Potentially Avoidable Hospital Readmissions in Patients With Advanced Cancer

P. Connor Johnson, MD; Yian Xiao, MD; Risa L. Wong, MD; Sara D'Arpino; Samantha M.C. Moran; Daniel E. Lage, MD; Brandon Temel; Margaret Ruddy; Lara N. Traeger, PhD; Joseph A. Greer, PhD; Ephraim P. Hochberg, MD; Jennifer S. Temel, MD; Areej El-Jawahri, MD; Ryan D. Nipp, MD

Disclosures

J Oncol Pract. 2019;15(5):e420-e427. 

In This Article

Abstract and Introduction

Abstract

Purpose: Patients with cancer often prefer to avoid time in the hospital; however, data are lacking on the prevalence and predictors of potentially avoidable readmissions (PARs) among those with advanced cancer.

Methods: We enrolled patients with advanced cancer from September 2, 2014, to November 21, 2014, who had an unplanned hospitalization and assessed their patient-reported symptom burden (Edmonton Symptom Assessment System) at the time of admission. For 1 year after enrollment, we reviewed patients' health records to determine the primary reason for every hospital readmission and we classified readmissions as PARs using adapted Graham's criteria. We examined predictors of PARs using nonlinear mixed-effects models with binomial distribution.

Results: We enrolled 200 (86.2%) of 232 patients who were approached. For these 200 patients, we reviewed 277 total hospital readmissions and identified 108 (39.0%) of these as PARs. The most common reasons for PARs were premature discharge from a prior hospitalization (30.6%) and failure of timely follow-up (28.7%). PAR hospitalizations were more likely than non-PAR hospitalizations to experience symptoms as the primary reason for admission (28.7% v 13.0%; P = .001). We found that married patients were less likely to experience PARs (odds ratio, 0.30; 95% CI, 0.15 to 0.57; P < .001) and that those with a higher physical symptom burden were more likely to experience PARs (odds ratio, 1.03; 95% CI, 1.01 to 1.05; P = .012).

Conclusion: We observed that a substantial proportion of hospital readmissions are potentially avoidable and found that patients' symptom burdens predict PARs. These findings underscore the need to assess and address the symptom burden of hospitalized patients with advanced cancer in this highly symptomatic population.

Introduction

Patients with advanced cancer often experience numerous symptoms and stressors that can affect their quality of life.[1–3] In addition, patients with cancer frequently require hospitalizations to help with the management of troubling symptoms, but hospital stays may cause additional distress for this population.[4] Patients with cancer often wish to maximize their time away from the hospital;[5–7] however, those with cancer often experience frequent hospitalizations and readmissions, some of which may be potentially avoidable.[8–10] Potentially avoidable readmissions (PARs) are hospital readmissions that might have been avoided because of either a preventable condition or treatment that was possible as an outpatient.[8] To date, research investigating PARs among patients with advanced cancer is lacking; therefore, a critical need exists to understand the prevalence and predictors of PARs in this population with high health care utilization.

Much of the existing data on potentially avoidable hospital admissions originate from the general medicine literature, which suggests remarkably high rates of potentially avoidable health care utilization. In this population, studies demonstrate that nearly 30% of hospital admissions are potentially avoidable.[10–14] Currently, the data in oncology suggest that nearly one third of hospitalizations may be potentially avoidable;[15–19] however, researchers, to date, have not studied the prevalence and predictors of subsequent readmissions that may be potentially avoidable. In addition, the current literature in oncology investigating potentially avoidable health care utilization has been conducted using data that lack patient-reported outcomes. Inclusion of patient-reported outcomes could help to deepen our understanding of the relationship between patients' symptoms and potentially avoidable health care utilization. Of importance, hospitalized patients often experience worse symptom burdens than those in the outpatient setting,[20] and the association between hospitalized patients' symptom burdens and PARs is currently unknown. Thus, additional research is needed to help understand the predictors and characteristics of PARs among hospitalized patients with cancer as well as to investigate associations with patient-reported symptom burden.

In the current work, we sought to conduct a comprehensive study focused on identifying rates and predictors of PARs among patients with advanced cancer. Specifically, we aimed to examine associations among PARs, patient characteristics, and self-reported symptom burden. We anticipate that these findings will inform the development of future interventions targeting PARs in patients with advanced cancer.

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