Five Steps to Keep Patients With Cancer Out of ED

Five Steps to Keep Patients With Cancer Out of ED

Visits to the emergency department (ED) and hospitalizations are common for patients with cancer, but many times they are unnecessary.

Researchers at the University of Pennsylvania in Philadelphia have now identified what they consider the five best practices to reduce ED visits and hospitalizations, which they describe as “unplanned acute care” that can be debilitating to the patient and needlessly drive up costs.

In a new paper published online April 17 in the Journal of Oncology Practice, the authors note that these strategies, whether implemented separately or as an integrated program, can improve healthcare quality in oncology.

The five strategies are as follows: 

• Identify patients at high risk for unplanned acute care;

• Enhance access and care coordination among healthcare providers;

• Standardize clinical pathways for symptom management;

• Develop new loci for urgent cancer care; and

• Use early palliative care.

Except for approaches such as predictive analytics for targeting resources and automated  monitoring in the outpatient setting, these strategies are low tech, explained lead author, Nathan R Handley, MD, a hematology-oncology fellow at Penn’s Perelman School of Medicine and an MBA candidate at the Wharton School.

“I think there are a few reasons that these haven’t been implemented broadly,” he said.

One reason is a lack of clarity about the efficacy of interventions. “I imagine many centers are aware of some of these strategies conceptually, but many may not know how effective they are or are not,” he told Medscape Medical News. 

Another reason is a lack of financial imperative to reduce readmissions. “From a policy standpoint, we’re seeing an increasing movement toward value-based care initiatives that reduce or eliminate reimbursement for unnecessary or preventable care,” said Handley.

However, in oncology, it has been hard to define what, exactly, constitutes “preventable,” as patients tend to be quite complex, and quite sick. OP-25, a new oncology measure proposed by the Centers for Medicare & Medicaid Services (see below) “would provide a definition for Medicare, and I suspect private payers would adopt this, or something similar, as well — and some are already doing so,” Handley explained.

One of the strategies identified was the implementation of dedicated urgent care centers for patients with cancer, which could sidestep an ED visit. While these can be effective, they require scale to be efficient, he noted.

“What I’ve seen happen more frequently in the community is walk-in hours at oncology clinics,” Handley said. “These aren’t usually 24-hour clinics, but they provide the flexibility for patients to be seen same-day, and flexibility is key.”

The advantage to this approach is that patients are seen within a system they know, and that knows them. “A number of community practices are very good at this — perhaps in part because the need to adapt to payment reform is felt more acutely in the community setting,” he added. “Smaller practices can sometimes implement new processes more quickly than large centers because fewer stakeholders are involved.”

Study Details

Handley and his colleagues point out that an essential challenge in cancer acute care is identifying planned, unplanned, and preventable hospitalizations. While the Agency for Healthcare Research and Quality has defined criteria for preventable hospitalizations in primary and preventive care, these definitions are currently lacking in oncology.

The Centers for Medicare & Medicaid Services has proposed adding an oncology measure to its Hospital Outpatient Quality Reporting Program. Known as OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, it would assess the quality of care for patients receiving chemotherapy and encourage performance improvement. If finalized, it would begin in 2020 and provide a definition for unplanned admissions.

For this study, the authors reviewed best practices to reduce acute care for patients with cancer. Literature published between 2000 and 2017 was reviewed, along with quality guidelines published by professional organizations.

They also examined five care delivery models that have defined and developed systems for high-quality oncology care. These models include the National Committee for Quality Assurance patient-centered medical home, and patient-centered specialty practice; the Community Oncology Medical Home, the CMS Oncology Care Model, and the Commission on Cancer Oncology Medical Home.

Finally, the authors evaluated each strategy according to specific outcomes: reduction in ED visits, reduction in hospitalizations, and reduction in rehospitalizations within 30 days.

Penn Medicine and the Abramson Cancer Center at the University of Pennsylvania have already implemented a few of the strategies that were identified, with promising results. As an example, the Abramson Cancer Center has developed new pathways that are diverting patients from the ED to a specialized urgent care clinic.

“We’ve seen excellent results with this approach here at Penn with our Oncology Evaluation Center, an urgent care-type clinic specifically for our cancer patients,” said study coauthor Lynn Schuchter, MD, chief of Hematology and Oncology, in a statement.

Handley has disclosed no relevant financial relationships. Schuchter discloses a relationship with Incyte.

J Oncol Pract. Published online April 17, 2018. Abstract

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