Vol. 49 No. 3 March 2015
Journal of Pain and Symptom Management 497
Original Article
Avoidable and Unavoidable Visits to the Emergency Department Among Patients With Advanced Cancer Receiving Outpatient Palliative Care Marvin Omar Delgado-Guay, MD, Yu Jung Kim, MD, Seong Hoon Shin, MD, Gary Chisholm, MS, Janet Williams, MPH, Julio Allo, MPH, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (M.O.D.-G., Y.J.K., J.W., J.A., E.B.) and Department of Biostatistics (G.C.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine (Y.J.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Internal Medicine (S.H.S.), College of Medicine, Kosin University, Busan, Republic of Korea
Abstract Context. Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable. Objectives. To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs). Methods. We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED. Results. Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99). Conclusion. Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed. J Pain Symptom Manage 2015;49:497e504. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Supportive care, palliative care outpatient, emergency department, advanced cancer
Introduction Although early integration of a specialized palliative care service in the trajectory of cancer treatment is considered important, most of those seen in palliative Drs. Delgado-Guay and Kim contributed equally to this article. Address correspondence to: Marvin Omar Delgado-Guay, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
care clinics are patients with advanced cancer who are nearing the end of life.1e3 For these patients, multiple emergency department (ED) visits are considered an indicator of poor-quality cancer care, along with
Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA. E-mail: [email protected] Accepted for publication: July 6, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.07.007
498
Delgado-Guay et al.
chemotherapy in the last 14 days of life, multiple hospitalizations, intensive care unit admissions, and death in an acute care institution.4,5 In addition, ED visits in the last few months, weeks, or days of life can cause great distress to the cancer patients themselves and to their caregivers.6,7 Despite these concerns, the aggressiveness of cancer treatment near the end of life, resulting in multiple ED visits, has been increasing over time in the U.S. and Canada, and the overall rate of advanced cancer patients with multiple ED visits is higher in the U.S. compared with Canada.8,9 It is encouraging for patients receiving palliative care that palliative care has been recognized as a subspecialty of emergency medicine in the past decade.10e12 There is a growing interest among emergency medicine physicians in increasing and/or improving palliative care training and establishing an optimal collaboration between palliative care teams (PCTs) and emergency providers to fulfill unmet symptom management needs of patients with serious illnesses visiting the ED.12e15 However, although delivering appropriate palliative care to these patients in the ED is extremely important, identifying the causes of ED visits and preventing potentially avoidable ED visits (AvEDs) in advance might be important as well. In the general population, more than 50% of the ED visits were for nonurgent care or for conditions that could have been treated in a primary care setting.16 Limited research exists on the clinical characteristics of patients with advanced cancer receiving palliative care who present to EDs and whether these visits could be avoided.6,7 In a study using administrative data from the Ontario Cancer Registry, AvEDs were found to account for 2.8% of all ED visits in the final six months of life.6 However, as the authors noted, the administrative data were not well suited for detecting the exact reasons for advanced cancer patients’ ED visits. Contrary to that study, Wallace et al.7 analyzed 35 ED visits by 30 patients with terminal illness receiving a specialist palliative care in the Mid-Western Regional Hospital, Limerick, and reported that 52% of the ED visits were deemed potentially avoidable. The primary objective of our study was to determine the frequency of potentially AvEDs for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center. The secondary objectives were to identify the clinical characteristics of the patients receiving palliative care who visited the ED and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).
Vol. 49 No. 3 March 2015
During the study period (January 1, 2010 to December 31, 2011), a total of 2713 patients with cancer were evaluated in our outpatient palliative care clinic at M. D. Anderson Cancer Center (i.e., the Supportive Care Center). Among these patients, 1841 (68%) had visited the ED at M. D. Anderson Cancer Center at least once during the study period. From these 1841 patients, we randomly selected 200 patients with advanced cancer aged 18 years or older who visited the ED after their first visit to our outpatient clinic and retrospectively reviewed their medical records. We obtained data on baseline demographic and clinical characteristics from the palliative care clinic, including symptom burden according to the Edmonton Symptom Assessment System (ESAS), and data on ED visits from the ED, including the chief complaint on presentation at the ED and clinical diagnoses made at the ED. Only the first ED visit for each patient was included in this analysis. We defined advanced cancer as locally advanced, metastatic, or locally recurrent disease for a solid tumor and as primary progressive or relapsed/refractory disease for a hematologic malignancy. All the patients were followed by both the palliative care specialists and their primary oncologists. In the M. D. Anderson outpatient palliative care clinic, patients are managed by an interdisciplinary PCT comprising palliative care specialists, fellows, midlevel practitioners, palliative care nurses, social workers, chaplains, psychologists, and pharmacists.17 The M. D. Anderson ED operates a 44-bed center that treats patients with a cancer diagnosis at all stages with a large variety of emergencies. We classified patients as having an AvED or an UnAvED according to a predefined criterion: an ED visit was classified as potentially avoidable if the problem could have been managed at the outpatient palliative care clinic or by telephone. The use of late-line chemotherapy and delayed hospice referral were not considered avoidable reasons for an ED visit. To determine the avoidability of an ED visit, a palliative care specialist with internal medicine and geriatrics background and a medical oncologist with palliative care training independently reviewed the medical records of all patients. Initial disagreement between the two physicians was observed for 27 patients (14%), and the inter-rater agreement was moderate (Cohen’s kappa ¼ 0.62, P < 0.001). In those cases, the physicians reviewed the medical records together and reached a consensus on the avoidability of the visit.
Methods The Institutional Review Board at The University of Texas M. D. Anderson Cancer Center approved this study and waived the requirement for informed consent.
Statistical Analysis Our hypothesis was that the proportion of ED visits that are avoidable is greater than 50%. Two hundred
Vol. 49 No. 3 March 2015
Avoidable and Unavoidable ED Visits for Advanced Cancer Patients
patients provide 86% power to reject the null hypothesis that AvED is less than 50% when the true proportion is 60% using a one-sided exact test with an alpha level of 0.05. All collected variables were described with simple statistics, such as means, medians, SDs, and interquartile ranges and tested for differences between the AvED and UnAvED groups using Pearson c2 tests, Fisher exact tests, or Kruskal-Wallis tests, as appropriate. The median survival was calculated using the Kaplan-Meier method, and survival was compared between the AvED and UnAvED groups using log-rank tests. Multivariate logistic regression analysis was performed to identify independent factors associated with AvEDs and UnAvEDs. Age, sex, and variables with a P-value lower than 0.2 on univariate analysis were included in the multivariate analysis. In the case of collinear variables, only one variable was chosen for multivariate analysis. Two-sided P-values less than 0.05 were considered significant, and CIs were calculated at a 95% confidence level. All analyses
499
were performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY).
Results Table 1 summarizes patients’ clinical characteristics. The mean age was 57 years, and 96 (48%) were females. Forty-six (23%) ED visits were classified as AvEDs, whereas 154 (77%) ED visits were classified as UnAvEDs. Baseline symptom burden at the time of the first visit to the palliative care clinic, using the ESAS, did not significantly differ between the two groups except in that baseline dyspnea was more common in patients with UnAvEDs (P ¼ 0.039). Table 2 shows the reasons for the ED visits by the chief complaint and final clinical diagnosis at the ED. Pain (71/200, 36%) was the most common chief complaint in both groups (34% for UnAvED and 39% for AvED). Only patients in the UnAvED group had altered mental status (14% vs. 0%), dyspnea (10% vs. 0%), fever (11% vs. 0%), or bleeding (6% vs. 0%). Conversely, falls were present in the AvED
Table 1 Baseline Demographic and Clinical Characteristics All Patients (n ¼ 200) Characteristic Age, yrs, mean SD Female Ethnicity White African American Hispanic Asian Other Marital status Single Married Divorced/separated Widowed Primary cancer diagnosis Breast Thoracic Head and neck Gastrointestinal Urologic Gynecologic Hematologic Other Cancer status Local/locally advanced Metastatic Locally recurrent Primary progressive or relapseda Treatment status Newly diagnosed Curative/definitive treatment Palliative chemotherapy First line Second or third line Beyond third line Other a
Hematologic malignancy.
Patients With Unavoidable Visits (n ¼ 154)
Patients With Avoidable Visits (n ¼ 46)
n (%) 56.5 13.6 96 (48)
56.8 13.1 73 (47)
P 55.2 15.0 23 (50)
0.491 0.757
137 33 19 10 1
(69) (17) (10) (5) (1)
113 22 12 7 0
(73) (14) (8) (5) (0)
24 11 7 3 1
(52) (24) (15) (7) (2)
0.041
35 120 26 18
(18) (60) (13) (9)
25 95 23 11
(16) (62) (15) (7)
10 26 3 7
(22) (57) (7) (15)
0.153
21 45 22 36 14 18 10 34
(11) (23) (11) (18) (7) (9) (5) (17)
13 37 17 29 12 15 8 23
(8) (24) (11) (19) (8) (10) (5) (15)
8 8 5 7 2 3 2 11
(17) (17) (11) (15) (4) (7) (4) (32)
0.495
25 160 10 5
(13) (80) (5) (3)
18 125 8 3
(12) (81) (5) (2)
7 35 2 2
(15) (76) (4) (4)
0.721
5 (11) 7 (15)
0.631
22 (11) 23 (12)
17 (11) 16 (10)
22 70 58 5
20 52 45 4
(11) (35) (29) (3)
(13) (34) (29) (3)
2 18 13 1
(4) (39) (28) (20)
500
Delgado-Guay et al.
Vol. 49 No. 3 March 2015
Table 2 Reasons for ED Visits After Visiting Palliative Care Clinic All Patients (n ¼ 200)
Patients With Unavoidable Visits (n ¼ 154)
Variable According to chief complaint Pain N/V or other GI symptoms Dyspnea Altered mental status Other neurologic symptoms Fever/chill Bleeding Edema/swelling General weakness Fell down Other According to clinical diagnosis at ED Cancer pain Cancer-related dyspnea Dehydration Infection Neurologic events Metabolic events Hemorrhage Thromboembolism Small bowel obstruction Constipation Treatment-related complications Catheter-related events Medication refill Others Five most common clinical diagnoses found in ED
Patients With Avoidable Visits (n ¼ 46)
n (%) 71 18 16 22 8 17 9 5 12 3 19
1. 2. 3. 4. 5.
(36) (9) (8) (11) (4) (9) (5) (3) (6) (2) (10)
34 (17) 13 (7) 6 (3) 28 (14) 17 (9) 9 (5) 8 (4) 2 (1) 6 (3) 12 (6) 31 (16) 6 (3) 4 (2) 19 (10) Cancer pain Treatment-related complications Infection Neurologic events Cancer-related dyspnea
53 10 16 22 7 17 9 2 11 0 7
1. 2. 3. 4. 5.
P
(34) (7) (10) (14) (5) (11) (6) (1) (7) (0) (5)
28 (18) 13 (8) 6 (4) 26 (17) 16 (10) 9 (6) 8 (5) 2 (1) 6 (4) 3 (2) 20 (13) 3 (2) 0 (0) 14 (9) Cancer pain Infection Treatment-related complications Neurologic events Cancer-related dyspnea
(39) (17) (0) (0) (2) (0) (0) (7) (2) (7) (26)
Journal of Pain and Symptom Management 497
Original Article
Avoidable and Unavoidable Visits to the Emergency Department Among Patients With Advanced Cancer Receiving Outpatient Palliative Care Marvin Omar Delgado-Guay, MD, Yu Jung Kim, MD, Seong Hoon Shin, MD, Gary Chisholm, MS, Janet Williams, MPH, Julio Allo, MPH, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (M.O.D.-G., Y.J.K., J.W., J.A., E.B.) and Department of Biostatistics (G.C.), The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine (Y.J.K.), Seoul National University Bundang Hospital, Seongnam; and Department of Internal Medicine (S.H.S.), College of Medicine, Kosin University, Busan, Republic of Korea
Abstract Context. Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable. Objectives. To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs). Methods. We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED. Results. Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99). Conclusion. Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed. J Pain Symptom Manage 2015;49:497e504. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Supportive care, palliative care outpatient, emergency department, advanced cancer
Introduction Although early integration of a specialized palliative care service in the trajectory of cancer treatment is considered important, most of those seen in palliative Drs. Delgado-Guay and Kim contributed equally to this article. Address correspondence to: Marvin Omar Delgado-Guay, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
care clinics are patients with advanced cancer who are nearing the end of life.1e3 For these patients, multiple emergency department (ED) visits are considered an indicator of poor-quality cancer care, along with
Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA. E-mail: [email protected] Accepted for publication: July 6, 2014.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2014.07.007
498
Delgado-Guay et al.
chemotherapy in the last 14 days of life, multiple hospitalizations, intensive care unit admissions, and death in an acute care institution.4,5 In addition, ED visits in the last few months, weeks, or days of life can cause great distress to the cancer patients themselves and to their caregivers.6,7 Despite these concerns, the aggressiveness of cancer treatment near the end of life, resulting in multiple ED visits, has been increasing over time in the U.S. and Canada, and the overall rate of advanced cancer patients with multiple ED visits is higher in the U.S. compared with Canada.8,9 It is encouraging for patients receiving palliative care that palliative care has been recognized as a subspecialty of emergency medicine in the past decade.10e12 There is a growing interest among emergency medicine physicians in increasing and/or improving palliative care training and establishing an optimal collaboration between palliative care teams (PCTs) and emergency providers to fulfill unmet symptom management needs of patients with serious illnesses visiting the ED.12e15 However, although delivering appropriate palliative care to these patients in the ED is extremely important, identifying the causes of ED visits and preventing potentially avoidable ED visits (AvEDs) in advance might be important as well. In the general population, more than 50% of the ED visits were for nonurgent care or for conditions that could have been treated in a primary care setting.16 Limited research exists on the clinical characteristics of patients with advanced cancer receiving palliative care who present to EDs and whether these visits could be avoided.6,7 In a study using administrative data from the Ontario Cancer Registry, AvEDs were found to account for 2.8% of all ED visits in the final six months of life.6 However, as the authors noted, the administrative data were not well suited for detecting the exact reasons for advanced cancer patients’ ED visits. Contrary to that study, Wallace et al.7 analyzed 35 ED visits by 30 patients with terminal illness receiving a specialist palliative care in the Mid-Western Regional Hospital, Limerick, and reported that 52% of the ED visits were deemed potentially avoidable. The primary objective of our study was to determine the frequency of potentially AvEDs for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center. The secondary objectives were to identify the clinical characteristics of the patients receiving palliative care who visited the ED and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).
Vol. 49 No. 3 March 2015
During the study period (January 1, 2010 to December 31, 2011), a total of 2713 patients with cancer were evaluated in our outpatient palliative care clinic at M. D. Anderson Cancer Center (i.e., the Supportive Care Center). Among these patients, 1841 (68%) had visited the ED at M. D. Anderson Cancer Center at least once during the study period. From these 1841 patients, we randomly selected 200 patients with advanced cancer aged 18 years or older who visited the ED after their first visit to our outpatient clinic and retrospectively reviewed their medical records. We obtained data on baseline demographic and clinical characteristics from the palliative care clinic, including symptom burden according to the Edmonton Symptom Assessment System (ESAS), and data on ED visits from the ED, including the chief complaint on presentation at the ED and clinical diagnoses made at the ED. Only the first ED visit for each patient was included in this analysis. We defined advanced cancer as locally advanced, metastatic, or locally recurrent disease for a solid tumor and as primary progressive or relapsed/refractory disease for a hematologic malignancy. All the patients were followed by both the palliative care specialists and their primary oncologists. In the M. D. Anderson outpatient palliative care clinic, patients are managed by an interdisciplinary PCT comprising palliative care specialists, fellows, midlevel practitioners, palliative care nurses, social workers, chaplains, psychologists, and pharmacists.17 The M. D. Anderson ED operates a 44-bed center that treats patients with a cancer diagnosis at all stages with a large variety of emergencies. We classified patients as having an AvED or an UnAvED according to a predefined criterion: an ED visit was classified as potentially avoidable if the problem could have been managed at the outpatient palliative care clinic or by telephone. The use of late-line chemotherapy and delayed hospice referral were not considered avoidable reasons for an ED visit. To determine the avoidability of an ED visit, a palliative care specialist with internal medicine and geriatrics background and a medical oncologist with palliative care training independently reviewed the medical records of all patients. Initial disagreement between the two physicians was observed for 27 patients (14%), and the inter-rater agreement was moderate (Cohen’s kappa ¼ 0.62, P < 0.001). In those cases, the physicians reviewed the medical records together and reached a consensus on the avoidability of the visit.
Methods The Institutional Review Board at The University of Texas M. D. Anderson Cancer Center approved this study and waived the requirement for informed consent.
Statistical Analysis Our hypothesis was that the proportion of ED visits that are avoidable is greater than 50%. Two hundred
Vol. 49 No. 3 March 2015
Avoidable and Unavoidable ED Visits for Advanced Cancer Patients
patients provide 86% power to reject the null hypothesis that AvED is less than 50% when the true proportion is 60% using a one-sided exact test with an alpha level of 0.05. All collected variables were described with simple statistics, such as means, medians, SDs, and interquartile ranges and tested for differences between the AvED and UnAvED groups using Pearson c2 tests, Fisher exact tests, or Kruskal-Wallis tests, as appropriate. The median survival was calculated using the Kaplan-Meier method, and survival was compared between the AvED and UnAvED groups using log-rank tests. Multivariate logistic regression analysis was performed to identify independent factors associated with AvEDs and UnAvEDs. Age, sex, and variables with a P-value lower than 0.2 on univariate analysis were included in the multivariate analysis. In the case of collinear variables, only one variable was chosen for multivariate analysis. Two-sided P-values less than 0.05 were considered significant, and CIs were calculated at a 95% confidence level. All analyses
499
were performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corp., Armonk, NY).
Results Table 1 summarizes patients’ clinical characteristics. The mean age was 57 years, and 96 (48%) were females. Forty-six (23%) ED visits were classified as AvEDs, whereas 154 (77%) ED visits were classified as UnAvEDs. Baseline symptom burden at the time of the first visit to the palliative care clinic, using the ESAS, did not significantly differ between the two groups except in that baseline dyspnea was more common in patients with UnAvEDs (P ¼ 0.039). Table 2 shows the reasons for the ED visits by the chief complaint and final clinical diagnosis at the ED. Pain (71/200, 36%) was the most common chief complaint in both groups (34% for UnAvED and 39% for AvED). Only patients in the UnAvED group had altered mental status (14% vs. 0%), dyspnea (10% vs. 0%), fever (11% vs. 0%), or bleeding (6% vs. 0%). Conversely, falls were present in the AvED
Table 1 Baseline Demographic and Clinical Characteristics All Patients (n ¼ 200) Characteristic Age, yrs, mean SD Female Ethnicity White African American Hispanic Asian Other Marital status Single Married Divorced/separated Widowed Primary cancer diagnosis Breast Thoracic Head and neck Gastrointestinal Urologic Gynecologic Hematologic Other Cancer status Local/locally advanced Metastatic Locally recurrent Primary progressive or relapseda Treatment status Newly diagnosed Curative/definitive treatment Palliative chemotherapy First line Second or third line Beyond third line Other a
Hematologic malignancy.
Patients With Unavoidable Visits (n ¼ 154)
Patients With Avoidable Visits (n ¼ 46)
n (%) 56.5 13.6 96 (48)
56.8 13.1 73 (47)
P 55.2 15.0 23 (50)
0.491 0.757
137 33 19 10 1
(69) (17) (10) (5) (1)
113 22 12 7 0
(73) (14) (8) (5) (0)
24 11 7 3 1
(52) (24) (15) (7) (2)
0.041
35 120 26 18
(18) (60) (13) (9)
25 95 23 11
(16) (62) (15) (7)
10 26 3 7
(22) (57) (7) (15)
0.153
21 45 22 36 14 18 10 34
(11) (23) (11) (18) (7) (9) (5) (17)
13 37 17 29 12 15 8 23
(8) (24) (11) (19) (8) (10) (5) (15)
8 8 5 7 2 3 2 11
(17) (17) (11) (15) (4) (7) (4) (32)
0.495
25 160 10 5
(13) (80) (5) (3)
18 125 8 3
(12) (81) (5) (2)
7 35 2 2
(15) (76) (4) (4)
0.721
5 (11) 7 (15)
0.631
22 (11) 23 (12)
17 (11) 16 (10)
22 70 58 5
20 52 45 4
(11) (35) (29) (3)
(13) (34) (29) (3)
2 18 13 1
(4) (39) (28) (20)
500
Delgado-Guay et al.
Vol. 49 No. 3 March 2015
Table 2 Reasons for ED Visits After Visiting Palliative Care Clinic All Patients (n ¼ 200)
Patients With Unavoidable Visits (n ¼ 154)
Variable According to chief complaint Pain N/V or other GI symptoms Dyspnea Altered mental status Other neurologic symptoms Fever/chill Bleeding Edema/swelling General weakness Fell down Other According to clinical diagnosis at ED Cancer pain Cancer-related dyspnea Dehydration Infection Neurologic events Metabolic events Hemorrhage Thromboembolism Small bowel obstruction Constipation Treatment-related complications Catheter-related events Medication refill Others Five most common clinical diagnoses found in ED
Patients With Avoidable Visits (n ¼ 46)
n (%) 71 18 16 22 8 17 9 5 12 3 19
1. 2. 3. 4. 5.
(36) (9) (8) (11) (4) (9) (5) (3) (6) (2) (10)
34 (17) 13 (7) 6 (3) 28 (14) 17 (9) 9 (5) 8 (4) 2 (1) 6 (3) 12 (6) 31 (16) 6 (3) 4 (2) 19 (10) Cancer pain Treatment-related complications Infection Neurologic events Cancer-related dyspnea
53 10 16 22 7 17 9 2 11 0 7
1. 2. 3. 4. 5.
P
(34) (7) (10) (14) (5) (11) (6) (1) (7) (0) (5)
28 (18) 13 (8) 6 (4) 26 (17) 16 (10) 9 (6) 8 (5) 2 (1) 6 (4) 3 (2) 20 (13) 3 (2) 0 (0) 14 (9) Cancer pain Infection Treatment-related complications Neurologic events Cancer-related dyspnea
(39) (17) (0) (0) (2) (0) (0) (7) (2) (7) (26)
