Avoidable and Unavoidable Visits to the Emergency Department Among Advanced Cancer Patients (AdCa) Followed by the Supportive Care (SCPC) Outpatient Clinic (S715)

Abstract

1.Describe characteristics of advanced cancer patients who visit emergency room.2.Describe possible interventions to prevent avoidable visits to ER of advanced cancer patients. Admissions to ED are considered undesirable for patients receiving palliative care. There is limited research about the clinical characteristics of Advanced Cancer patients (AdCa) followed by SCPC who visited ED, and if these ED visits can be categorized as avoidable or unavoidable. Retrospective study of 200 consecutive AdCa evaluated by the Supportive Care physician who visited the ED between January 2010 and December 2011. All patients were instructed to call our main number if there was any change in symptoms. Based on pre-defined criteria patients were classified as having an avoidable (if the problem could have been managed at the outpatient center or by telephone) or unavoidable visit. Demographics and clinical characteristics were collected and analyzed. 47/200(23.5%) AdCa were classified as having had avoidable ED visits (AvED) while 153/200(76.5%) had unavoidable ED visits (NAvED). Main reasons for NAvED were: changes in mental status (24/153, 16%), infectious processes (32/153, 21%), new onset/worsening of pain and dyspnea (75/153, 49%), and severe worsening of other symptoms (22/153, 14%). Age, gender, marital status, and cancer types or stages, and reasons for referral to SCPC and time to ED visit after SCPC evaluation were not significantly different between AvED and NAvED patients. Baseline Edmonton Symptom Assessment Scale (ESAS) showed no significant difference in pain, dyspnea, fatigue, drowsiness, nausea, well-being, anxiety, and depression for AvED vs. NAvED; except for sleep ≥1: 141/153 (92%) vs. 37/47 (79%), p=0.01001, respectively. None of the patients phoned the SCPC before the ED visit. 17/153 (11%) of AdCa called their primary oncologist before NAvED visit vs. 1/46 (2%) having called before AvED, p=0.078. Multivariate analysis showed that NAvED was associated with worsening of pain (OR:2.485, p<0.0179), changes in mental status (OR:23.143, p<0.0098), and sleep disturbance (OR:3.611, p<0.0116). 0/47 (0%) AvED vs. 93/153 (51%) of NAvED were admitted to the hospital, p<0.0001. More than one in five of ED visits by AdCa are avoidable. Efforts to improve communication after the scheduled appointments through clinician initiated phone calls, electronic communication, and more frequent visits are needed.