A new study finds that patients with cancer, especially those aged 75 or older, are more likely to be admitted to the hospital – and less likely to be observed and released home – than patients 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.
The research was led by Allison Lipitz-Snyderman, PhD, Assistant Attending Outcomes Research Scientist, Memorial Sloan Kettering Cancer Center, along with Adam Klotz, MD; Renee L. Gennarelli, MS; and Jeffrey Groeger, MD. The findings were published in the October issue of JNCCN – Journal of the National Comprehensive Cancer Network.
“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 Dr. Groeger. “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.”
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, versus 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.
The research focused on Medicare beneficiaries aged 66 and older. Dr. Lipitz-Snyderman and her team analyzed 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.
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 in the most optimal way.
“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.”
“This study raises important questions about how to provide medical care for older adults with cancer who present to the emergency department,” said Dr. 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.”
Complimentary access to the study, “A Population-Based Assessment of Emergency Department Observation Status for Older Adults with Cancer,” is available until December 11, 2017 on JNCCN.org.
About JNCCN—Journal of the National Comprehensive Cancer Network More than 25,000 oncologists and other cancer care professionals across the United States read JNCCN—Journal of the National Comprehensive Cancer Network. This peer-reviewed, indexed medical journal provides the latest information about best clinical practices, health services research, and translational medicine. JNCCN features updates on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), review articles elaborating on guidelines recommendations, health services research, and case reports highlighting molecular insights in patient care. JNCCN is published by Harborside Press. Visit JNCCN.org. To inquire if you are eligible for a FREE subscription to JNCCN, visit http://www.nccn.org/jnccn/subscribe.asp. Follow JNCCN on Twitter @JNCCN.
About the National Comprehensive Cancer Network The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.
The NCCN Member Institutions are: Fred & Pamela Buffett Cancer Center, Omaha, NE; Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Mayo Clinic Cancer Center, Phoenix/Scottsdale, AZ, Jacksonville, FL, and Rochester, MN; Memorial Sloan Kettering Cancer Center, New York, NY; Moffitt Cancer Center, Tampa, FL; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UC San Diego Moores Cancer Center, La Jolla, CA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Colorado Cancer Center, Aurora, CO; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Wisconsin Carbone Cancer Center, Madison, WI; Vanderbilt-Ingram Cancer Center, Nashville, TN; and Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT.