In a study reported in JCO Oncology Practice, Zibelli et al found that patients with cancer readmitted to hospital within 30 days from index admission often made the decision to return to hospital themselves, without input from their care teams.
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Study Details
The study included 33 patients readmitted within 30 days to the oncology services at Thomas Jefferson University Hospital and Sidney Kimmel Cancer Center, both staffed by physicians from Sidney Kimmel Cancer Center. The cancer center has a strong telephone triage system, with trained oncology nurses being available by telephone from 8:30 AM to 5:00 PM on weekdays and physicians being available by telephone at all other times. A same-day clinic is available on site 7 days per week, with urgent infusion and blood transfusion and a staff including a nurse practitioner and an oncology physician. Readmitted patients were interviewed by trained interviewers at hospital bedside.
Key Findings
Of the 33 patients, 7 were unavailable due to clinical care or were discharged before attempted interview, 7 had scheduled admissions for planned chemotherapy, 2 refused to be interviewed, 1 did not speak English, and 1 could not be interviewed due to a confused state. Overall, 15 patients gave consent and were interviewed; 1 interview was not completed due to patient distress and 1 due to need for clinical care.
A total of 13 patients completed the interview. Of these, five were referred to the emergency room by the outpatient care team and eight presented for acute care without contacting the outpatient care team. The mean and median times to readmission after index admission were 11.7 days and 7 days (range = 2–27 days). Four of the 13 patients had an office visit prior to readmission.
Most patients believed that their initial discharge was not preventable. Most also believed that readmission was not preventable, with patients emphasizing the feeling that the hospital was a place of safety and many making the decision to seek inpatient care without input from their care teams. Patients and families frequently expressed that the hospital or emergency room was the appropriate setting in cases of serious illness or crisis.
Patients who returned to hospital on their own initiative were prompted by symptoms, with the most common being gastrointestinal symptoms such as vomiting or cramping. Other symptoms cited included shortness of breath, rash, fever, pain, dizziness, and weakness.
“Three major themes were identified: first, most patients saw their readmission as caused by problems that could not be treated in an outpatient setting. Second, the patients felt that they did not have sufficient resources at home to manage their care. Furthermore, the patients did not see the outpatient care team as a resource that they could call on for assistance. As a result, most of the decisions to return to the hospital were made by the patients themselves.”— Zibelli et al
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Lack of adequate care at home motivated some patients to seek readmission, with some patients who lived alone stating that they had no one to help them with their care and thus had to make all medical decisions on their own. Although other patients had family and friends available to help, patients often recognized and wished to avoid the burden placed on their helpers. Despite devoted caregiving in many instances, many of the caregivers took the patients to the emergency room or called emergency medical services—a factor indicating that improving the skills of caregivers could be a way to prevent readmissions.
As summarized by the investigators, “Three major themes were identified: first, most patients saw their readmission as caused by problems that could not be treated in an outpatient setting. Second, the patients felt that they did not have sufficient resources at home to manage their care. Furthermore, the patients did not see the outpatient care team as a resource that they could call on for assistance. As a result, most of the decisions to return to the hospital were made by the patients themselves.”
They concluded, “The decision that leads to readmission often happens at home, in response to unmanageable needs. Strengthening the bond between the care team and the patient, with the aim of providing care in the most appropriate setting, could decrease readmissions in patients with cancer. Possible interventions include home visits, enhanced discharge planning, and telehealth services.”
Allison Zibelli, MD, of Sidney Kimmel Cancer Center, Thomas Jefferson University, is the corresponding author for the JCO Oncology Practice article.
Disclosure: For full disclosures of the study authors, visit ascopubs.org.
