More than half of ED visits among cancer patients, or over 18 million visits overall between 2012 and 2019, may have been preventable, according to a new study published in JAMA Network Open.

Study details and key findings

For the study, researchers used the National Hospital Ambulatory Medical Care Survey to analyze data on ED visits between Jan. 1, 2012, and Dec. 31, 2019. CDC's U.S. Cancer Statistics reports were also used to estimate new cancer cases each year of the study period.

In total, there were 854,911,106 ED visits between 2012 and 2019, and 35,510,014 (4.2%) were made by patients with cancer. Among these patients, the mean age was 66.2 years, 73.2% were white, 55.2% were women, and 54.3% were enrolled in Medicare.

During the study period, ED visits among cancer patients increased by 67.1%, going from 3,734,101 visits in 2012 to 6,240,650 visits in 2019. The percentage of ED visits from patients with cancer per new cancer case also rose from 2.44 in 2012 to 3.54 in 2019, a 45.1% increase.

Of all the ED visits among cancer patients, 51.6% were considered to be potentially preventable, and 21.3% were classified as high acuity. Between 2012 and 2019, the absolute number of potentially preventable ED visits among cancer patients increased from 1,851,692 to 3,214,276.

The most common reason for these potentially preventable ED visits was pain (37%). In addition, the researchers found that pain was the diagnosis code for 39.8% of ED visits that ended in discharge and 33.1% of high acuity ED visits. Between 2012 and 2019, the number of cancer patients who visited the ED for pain increased from 1,192,197 to 2,405,849.

Other reasons that cancer patients chose to visit the ED include fever (3.5%), nausea (3.5%), and emesis (2.3%).

Male patients and patients who lived in nursing homes were more likely to have a potentially preventable ED visit. In comparison, Black patients and patients younger than 65 were less likely to have a potentially preventable ED visit.

Although most of the ED visits in the study were considered to be potentially preventable, 28.9% resulted in unplanned hospitalizations. Between 2012 and 2019, hospital admissions per new cancer case increased by 21.9%, going from 0.73 admissions to 0.89 admissions.

The most common reasons for an unplanned hospitalization among cancer patients was sepsis (93.3%), pneumonia (76.2%), and anemia (71.7%). Hispanic patients and those who had more than one comorbidity were more likely to have an unplanned hospitalization, while patients who had low acuity ED visits and were younger than 65 were less likely to be hospitalized.

Commentary

According to the researchers, the "disproportionate increase in the number of ED visits by patients with cancer has put a substantial burden on EDs that are already operating at peak capacity" and "reinforces the need for cancer care programs to devise innovative ways to manage complications associated with cancer treatment in the outpatient and ambulatory settings."

This increase in preventable ED visits could also be an "unintended" consequence of efforts to reduce opioid usage amid an ongoing epidemic, the researchers wrote, citing a recent study that found that roughly half of cancer patients experiencing severe pain did not receive outpatient opioids in the week before they visited the ED.

"These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings," the researchers wrote.

In an accompanying editorial, Erek Majka, from Summerlin Hospital, and N. Seth Trueger, from Northwestern University, expressed a similar sentiment, saying that "patients at risk for having uncontrolled pain could potentially be identified earlier, and steps could be taken that would address their pain and help prevent acute care visits."

"Even access to outpatient care does not mean patients can get the care they need outside an ED," Majka and Trueger wrote. Because of this, "it is no surprise that patients are sent to the ED if the alternatives do not have the staff or diagnostic and therapeutic capabilities the patients need."

Overall, the "goal is not to eliminate ED visits for their own sake; rather, the goal is better care of patients with cancer, and secondarily, in a manner that is cost-effective," Majka and Trueger wrote. (Taylor, Becker's Hospital Review, 1/25; Brooks, Medscape, 1/24; Tabriz et al., JAMA Network Open, 1/19)