Individualized Care Plans Decrease Emergency Department Use

At the Taussig Cancer Institute, just 6% of all discharged patients accounted for more than 40% of unplanned readmissions (defined as a hospitalization occurring within 30 days of discharge). Those patients are also at high risk for future admissions, intensive care unit (ICU) stay, ED visits, overuse of chemotherapy, and underuse of hospice resources. Researchers developed an individualized care plan (ICP) for patients with the highest preventable use to see if this would impact hospital use and readmissions. Girish Kunapareddy, MD, at the Taussig Cancer Institute at the Cleveland Clinic in Ohio, discussed the findings at the ASH Annual Meeting (https://ash.confex.com/ash/2017/webprogram/Paper107876.html).

They created an interdisciplinary care team (ICT) that included palliative medicine and oncology physicians, social workers, care coordinators, advanced practice providers, and nurses. Adult patients with at least two unplanned hospital readmissions during the previous 60 days were identified on a bimonthly basis. Hospitalizations for planned chemotherapy were excluded, as well as patients who had already been referred to hospice or had died.

The ICT reviewed the cohort to identify specific patient needs. Based on the findings, ICPs were created using a team-based approach with parallel input from patients’ primary outpatient oncology providers. The recommendations were then communicated to appropriate healthcare providers for implementation.

Thirty-six high-risk patients (median age = 55.2 years, range = 20–74) who accounted for 226 hospitalizations and 163 ED visits were identified and evaluated. Patients had relapsed or refractory hematologic malignancy (42%) or metastatic solid tumor disease (58%). Diagnoses included gastrointestinal malignancy (22.2%), acute leukemia (19.4%), and aggressive lymphoma (13.9%).

The creation of ICPs resulted in a decrease in the number of hospitalizations, ED visits, unplanned readmissions, and length of stay in all disease groups. After ICPs were implemented, hospitalizations decreased from 0.89 per patient-month to 0.36 per patient-month, with an average length of stay decreasing from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 per patient-month to 0.34 per patient-month, and the average number of unplanned readmissions decreased from 0.43 per patient-month to 0.13 per patient-month.

Ten patients died since the creation of ICPs: eight used hospice care, whereas two died in the ICU. The average time to death from the creation of ICPs was 72 days among these patients, whereas time to death from last exposure to chemotherapy was 58 days.

When examining outcomes based on cancer type, ICPs appeared to better benefit patients with solid tumors in terms of ED use and outcomes compared to those with hematologic malignancies. The researchers found that patients with hematologic malignancies had an average hospitalization of 0.89 per patient-month, which decreased to 0.48 per patient-month, whereas patients with solid tumors had a decrease from 0.87 per patient-month to 0.27 per patient-month. Average readmissions per patient-month reduced from 0.4 to 0.28 in patients with hematologic malignancies and reduced from 0.445 to 0.03 in those with solid tumors. The average length of stay before ICP was 8.48 days for those with hematologic malignancies and 10.2 days for those with solid tumors. These stays decreased to 6.16 and 2.55 days, respectively, after ICP implementation.

“The selection process and the interventions from the multidisciplinary group were able to identify and significantly improve overall utilizations in the solid tumor cohort, but in order to achieve the same effect [in those with hematologic malignancies], a more selective process may be required,” the researchers concluded. A more selective process in the latter cohort that only includes patients who are more than 100 days post-hematopoietic cell transplantation and excludes those undergoing curative management with induction or consolidation therapy may better identify those best suited to benefit from ICPs, the researchers suggested.