Emergency department (ED) visits by patients with cancer increased by 67.1% between the start of 2012 and the end of 2019, compared with an increase of just 7.5% in cancer incidence, according to a recent study in JAMA Network Open.1 Factors identified as possible explanations for the disproportionate increase in the number of ED visits include an aging population, novel therapies, increasing use of oral and topical chemotherapy, and a general shift to ambulatory care. The authors called for innovative solutions to improve the management of cancer treatment complications in outpatient and ambulatory settings, with a particular emphasis on pain management.
“Emergency departments are not the best places to address the needs of patients with cancer,” the study’s lead author Amir Alishahi Tabriz, MD, PhD, MPH, said in an interview with The ASCO Post. “The ED is suboptimal for the care of patients with cancer, as it poses a risk of complications and may result in higher health-care expenditures compared to alternative settings,” he added. Dr. Alishahi is Assistant Member, Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida.
Decreasing the number of potentially preventable emergency department visits is not the goal. Increasing the quality of care is the goal.— Amir Alishahi Tabriz, MD, PhD, MPH
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What Is a Preventable Emergency Department Visit?
Researchers from Moffitt Cancer Center and the University of North Carolina at Chapel Hill used National Hospital Ambulatory Medical Care Survey to identify ED visits among adult patients with current cancer diagnoses and data from the Centers for Disease Control and Prevention (CDC) Cancer Statistics to estimate the new cancer cases each year. “Because some information is not collected by the survey, we were unable to consider other important factors, such as cancer type and stage, cancer treatment type and duration, usual source of care, or level of social support,” the authors noted.
“The primary outcome of interest was ED visits, including potentially preventable ED visits,” the authors explained. “Potentially preventable ED visits have been associated with poor patient experiences and increasing cancer care costs.”
“We used the Centers for Medicare & Medicaid Services [CMS] definition of a potentially preventable ED visit among patients receiving chemotherapy. The CMS defines an ED visit as potentially preventable if the primary diagnosis for the visit was one of the following: anemia, nausea, fever, dehydration, neutropenia, diarrhea, pain, pneumonia, sepsis, or emesis,” they added.
There is, however, “no universally accepted definition of a potentially preventable ED visit,” the researchers reported. “We have different words that we use interchangeably: preventable, avoidable, unnecessary, unwarranted. They seem the same, but they are not exactly the same. We need to come up with a more accurate and practical definition,” Dr. Alishahi said.
The issue is: “maybe they are not really preventable but were classified as such based on billing codes that did not reflect the true nature of the reason for the visit,” Dr. Alishahi said. “The CMS uses a diagnosis-based approach for its chemotherapy quality measures (OP-35) to encourage hospitals to develop interventions to reduce the number of potentially preventable emergency department visits and hospitalization. However, no study has validated the CMS method of classifying potentially preventable emergency department visits among patients with cancer. We need to talk about it because we need to come up with a more accurate and better definition of what is actually a potentially preventable emergency department visit.”
Potentially Preventable ED Visits From the Lens of Health Equity
Dr. Alishahi noted that he and his colleagues are working on another paper to conceptually challenge the definition of potentially preventable ED visits used by payers and public health organizations such as CMS. “We are expanding our communication and network and talking with other emergency physicians and oncologists and gathering their insight,” he added, in anticipation of suggesting that CMS adopt a more accurate and practical definition of “potentially preventable.”
“We need to come up with a much more accurate definition of what are actually considered potentially avoidable emergency department visits,” Dr. Alishahi said. This is important because hospitals and eventually patients cannot be refused payment for ED visits based on unvalidated methods. “Decision to go to an ED depends on many external factors such as day of week or time of the day, patients’ social support, and socioeconomic factors, cultural background, and financial hardship, as well as accessibility and affordability of alternative sources of care, particularly for underserved populations. The ED may be the only site of service for a nonurgent complaint when there are no other available sites to provide timely care to the patient. Therefore, the approach that is currently using by payers to identify preventable ED visits may unfairly penalize certain hospitals, such as SafetyNet hospitals, that are already under financial pressure due to caring for underserved populations. If you don’t have access to a primary care physician, or the nearest urgent care is 100 miles from your home, you need to go to the ER,” Dr. Alishahi said.
Uncontrolled Pain
The researchers found that the percentage of potentially preventable ED visits among patients with cancer did not change significantly between 2012 and 2019 (49.6% in 2012 vs 51.5% in 2019). However, the absolute number of potentially preventable ED visits increased by 73.6%, “largely because of the significant increase in patients with cancer who visited the ED because of uncontrolled pain.”
An accompanying editorial2 stated that “patients at risk for having uncontrolled pain could potentially be identified earlier, and steps could be taken that would address the pain and help prevent acute care visits.”
“Consistent with previous studies, we found that pain was the most common presenting symptom (36.9%) in ED visits among patients with cancer, and the number of patients with cancer who visited an ED because of pain more than doubled over the study period,” the researchers reported. “A possible explanation could be the unintended consequences of the efforts within the past decade to decrease overall opioid administration in response to the opioid epidemic.”
“Our study shows that we have a large shift from overprescribing opioids to not prescribing an opioid at all, which meant patients who actually needed it didn’t receive it,” Dr. Alishahi elaborated. “So, patients go to the hospital to receive pain management.”
Options for better pain management include “better education for physicians to prescribe the proper amount of the opioid or nonopioid pain management,” Dr. Alishahi said.
Contributing to the problem of uncontrolled pain among patients with cancer is widespread failure to “recognize palliative care as a key part of the cancer care continuum,” Dr. Alishahi stated. Too often, people equate palliative care with hospice, “which it is not,” Dr. Alishahi stressed. “Palliative care can be received from the beginning of the cancer care continuum, and it is way more than hospice care.”
Unplanned Hospitalizations
The article also tracked unplanned hospitalizations. “Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019),” the authors noted.
Among ED visits considered potentially preventable using the CMS definition, 30.2% resulted in hospitalization. There was a “wide range of hospitalization rates among the 10 conditions the CMS identified as potentially preventable reasons for ED visits,” the researchers reported. “Sepsis (93.3%) had the highest admission rate, followed by pneumonia (76.2%) and anemia (71.7%), whereas pain (23.5%), dehydration (28.0%), and nausea (31.8%) had the lowest hospitalization rates.”
“Some would argue that a patient with cancer and sepsis should go to the ER,” Dr. Alishahi said, “and more than 93% are going to be admitted immediately. However, one can also argue that we can prevent sepsis from happening in the first place. We need go one step back and see how we can do that.”
Avoiding Emergency Department Visits
There are many reasons to avoid ED visits. They include increasing cost and exposure to communicable and infectious diseases, which the study notes, can be “particularly detrimental to patients with cancer because of complications from cancer treatment, a damaged integumentary system, and immune system dysfunction.”
“One of the main concerns is financial toxicity,” Dr. Alishahi stated. People worry about being charged thousands of dollars and having their insurance claims denied. “So, they don’t go to the ER to the point that they have no other options, and maybe at that point, it is too late, and the cost increases significantly. We need to do a much better job,” he said, of explaining to patients with cancer who are concerned about a sign or symptom not to postpone seeking care.
“Decreasing the number of potentially preventable ED visits is not the goal. Increasing the quality of care is the goal,” Dr. Alishahi stressed. Although decreasing potentially preventable visits can be a way to do that, Dr. Alishahi estimated that around 10% to 15% of patients eventually will need to visit the ER. “This is the nature of the disease.”
“We are currently working on predictive models to find out the variables to help us identify which patients may be at higher risk of going back to the hospital and do something about that,” Dr. Alishahi countered. “We are not going to focus only on the variables we can’t actually do something about, but rather on the variables we can do something about. We have some predictive models that, for example, say if patients have a stage IV cancer or are at least aged 75, they are at a higher risk of going back. That is good information, although we cannot change the type of cancer, the stage of cancer, or the age of the patient.”
Dr. Alishahi continued: “For example, when we discharge patients from the hospital, we can check the lab tests to see whether they have a range of numbers on a lab test that could be related to a higher chance of going back to the hospital. Then, we are not going to discharge the patient until we correct those numbers.” In addition, Dr. Alishahi noted that at Moffitt, readmission committees meet every week to “see which of our patients are coming back to the hospital and why they are coming back and address their problems.”
Mobile Apps
Dr. Alishahi briefly discussed the role of mobile apps. “We are working with information technology companies on developing mobile apps for patients with cancer to help them to manage their symptoms remotely. Soon, the app will be made available to our patients. Upon their discharge, patients can use the app to manage certain signs and symptoms at home, thus avoiding the need to seek urgent care or hospitalization,” he said. Those apps may also help patients identify the closest medical facilities when they do need to go to the emergency department.
DISCLOSURE: Dr. Alishahi reported no conflicts of interest.
REFERENCES
1. Tabriz AA, Turner K, Hong YR, et al: Trends and characteristics of potentially preventable emergency department visits among patients with cancer in the US. JAMA Netw Open 6:e2250423, 2023.
2. Majka ES, Trueger NS: Emergency department visits among patients with cancer in the US. JAMA Netw Open 6:e2253797, 2023.
