Emergency Department Care for Older Adults With Cancer

Patients with cancer—especially those aged 75 and older—are more likely to be admitted to the hospital and less likely to be observed and released home than patients without cancer. This was a key finding of a recent study published in the Journal of the National Comprehensive Cancer Network.

To better understand how this patient population is treated, Adam Klotz, MD, and colleagues conducted a study to examine hospitals’ use of observation status for patients with cancer presenting to the emergency department (ED).

“The role of observation care has not yet been clearly defined for the management of oncologic emergencies,” says Dr. Klotz. “A variety of clinical, economic, and logistic factors have forced healthcare systems and payers to re-evaluate how to deliver care to patients presenting to the ED. Observation care can help align patients’ needs with the appropriate level and intensity of care.”

Observation Status Vs Hospital Admission

For the study, Dr. Klotz and colleagues used population-based SEER-Medicare data to assess differences in the use of observation status between Medicare beneficiaries aged 66 and older with and without cancer.

There were 222,009 inpatient admissions and 12,934 observation status visits among the cancer cohort and 85,526 and 6,536, respectively, among the non-cancer cohort. When considered in relation to inpatient admissions, the non-cancer cohort had a higher rate of observation status visits per 1,000 inpatient admissions compared with the cancer cohort. After adjusting for patient characteristics, the cancer cohort had an estimated 43 observation status visits per 1,000 inpatient admissions, compared with 69 per 1,000 inpatient admissions among non-cancer controls.

The estimated observation rate per 1,000 inpatient admissions was higher for beneficiaries younger than75 versus those aged 75 and older, those with a Charlson comorbidity index of 0 versus 1 or 2 or higher, and those without a prior hospitalization versus those with one of more prior hospitalizations. Patients with breast and prostate cancers had higher adjusted and unadjusted observation rates per 1,000 inpatient admissions compared with those with colon and lung cancers.

More Work to Be Done

“While observation care is an increasingly popular subfield within emergency medicine, there is not yet widespread acceptance of its role for older adults with cancer,” says Dr. Klotz. “A possible explanation is that ED providers view older adults with cancer as having a more comorbid disease and are therefore less likely to be ready for discharge following a stay in an observation unit.”

Dr. Klotz says that observation status has been shown to be a viable alternative to inpatient admission for patients presenting to the ED with specific conditions, such as chest pain, new-onset atrial fibrillation, COPD exacerbation, and transient ischemic attack. Observation status has also become more prevalent as hospitals experience increasing pressure to improve ED throughput and seek to minimize Medicare Recovery Audit Contractor penalties for inappropriate hospital admissions.

Dr. Klotz adds that since observation status is used proportionately less for beneficiaries with cancer than for those without the disease, there may be opportunities to develop guidelines and protocols for ED staff to manage certain conditions for patients with cancer in observation status and to reserve hospital resources for those who need it most.

Prior research from the study team showed that the implementation of an observation unit at a comprehensive cancer center was associated with a reduction in the overall rate of inpatient admission from the ED and true inpatient bed utilization.

“Emergency medicine has made remarkable progress in defining safe and cost-effective strategies for the evaluation and management of common conditions such as chest pain, new-onset atrial fibrillation, acute stroke, and COPD exacerbation,” says Dr. Klotz. “However, evidence is still needed to support similar consensus about how best to evaluate and treat common oncologic emergencies such as nausea/vomiting/dehydration, constipation, fever, abdominal and back pain, electrolyte derangements, and dyspnea.”