Study Identifies Factors Linked to ED Visits by Cancer Patients

Veronica Hackethal, MD

January 02, 2015

A meta-analysis covering more than one million patients with cancer has identified several factors that make these patients more likely to visit the emergency department (ED) in their last month of life. Such patients are more likely to be men, black, have lung cancer, low socioeconomic status, or no palliative care.

The study was published online on December 22 in the Journal of Clinical Oncology.

"These findings may be used to develop screening interventions for high-risk cancer patients and also provide evidence to assist policy-makers when allocating limited resources for maximal impact," wrote first author Lesley Henson, MBBS, MRCP, and colleagues at King's College, London.

More than one ED visit by cancer patients in the last month of life is thought to indicate overly aggressive and possibly worse quality of care, according to background information in the article. Overly aggressive end-of-life care may not necessarily increase life expectancy and is linked to lower quality of life. It can also increase resource demand and healthcare costs. Studies have also suggested that most patients with cancer prefer home-based care and provider continuity.

Moreover, visiting the ED can expose cancer patients to a hectic environment and risks such as infection, which could be detrimental to cancer patients who are immunocompromised. Additionally, some ED physicians may not feel qualified to treat palliative care patients.

Researchers searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsychINFO, and the Cochrane Library) for studies about ED attendance near the end of life in adult cancer patients. Without using time or language limitations, they looked at studies published through February 2014. They also did manual reviews of citations in key articles. They analyzed risk for bias using a validated review tool.

"Considerable" heterogeneity between studies may limit the meta-analysis, the researchers noted. Additionally, the study could not explore personal and psychological factors because of lack of data in the included studies.

The analysis included 30 studies from five countries covering 1,181,842 patients. Results suggested that men (OR, 1.24; 95% CI, 1.19 - 1.29), blacks (OR, 1.45; 95% CI, 1.40 - 1.50), patients with lung cancer (OR, 1.17; 95% CI, 1.10 - 1.23), and those belonging to the lowest socioeconomic status (OR, 1.15; 95% CI, 1.10 - 1.19) had increased likelihood of ED attendance in the last month of life. Those receiving palliative care were less likely to go to the ED during the last month of life, compared with those not receiving palliative care (OR, 0.43; 95% CI, 0.36 - 0.51).

Some studies also linked respiratory symptoms, chemotherapy within 2 months of death, and Medicare fee for service to increased ED visits in the last month of life.

Variables linked to reduced use of the ED in the last month of life included older age, being single, end-of-life discussion 30 or more days before death, having an oncologist as the main healthcare provider, and having high continuity of care.

The timing of palliative care referral was linked to increased or decreased ED use, with results pointing to wide variability in palliative care delivery. Dr Henson and colleagues noted that models of palliative care vary widely and that the best delivery method remains unclear.

The ED remains the appropriate setting for urgent needs, Dr Henson and colleagues pointed out, although individualized patient-centered care should still continue to be a goal, even in the ED.

"Our finding that patients with cancer who are receiving palliative care have a significantly reduced risk of multiple ED visits in their last 30 days of life has added further high-quality evidence to the scientific literature demonstrating the benefits that can be gained from palliative care," Dr Henson and colleagues highlighted. "We have also added to the small but growing body of evidence supporting improved patient outcomes with earlier palliative care involvement."

The authors have reported no relevant financial relationships.

J Clin Oncol. Published online December 22, 2014. Abstract

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