Abstract
BACKGROUND:
Reducing unplanned hospital readmissions, defined as a hospitalization occurring within 30 days of discharge, is a national policy priority that is aimed at improving health care quality. Unplanned hospitalizations and emergency department visits are a major problem in medical oncology patients. In our cancer institute, just 6% of all discharged patients accounted for > 40% of unplanned readmissions. These patients continue to be highest risk of future admissions, ICU stay, ED visits, over use of chemotherapy and underuse of hospice resources. We hypothesized that developing individualized care plans (ICP) for patients with the highest preventable utilization will better address the complex needs of this patient population and subsequently decrease preventable admissions, readmissions, and ED visits.
METHODS:
An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, advanced practice providers and nurses. On a bimonthly basis, adult patients (>18) with at least two unplanned hospital readmissions during the previous 60 days were identified. Hospitalizations for planned chemotherapy were excluded, along with patients who have already been referred to hospice or have since been deceased. All other patients otherwise were included. The identified patients were then reviewed by the ICT to identify opportunities specific to the needs of each patient. ICPs were then created using a team-based approach with parallel input from the patients' primary outpatient oncology providers. These recommendations were then communicated to applicable providers to be implemented.
RESULTS:
226 hospitalizations, and 163 ED visits for 36 individual high-risk patients were evaluated. All of the patients had relapsed/refractory hematological malignancy or metastatic solid tumor disease. Median age was 55.2 with a range of 20-74. 50% of the patients were female. 42% of the patients had a primary diagnosis of a hematological malignancy, while 58% had an underlying solid tumor malignancy. 22.2% of the patients had gastrointestinal malignancy, 19.4% of the patients had acute leukemia, and 13.9% of the patients had an aggressive lymphoma.
After implementation of ICP, hospitalizations decreased from 0.89 per patient month (ppm) to 0.36 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days.
On further analysis, patients with hematological malignancies (HM) had an average hospitalization of 0.89 ppm which decreased to 0.48, while solid tumor patients (ST) had a decrease from 0.87 to 0.27 ppm. Average readmissions ppm reduced from 0.4 to 0.28 in patients with HM while it reduced from 0.445 to 0.03 in ST. Average length of stay before ICP was 8.48 days vs 10.2 days in MH vs ST, which changed to 6.16 and 2.55 days respectively after ICP. As seen in table 2b, there was not a consistent change in all metrics in HM compared to ST.
CONCLUSION:
Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay in all disease groups, but ST patients seemed to have a greater impact than in HM patients. The selection process and the interventions from the multidisciplinary group were able to identify and significantly improve overall utilizations in the ST cohort, but in order to achieve the same effect a more selective process may be required in HM patients. Given the difference in biology of the diseases and expected management and side effects of treatment, HM patient cohort benefitted less as a cohort in this study. A more selective process in the HM patients to only include patients >100 days from hematopoietic stem cell transplant, and excluding patients undergoing curative management with induction/consolidation therapy may better isolate the cohort best suited to benefit from this ICT.
No relevant conflicts of interest to declare.
This feature is available to Subscribers Only
Sign In or Create an Account Close Modal