cellulitis, hypercalcemia, and steroid-related hyperglycemia. Additionally, partnering with medical and surgical consultants can offer significant relief to patients with pleural effusions, ascites, as well as those with malfunction around the placement of catheters and drains.”

Commentary

“This study raises important questions about how to provide medical care for older adults with cancer who present to the emergency department,” said Louise C. Walter, MD, Professor of Medicine, Chief, Division of Geriatrics, UCSF Helen Diller Family Comprehensive Cancer Center. Dr. Walter is a member of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Older Adult Oncology.

“As a geriatrician, I would go beyond advocating for developing standards for emergency department staff to manage more patients with cancer in observation status. We need to think broadly about the best location to provide medical care for this population. This should include implementing more Hospital at Home models and Housecalls programs to provide the same level of acute care for certain conditions in a patient's home, in order to avoid the hazards of long emergency department stays and unnecessary hospitalizations,” Dr. Walter concluded.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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