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Journal of Pain and Symptom Management 1
Original Article
Characteristics and Outcomes of Patients Admitted to the Acute Palliative Care Unit From the Emergency Center Seong Hoon Shin, MD, David Hui, MD, MSc, Gary B. Chisholm, MS, Jung Hye Kwon, MD, Maria Teresa San-Miguel, RN, Julio A. Allo, MPH, Sriram Yennurajalingam, MD, MS, Susan E. Frisbee-Hume, RN, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (S.H.S., D.H., J.A.A., S.Y., S.E.F.-H., E.B.); and Department of Biostatistics (G.B.C.), University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine (S.H.S.), College of Medicine, Kosin University, Busan; Department of Internal Medicine (J.H.K.), Kangdong Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea; and Department of Palliative Medicine (M.T.S.-M.), Clinica Universidad de Navarra, Pamplona, Spain
Abstract Context. Most patients admitted to acute palliative care units (APCUs) are transferred from inpatient oncology units. We hypothesized that patients admitted to APCUs from emergency centers (ECs) have symptom burdens and outcomes that differ from those of transferred inpatients. Objectives. The purpose of this retrospective cohort study was to compare the symptom burdens and survival rate of patients admitted to an APCU from an EC with those of inpatients transferred to the APCU. Methods. Among the 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008, 312 (12%) were EC patients. We randomly selected 300 inpatients transferred to the APCU as controls (The outcome data were unavailable for two patients). We retrieved data on patient demographics, cancer diagnosis, Edmonton Symptom Assessment System scores, discharge outcomes, and overall survival from time of admission to the APCU. Results. The EC patients had higher rates of pain, fatigue, nausea, and insomnia and were less likely to be delirious. They were more than twice as likely to be discharged alive than transferred inpatients. Kaplan-Meier plot tests for productlimit survival estimate from admission to APCU for EC patients and inpatients were statistically significant (median survival 34 vs. 31 days, P < 0.0001). In multivariate analysis, EC admission (odds ratio [OR] ¼ 1.8593, 95% confidence interval [CI] 1.1532e2.9961), dyspnea (OR ¼ 0.8533, 95% CI 0.7892e0.9211), well-being (OR ¼ 1.1192, 95% CI 1.0234e1.2257), and delirium (OR ¼ 0.3942, 95% CI 0.2443e0.6351) were independently associated with being discharged alive.
Address correspondence to: Eduardo Bruera, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Boulevard, Houston, TX 77030, USA. E-mail: [email protected] Accepted for publication: July 23, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.07.015
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Conclusion. The EC patients have a higher acute symptom burden and are more likely to be discharged alive than transferred inpatients. The APCU was successful at managing symptoms and facilitating the discharge of both inpatients and EC patients to the community although the patients had severe symptoms on admission. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Acute palliative care unit, emergency center, symptom burden
Introduction Many patients with advanced cancer suffer severe physical and psychosocial distress.1 Severe symptoms can worsen quality of life and complicate the treatment process.1e4 Some patients are referred to hospice for symptom control and end-of-life care.1,5 However, many patients are not referred to hospice because they need complex medical care.1,6e10 In 2003, The University of Texas M. D. Anderson Cancer Center opened a 12-bed acute palliative care unit (APCU) to serve the complicated care needs of patients with advanced cancer.4,11e13 The APCUs differ from palliative care units, which offer more extensive long-term palliative care or exclusively terminal care.9,14e16 The focus of APCUs is rapid symptom control and intensive psychosocial care, with a shorter length of stay (up to two weeks) and a lower death rate (20e50%) than those in traditional palliative care units.4,6,9,11,12,17e20 Most patients admitted to APCUs are transferred from inpatient oncology units.11,18,19 However, the patients admitted to APCUs from emergency centers (ECs) have distinct clinical characteristics. The purpose of this retrospective study was to compare the symptom burden and survival rate of patients admitted to an APCU from an EC with the symptom burden and survival rate of transferred inpatients and to identify the characteristics of patients discharged alive from the APCU.
Methods Patients A search of the institution’s database identified 2568 patients admitted to M. D. Anderson’s APCU between September 1, 2003, and August 31, 2008. Patients are admitted to the
APCU when they present with severe physical and psychosocial distress requiring inpatient primary care under a palliative medicine specialist. Of those, 312 patients were admitted from the EC and were included in this retrospective study. For a control group, we randomly selected 300 patients (outcome data were unavailable for two patients) transferred to the APCUs from the hospital’s oncology unit. The M. D. Anderson Cancer Center’s Institutional Review Board approved this study and waived the requirement for informed consent.
Patient Characteristics and Discharge Outcomes From the eligible patients’ medical records, the following data were collected: demographics (age, sex, ethnicity, marital status, religious affiliation, and insurance status), clinical data (primary cancer diagnosis and stage), delirium (either clinical diagnosis of delirium by the palliative care specialist or a Memorial Delirium Assessment Scale score higher than seven of 30), the Edmonton Symptom Assessment System score at admission to the APCU, discharge outcomes (alive or dead), and survival times (from the date of discharge from the APCU; collected from institutional databases and electronic health records). The Edmonton Symptom Assessment System is a widely used and validated tool for assessing nine symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, shortness of breath, and sleep) and general feeling of well-being on a scale from zero (no symptoms) to 10 (worst symptom imaginable).21
Statistical Analysis We summarized baseline demographics, clinical characteristics, and discharge outcomes
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APCU Outcomes for EC Patients vs. Transferred Inpatients
using descriptive statistics, including medians, means, standard deviations, ranges, and frequencies, together with 95% confidence intervals (CIs). Survival analyses were plotted by using the Kaplan-Meier method, and survival curves were compared by the log-rank test. Overall survival time was calculated from the time of admission to the APCU to the date of death from any cause or the date on which the patient was last known to be alive. Multivariate analysis was performed by using logistic regression with backward elimination. Continuous variables that were normally distributed were compared with the Student t-test; continuous, nonparametric variables were compared with the Mann-Whitney test, and categorical variables were compared by Pearson’s c2 test. The SAS version 9.2 (SAS Institute, Cary, NC) and R version 2.3.1 (The R Foundation for Statistical Computing, Vienna, Austria) were used to perform the analyses.
Results The 312 EC patients represented 12% of the total 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008. The median age of the EC patients was 59 years, and 169 patients (54%) were male (Table 1). Around 95% of the EC patients had solid tumors, and 5% had hematologic malignancies. The most common primary cancers diagnosed for the two patient groups combined were respiratory (25%) and gastrointestinal (22%) cancers. Compared with inpatients, EC patients were more likely to be black (22% vs. 11%, P ¼ 0.0006) and less likely to have hematologic cancer (5% vs. 14%, P ¼ 0.0002). The EC patients had significantly higher levels of pain, fatigue, nausea, and insomnia and were less likely to be delirious (41% vs. 55%, P ¼ 0.001) than transferred inpatients (Table 1). The EC patients had a higher rate of public insurance coverage (44% vs. 38%, P ¼ 0.0142), higher rate of home discharge from the APCU (29% vs. 11%, P ¼ 0.0001), and longer stays in the APCU (mean 8.4 [95% CI 8.0e8.9] vs. mean 7.6 [95% CI 7.0e8.2] days, P ¼ 0.0002), and were 2.3 times as likely to be discharged alive as were inpatients (P < 0.0001, Wald c2 test). Marital status, sex, age, and religion did not differ significantly between the two groups. The Kaplan-Meier plots
3
of product-limit survival estimate from the date of admission to the APCU differed significantly between EC patients and inpatients (median [range] survival times after discharge were 34 [30e41] and 31 [27e38] days, respectively; P < 0.0001). The survival curves of EC patients and inpatients diverge early after discharge and converge about a year postdischarge (Fig. 1). In univariate logistic regressions, delirium (P < 0.0001), hematologic malignancy (P ¼ 0.0017), fatigue (P ¼ 0.0272), drowsiness (P ¼ 0.0169), dyspnea (P < 0.0001), and insomnia (P ¼ 0.017) were significant predictors of the likelihood that the patient would not be discharged alive. In multivariate analysis of the data, we found that EC admission (odds ratio [OR] ¼ 1.8593; 95% CI 1.1532e2.9961), delirium (OR ¼ 0.3942; 95% CI 0.2443e0.6351), dyspnea (OR ¼ 0.8533; 95% CI 0.7892e0.9211), and well-being (OR ¼ 1.1192; 95% CI 1.0234e 1.2257) were related to discharge status (Table 2). There were small independent associations of well-being and dyspnea with in-hospital mortality and larger independent associations of delirium and inpatient transfer with in-hospital mortality (Table 2).
Discussion In this study, the proportion of patients admitted to the APCU from the EC was low (12%), and EC patients were 2.3 times more likely to be discharged alive than were inpatients. In terms of symptoms, higher levels of pain, fatigue, nausea, and sleep disturbance had a significant association with admission from the EC. The median length of stay in the APCU among the patients from the EC was longer (8.4 days) than that for the inpatients (7.6 days). The longer stay may be explained by the heavier symptom burden among patients from the EC. Our finding shows that delirium was very frequent on admission to the APCU in both inpatients transferred and EC patients. This finding suggests that all patients transferred to the APCU should be screened for delirium. The higher frequency of delirium among inpatients than among EC patients also confirms previous reports of delirium as an indicator of poor prognosis for home discharge.13,22e25 Black or Asian race and public insurance coverage are associated with higher rates of EC admission.
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Table 1 Characteristics of the Acute Palliative Care Unit Patients Admitted From Emergency Center (EC) and Inpatient Transfer (IP) Characteristics Sex Female Age Mean (95% CI) Race White Black Asian Others Cancer diagnosis Hematologic Gastrointestinal Respiratory Breast Genitourinary/gynecologic Head and neck Others Religion Christian Other Delirium Presence Home discharge Yes Insurance Public Private Self-pay Marital status Married Single Divorced/separated Widowed APCU stay (d) Mean (95% CI) ESAS, mean (95% CI) Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Insomnia
Overall, N (%)
EC (N ¼ 312), n (%)
IP (N ¼ 298), n (%)
P-Value
289 (47)
143 (46)
146 (49)
0.4656a
58.9 (57.8e60.0)
59.1 (57.6e60.6)
58.6 (57.0e60.2)
0.6244b
403 101 32 74
(66) (17) (5) (12)
190 68 21 33
(61) (22) (7) (11)
213 33 11 41
(71) (11) (4) (14)
0.0006a
58 129 149 42 85 41 96
(10) (22) (25) (7) (14) (7) (16)
16 75 78 21 48 27 37
(5) (25) (26) (7) (16) (9) (12)
42 54 71 21 37 14 59
(14) (18) (24) (7) (12) (5) (20)
0.0002c
503 (94) 33 (6)
257 (94) 15 (6)
246 (93) 18 (7)
0.5919a
284 (48)
128 (41)
156 (55)
0.0010a
124 (20)
92 (29)
32 (11)
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No.
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2013
Journal of Pain and Symptom Management 1
Original Article
Characteristics and Outcomes of Patients Admitted to the Acute Palliative Care Unit From the Emergency Center Seong Hoon Shin, MD, David Hui, MD, MSc, Gary B. Chisholm, MS, Jung Hye Kwon, MD, Maria Teresa San-Miguel, RN, Julio A. Allo, MPH, Sriram Yennurajalingam, MD, MS, Susan E. Frisbee-Hume, RN, and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine (S.H.S., D.H., J.A.A., S.Y., S.E.F.-H., E.B.); and Department of Biostatistics (G.B.C.), University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine (S.H.S.), College of Medicine, Kosin University, Busan; Department of Internal Medicine (J.H.K.), Kangdong Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea; and Department of Palliative Medicine (M.T.S.-M.), Clinica Universidad de Navarra, Pamplona, Spain
Abstract Context. Most patients admitted to acute palliative care units (APCUs) are transferred from inpatient oncology units. We hypothesized that patients admitted to APCUs from emergency centers (ECs) have symptom burdens and outcomes that differ from those of transferred inpatients. Objectives. The purpose of this retrospective cohort study was to compare the symptom burdens and survival rate of patients admitted to an APCU from an EC with those of inpatients transferred to the APCU. Methods. Among the 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008, 312 (12%) were EC patients. We randomly selected 300 inpatients transferred to the APCU as controls (The outcome data were unavailable for two patients). We retrieved data on patient demographics, cancer diagnosis, Edmonton Symptom Assessment System scores, discharge outcomes, and overall survival from time of admission to the APCU. Results. The EC patients had higher rates of pain, fatigue, nausea, and insomnia and were less likely to be delirious. They were more than twice as likely to be discharged alive than transferred inpatients. Kaplan-Meier plot tests for productlimit survival estimate from admission to APCU for EC patients and inpatients were statistically significant (median survival 34 vs. 31 days, P < 0.0001). In multivariate analysis, EC admission (odds ratio [OR] ¼ 1.8593, 95% confidence interval [CI] 1.1532e2.9961), dyspnea (OR ¼ 0.8533, 95% CI 0.7892e0.9211), well-being (OR ¼ 1.1192, 95% CI 1.0234e1.2257), and delirium (OR ¼ 0.3942, 95% CI 0.2443e0.6351) were independently associated with being discharged alive.
Address correspondence to: Eduardo Bruera, MD, Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Boulevard, Houston, TX 77030, USA. E-mail: [email protected] Accepted for publication: July 23, 2013. 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.07.015
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Conclusion. The EC patients have a higher acute symptom burden and are more likely to be discharged alive than transferred inpatients. The APCU was successful at managing symptoms and facilitating the discharge of both inpatients and EC patients to the community although the patients had severe symptoms on admission. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Acute palliative care unit, emergency center, symptom burden
Introduction Many patients with advanced cancer suffer severe physical and psychosocial distress.1 Severe symptoms can worsen quality of life and complicate the treatment process.1e4 Some patients are referred to hospice for symptom control and end-of-life care.1,5 However, many patients are not referred to hospice because they need complex medical care.1,6e10 In 2003, The University of Texas M. D. Anderson Cancer Center opened a 12-bed acute palliative care unit (APCU) to serve the complicated care needs of patients with advanced cancer.4,11e13 The APCUs differ from palliative care units, which offer more extensive long-term palliative care or exclusively terminal care.9,14e16 The focus of APCUs is rapid symptom control and intensive psychosocial care, with a shorter length of stay (up to two weeks) and a lower death rate (20e50%) than those in traditional palliative care units.4,6,9,11,12,17e20 Most patients admitted to APCUs are transferred from inpatient oncology units.11,18,19 However, the patients admitted to APCUs from emergency centers (ECs) have distinct clinical characteristics. The purpose of this retrospective study was to compare the symptom burden and survival rate of patients admitted to an APCU from an EC with the symptom burden and survival rate of transferred inpatients and to identify the characteristics of patients discharged alive from the APCU.
Methods Patients A search of the institution’s database identified 2568 patients admitted to M. D. Anderson’s APCU between September 1, 2003, and August 31, 2008. Patients are admitted to the
APCU when they present with severe physical and psychosocial distress requiring inpatient primary care under a palliative medicine specialist. Of those, 312 patients were admitted from the EC and were included in this retrospective study. For a control group, we randomly selected 300 patients (outcome data were unavailable for two patients) transferred to the APCUs from the hospital’s oncology unit. The M. D. Anderson Cancer Center’s Institutional Review Board approved this study and waived the requirement for informed consent.
Patient Characteristics and Discharge Outcomes From the eligible patients’ medical records, the following data were collected: demographics (age, sex, ethnicity, marital status, religious affiliation, and insurance status), clinical data (primary cancer diagnosis and stage), delirium (either clinical diagnosis of delirium by the palliative care specialist or a Memorial Delirium Assessment Scale score higher than seven of 30), the Edmonton Symptom Assessment System score at admission to the APCU, discharge outcomes (alive or dead), and survival times (from the date of discharge from the APCU; collected from institutional databases and electronic health records). The Edmonton Symptom Assessment System is a widely used and validated tool for assessing nine symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, shortness of breath, and sleep) and general feeling of well-being on a scale from zero (no symptoms) to 10 (worst symptom imaginable).21
Statistical Analysis We summarized baseline demographics, clinical characteristics, and discharge outcomes
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No.
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2013
APCU Outcomes for EC Patients vs. Transferred Inpatients
using descriptive statistics, including medians, means, standard deviations, ranges, and frequencies, together with 95% confidence intervals (CIs). Survival analyses were plotted by using the Kaplan-Meier method, and survival curves were compared by the log-rank test. Overall survival time was calculated from the time of admission to the APCU to the date of death from any cause or the date on which the patient was last known to be alive. Multivariate analysis was performed by using logistic regression with backward elimination. Continuous variables that were normally distributed were compared with the Student t-test; continuous, nonparametric variables were compared with the Mann-Whitney test, and categorical variables were compared by Pearson’s c2 test. The SAS version 9.2 (SAS Institute, Cary, NC) and R version 2.3.1 (The R Foundation for Statistical Computing, Vienna, Austria) were used to perform the analyses.
Results The 312 EC patients represented 12% of the total 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008. The median age of the EC patients was 59 years, and 169 patients (54%) were male (Table 1). Around 95% of the EC patients had solid tumors, and 5% had hematologic malignancies. The most common primary cancers diagnosed for the two patient groups combined were respiratory (25%) and gastrointestinal (22%) cancers. Compared with inpatients, EC patients were more likely to be black (22% vs. 11%, P ¼ 0.0006) and less likely to have hematologic cancer (5% vs. 14%, P ¼ 0.0002). The EC patients had significantly higher levels of pain, fatigue, nausea, and insomnia and were less likely to be delirious (41% vs. 55%, P ¼ 0.001) than transferred inpatients (Table 1). The EC patients had a higher rate of public insurance coverage (44% vs. 38%, P ¼ 0.0142), higher rate of home discharge from the APCU (29% vs. 11%, P ¼ 0.0001), and longer stays in the APCU (mean 8.4 [95% CI 8.0e8.9] vs. mean 7.6 [95% CI 7.0e8.2] days, P ¼ 0.0002), and were 2.3 times as likely to be discharged alive as were inpatients (P < 0.0001, Wald c2 test). Marital status, sex, age, and religion did not differ significantly between the two groups. The Kaplan-Meier plots
3
of product-limit survival estimate from the date of admission to the APCU differed significantly between EC patients and inpatients (median [range] survival times after discharge were 34 [30e41] and 31 [27e38] days, respectively; P < 0.0001). The survival curves of EC patients and inpatients diverge early after discharge and converge about a year postdischarge (Fig. 1). In univariate logistic regressions, delirium (P < 0.0001), hematologic malignancy (P ¼ 0.0017), fatigue (P ¼ 0.0272), drowsiness (P ¼ 0.0169), dyspnea (P < 0.0001), and insomnia (P ¼ 0.017) were significant predictors of the likelihood that the patient would not be discharged alive. In multivariate analysis of the data, we found that EC admission (odds ratio [OR] ¼ 1.8593; 95% CI 1.1532e2.9961), delirium (OR ¼ 0.3942; 95% CI 0.2443e0.6351), dyspnea (OR ¼ 0.8533; 95% CI 0.7892e0.9211), and well-being (OR ¼ 1.1192; 95% CI 1.0234e 1.2257) were related to discharge status (Table 2). There were small independent associations of well-being and dyspnea with in-hospital mortality and larger independent associations of delirium and inpatient transfer with in-hospital mortality (Table 2).
Discussion In this study, the proportion of patients admitted to the APCU from the EC was low (12%), and EC patients were 2.3 times more likely to be discharged alive than were inpatients. In terms of symptoms, higher levels of pain, fatigue, nausea, and sleep disturbance had a significant association with admission from the EC. The median length of stay in the APCU among the patients from the EC was longer (8.4 days) than that for the inpatients (7.6 days). The longer stay may be explained by the heavier symptom burden among patients from the EC. Our finding shows that delirium was very frequent on admission to the APCU in both inpatients transferred and EC patients. This finding suggests that all patients transferred to the APCU should be screened for delirium. The higher frequency of delirium among inpatients than among EC patients also confirms previous reports of delirium as an indicator of poor prognosis for home discharge.13,22e25 Black or Asian race and public insurance coverage are associated with higher rates of EC admission.
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Table 1 Characteristics of the Acute Palliative Care Unit Patients Admitted From Emergency Center (EC) and Inpatient Transfer (IP) Characteristics Sex Female Age Mean (95% CI) Race White Black Asian Others Cancer diagnosis Hematologic Gastrointestinal Respiratory Breast Genitourinary/gynecologic Head and neck Others Religion Christian Other Delirium Presence Home discharge Yes Insurance Public Private Self-pay Marital status Married Single Divorced/separated Widowed APCU stay (d) Mean (95% CI) ESAS, mean (95% CI) Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Well-being Dyspnea Insomnia
Overall, N (%)
EC (N ¼ 312), n (%)
IP (N ¼ 298), n (%)
P-Value
289 (47)
143 (46)
146 (49)
0.4656a
58.9 (57.8e60.0)
59.1 (57.6e60.6)
58.6 (57.0e60.2)
0.6244b
403 101 32 74
(66) (17) (5) (12)
190 68 21 33
(61) (22) (7) (11)
213 33 11 41
(71) (11) (4) (14)
0.0006a
58 129 149 42 85 41 96
(10) (22) (25) (7) (14) (7) (16)
16 75 78 21 48 27 37
(5) (25) (26) (7) (16) (9) (12)
42 54 71 21 37 14 59
(14) (18) (24) (7) (12) (5) (20)
0.0002c
503 (94) 33 (6)
257 (94) 15 (6)
246 (93) 18 (7)
0.5919a
284 (48)
128 (41)
156 (55)
0.0010a
124 (20)
92 (29)
32 (11)
