Redefining readmissions in gynecologic cancer: readmissions resulting in hospital-to-hospice transitions may represent high value care

Abstract

Objectives: Hospital readmissions are used as a marker of quality of care, with unplanned admissions identified as low value care. Hospice is a marker of high value care and a readmission resulting in discharge to hospice may indicate value in readmission. The primary objective of this study was to describe readmissions that resulted in discharge to hospice. Methods: We performed a retrospective cohort study of women with a diagnosis of gynecologic cancer who were readmitted within 30 days to a single urban academic hospital between July 2017 and April 2020. Patient demographics, oncology data, admission cost, discharge status, length of admission and length of hospice admission were collected from the electronic medical record. Length of hospice admission ≥3 days was defined as high value care. Descriptive statistics were performed to identify factors associated with discharge to hospice. Results: We identified 98 patients readmitted during the study period. 36.7% (n=36) had uterine cancer, 49.0% (n=48) had ovarian cancer, 12.2% (n=12) had cervical cancer and 2.0% (n=2) had vulvar cancer. 47% (n=46) had recurrent disease. 11.2% (n=11) of patients readmitted had a previous outpatient palliative care consult prior to the index admission and 28.6% (n=28) had an inpatient palliative care consult during the index admission. Patients were readmitted from the Emergency Department (n=50, 51.0%), ambulatory visit (n=31, 31.6%) or hospital transfer (n=17, 17.3%). The most common categories of reason for readmission were gastrointestinal (n=20, 20.4%), complication of metastases (n=15, 15.3%), and primary malignancy (n=12, 12.2%). The median time to readmission was 10 days (IQR 5-16 days) and the median length of readmission was 5 days (IQR 3-9 days). 23.5% (n=23) of patients had multiple readmissions, with a median of 2 readmissions (range 2-4). One-third of patients (n=36, 36.7%) received a palliative care consult and hospice was discussed with 21.4% (n=21) during readmission. 17.3% of patients (n=17) were discharged to hospice from a hospital readmission, with a median length of hospice admission, prior to death, of 7 days (IQR 2-14 days). 81% of patients with whom hospice was discussed were discharged to hospice. 70.6% of patients (n=12) had a length of hospice admission ≥3 days. There was a significant association of repeat readmission and discharge to hospice (p Conclusions: Hospital readmissions in gynecologic cancer patients resulted in a hospital-to-hospice transition in 17.3% of all patients, and 81% of patients with whom hospice was discussed. Multiple readmissions may precipitate a decision to enroll in hospice. Readmissions may not indicate substandard care and instead potentially demonstrate an opportunity to deliver high value care to patients, as both enrollment in hospice at end of life and hospice enrollment for ≥3 days are considered optimal quality oncology metrics.