Unplanned acute care continues to be a major contributor to growing healthcare costs in the United States, especially among patients with cancer. Quality measures have been developed to reduce healthcare expenditures and promote patient-centered, cost-effective care, some of which focus on high-need, high-cost patients who account for a small percentage of the US population but utilize a disproportionate amount of healthcare resources. “These ‘super-utilizers’ account for a significant proportion of emergency department (ED) visits, hospitalizations, and readmissions, some of which are potentially preventable,” says Lauren S. Prescott, MD, MPH.

Some studies have examined risk factors for healthcare super-utilization among patients with cancer, but few have focused specifically on women with gynecologic cancers. “Unfortunately, the care for patients with cancer is often siloed, but care for gynecologic oncology patients often falls under one umbrella,” Dr. Prescott says. “Patients with gynecologic cancer are unique in that many gynecologic oncologists provide both surgical and medical care and therefore provide care throughout the disease spectrum. As such, gynecologic oncologists are uniquely positioned to identify and understand characteristics of super-utilizers to inform the development and implementation of quality improvement measures to enhance care for these patients.”

Understanding Super-Utilizers

In a retrospective study published in Gynecologic Oncology Reports, Dr. Prescott and colleagues examined the prevalence of healthcare super-utilization among gynecologic oncology patients. They assessed patients who had an index unplanned encounter between January and December 2018. Those with three or more unplanned hospital encounters during 1 year starting at the time of the index unplanned encounter were defined as super-utilizers.

In the study, 37 of the 553 patients with gynecologic cancer assessed—or 7%—met criteria for being super-utilizers, but these patients accounted for 62% of unplanned hospital encounters, 63% of ED visits, 61% of admissions, and 82% of readmissions. This resulted in 881 days of patients being admitted during the study period. “Surprisingly, we found that a significant proportion of healthcare utilization occurred during the first year of a diagnosis of gynecologic cancer,” says Dr. Prescott.

Pain, gastrointestinal, and hematologic symptoms were identified as the most common presenting symptoms among patients with gynecologic cancer. Super-utilizers were more likely to have advanced stage cancer and to present with primary disease or recurrence in the last year of life than non-super-utilizers (Table). About one-third of super-utilizers had new cancer diagnoses without prior therapy, whereas 51% had prior chemotherapy, 46% had prior surgery, and 27% had prior radiation therapy at the time of their initial encounter.

The study team also found that super-utilizers tended to be younger, present in the primary phase of disease, had more aggressive and advanced disease, and had higher American Society of Anesthesiologists (ASA) and Charlson comorbidity index (CCI) scores than non-super-utilizers. Additionally, several social determinants of health increased the likelihood of super-utilization, including non-white race, Medicaid insurance, lack of insurance, and lower levels of education and/or self-reported health literacy.

Reducing Preventable Unplanned Acute Care Encounters

“Our study data can be used to inform and develop strategies to reduce preventable unplanned encounters,” Dr. Prescott says. “An important initiative should be to improve patient education, especially at the time of a cancer diagnosis. We need to teach patients how to monitor their symptoms to ensure they seek care when appropriate. The key is to engage potential super-utilizers to become active participants in their healthcare. We should be especially vigilant about social determinants of health. This requires improving care for minorities and those with lower socioeconomic status.”

Tools like ASA and CCI scores could be used as indicators for implementing educational or care coordination initiatives to reduce preventable unplanned acute care encounters. “Beyond optimizing pain and symptom management, it’s also important to maintain best practices for preventing surgical site and postoperative infections,” says Dr. Prescott. “Patient-reported outcomes are other factors to consider when managing patients. Ultimately, we need to get a better sense as to how patients are doing early after our encounters with them. This may help patients avoid unnecessary hospital visits and minimize the financial and emotional toll it takes on them.”