A substantial portion of emergency department (ED) visits by patients undergoing cancer treatment may be preventable, and those potentially preventable visits account for a high percentage of the ED visit costs, according to a new analysis.
“Roughly 44% of oncology patients visit the ED in the year after treatment initiation,” said Laura E. Panattoni, PhD, of the Fred Hutchinson Cancer Center in Seattle, at the American Society of Clinical Oncology (ASCO) 2017 Quality Care Symposium, held March 3–4 in Orlando, Florida. “I think there is growing awareness that many of these ED visits are due to poorly controlled disease or treatment-related symptoms such as pain, nausea, and dehydration, and they could be potentially preventable with better outpatient management.”
The Centers for Medicare and Medicaid Services (CMS) has recently proposed a new metric to assess costs associated with ED visits, which would become effective in 2020. It includes 10 symptoms with well-established evidence for outpatient management, but Panattoni noted that it excludes symptoms with emerging evidence because interventions are newer.
The new study (abstract 2) examined ED visits among cancer patients in a community setting across 13 counties in western Washington, using that CMS metric as well as a patient-reported outcomes tool to characterize the number and costs of the visits. Patients included in the study were 18 or older (mean age, 62 years), had been diagnosed with solid tumors, and were treated with chemotherapy and/or radiation. Of 7,053 eligible cancer patients, 2,543 (36%) visited an ED within 1 year of treatment initiation—2,839 total ED visits.
The potentially preventable diagnoses included dehydration, diarrhea, emesis, nausea, pain, and several others. There were three types of ED visits: those that included codes for diagnoses that are potentially preventable; those including codes for both preventable and non-preventable diagnoses; and those that included codes for only non-preventable diagnoses. Most patients in the study were white (90%), and the most common malignancies included breast cancer (23%), lung cancer (16%), and colorectal cancer (9%). About half of the patients (49%) received chemotherapy, 26% received radiotherapy, and 25% received both. The mean cost of all ED visits was $1,243.
The prevalent preventable diagnosis was pain, in 1,054 patients, at a cost per visit of $1,540. This was followed by dyspnea in 279 patients (10%, $1,588/visit), nausea in 232 patients (8%, $1,837/visit), and fever in 227 patients (8%, $1,421/visit).
The most prevalent non-preventable diagnosis codes included hypertension, diabetes, and hyperlipidemia, which Panattoni noted are all chronic conditions.
The overall cost of ED visits in this cohort was just over $3.5 million, and 9% of that total was entirely in the potentially preventable group; 27% of the cost was non-preventable only, and 64% was a mix of the two. Panattoni said that 63% of all visits included at least one potentially preventable code, and this translated to 73% of the total spending on ED visits. Notably, the presence of a potentially preventable diagnosis code was associated with significantly higher costs, at $1,209/visit vs $936/visit for those with no such diagnosis code.
Panattoni noted that there are clear limitations to using claims data, specifically in that it does not allow the conclusion that any individual patient’s ED visit was potentially preventable, and that the analysis excludes costs outside the ED such as imaging. Still, she said this highlights that many ED visits in the oncology setting may be avoided with more careful symptom management.