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Hospitalized patients with advanced cancer fare worse when discharged to postacute care

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November 2, 2017

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Patients with advanced cancer discharged to postacute care or hospice demonstrated substantially greater symptom burdens and impaired physical function, as well as worse survival, than those discharged to home, study data showed.

“Burdensome care transitions — particularly hospitalizations or transfers in place of care — may lead to poor quality care at the [end of life] and increase health care costs,” Areej El-Jawahri, MD, oncologist at Massachusetts General Hospital and instructor at Harvard Medical School, and colleagues wrote.

The researchers wrote that hospitalizations make up the largest share of health care spending for patients with advanced cancer, and that hospital use varies significantly at the end of life in the United States.

“Although studies have focused on potential drivers of hospital use at the [end of life], data are lacking on posthospital transitions of care for patients with advanced cancer, especially discharge to postacute care facilities,” they wrote.

El-Jawahri and colleagues performed a prospective study of 932 patients with advanced cancer who underwent unplanned hospitalizations between September 2014 and March 2016. The researchers assessed the patients’ physical symptoms with the Edmonton Symptom Assessment System, as well as psychological distress with the Patient Health Questionnaire, upon admission. Discharge to any setting served as the main outcome. Survival served as a secondary outcome.

Most patients (77.9%; n = 726) were discharged home without hospice, 12.7% (n = 118) were discharged to postacute care and 9.4% (n = 88) were discharged to hospice.

Patients discharged to hospice or postacute care reported high rates of severe symptoms, including constipation, low appetite, dyspnea, fatigue, depression and anxiety.

Logistic regression showed that patients who went to hospice or postacute care tended to be older (OR = 1.03; 95% CI, 1.02-1.05), live alone (OR = 1.95; 95% CI, 1.25-3.02) and have impaired mobility compared with those discharged home (OR = 5.08; 95% CI, 3.46-7.45). They also experienced longer hospital stays (OR = 1.15; 95% CI, 1.11-1.2), higher scores for physical symptoms (OR = 1.02; 95% CI, 1.003-1.032) and higher scores for depression (OR = 1.02; 95% CI, 1.01-1.25).

Those discharged to hospice care appeared more likely to have shorter hospital stays (0.84; 95% CI, 0.77-0.99) and to receive palliative care consultation (OR = 4.44; 95% CI, 2.12-9.29). Patients discharged to postacute care had lower survival compared with those who were discharged home (OR = 1.53; 95% CI, 1.22-1.93).

“The physical and psychological symptom burden of patients discharged to a [postacute care] facility was strikingly similar to that of those discharged to hospice, yet these facilities lack the palliative and supportive care infrastructure to optimize the quality of [end-of-life] care for this population,” the researchers wrote. “Future research should focus on developing targeted interventions to address the functional, social and symptomatic needs of this population.” – by Andy Polhamus

Disclosures: El-Jawahri reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.