Adults with cancer commonly present to the emergency department (ED) seeking relief from poorly controlled or worsening symptoms related to their disease and many are admitted or placed in observation. These data help demonstrate opportunities for improving ED care for patients with cancer.
In the United States, more than 4.5 million ED visits are made each year by patients with cancer, and approximately two-thirds of these visits result in hospital admission. “Based on retrospective data, we know the number of patients with cancer being cared for in the ED is increasing and expected to continue to grow,” says Jason Bischof, MD.
Recently, the National Cancer Institute supported Comprehensive Oncologic Emergencies Research Network (CONCERN), a multicenter research consortium that includes representatives from oncology and emergency medicine, was created to accelerate knowledge in this area by designing, executing, and translating oncologic emergency medicine research. A panel of key stakeholders convened to discuss the needs and priorities to enhance the emergency care of patients with cancer. For a study published in JAMA Open Network, Dr. Bischof and colleagues sought to establish a benchmark description of 1,075 patients with active cancer who presented to 18 EDs affiliated with CONCERN.
For the study, investigators examined the proportion of patients reporting various symptoms before and during ED visits and assessed medications administered in the ED and outpatient settings. The study also looked for the most common diagnoses and suspected infections. The authors identified proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days. Nearly three-quarters (73.9%) of the study participants had undergone cancer treatment in the preceding 30 days, about two-thirds (62.7%) had advanced or metastatic cancer, and 47.0% were aged 65 years or older.
Highlighting Key Findings
The study found that the five most common ED diagnoses among patients with cancer were symptom related, including abdominal pain, fever, breathing abnormalities, nausea and vomiting, and throat and chest pain. Pain during ED visits occurred in 62.1% of patients (Table) and was present in 72.2% of these people the week prior to presenting to the ED. Opioids were administered in the ED to 59.1% of patients with moderate to severe pain. Outpatient opioids were prescribed to 47.4% of those with pre-ED pain, with 57.0% of these individuals reporting they had “quite a bit” or “very much” pain. “These findings suggest an opportunity for improved pain control in both the ED and outpatient settings,” says Dr. Bischof. “Dyspnea and nausea were also frequently noted, suggesting additional areas for targeted improvements in care.”
The high symptom burden driving the utilization of emergency care suggests a need for improved, multidisciplinary approaches to symptom management in patient with cancer, according to Dr. Bischof. “We observed low rates of patients receiving palliative care (8.0%) or hospice care (1.9%), which further supports the need for multidisciplinary care of these patients given the 5.8% 30-day mortality rate that was noted in this population.”
Dr. Bischof adds that the study team also observed a high rate of suspected infections (23.7%) resulting in antibiotic usage (26.5%) and admission (57.2%) despite a low rate of febrile neutropenia (2.4%). “These data suggest an opportunity for improved processes of care to ensure appropriate resources and antibiotic utilization in patients with cancer and suspected infection,” he says. “Additionally, 19.1% of admitted patients had an LOS of no longer than 2 days, indicating the need for further study of ED observation protocols to safely and efficiently treat this population.”
According to Dr. Bischof, the study provides the epidemiologic foundation to pursue care improvement opportunities, notably symptom management in patients with cancer who present to the ED. “Our study is the first prospective, multicenter investigation that describes ED use by patients with cancer and identifies several key areas that require additional research,” he says. “Additional investigations are needed to improve ED-based risk stratification tools and to improve ED and outpatient oncology processes to facilitate the safe and expeditious care of patients with cancer. Greater collaboration across these medical specialties is necessary to improve the care of these patients before, during, and after an ED visit through new and innovative approaches care models and treatment guidelines.”
Caterino JM, Adler D, Durham DD, et al. Analysis of diagnoses, symptoms, medications, and admissions among patients with cancer presenting to emergency departments. JAMA Netw Open. 2019;2(3):e190979. Available at: https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2728627.