Letters
hospitalizations in patients with cancer should test specific interventions to enhance the delivery of outpatient cancer care, evaluating the effect of these interventions on hospitalization rates.
Figure. Percentage of Hospitalizations Considered to Be Potentially Avoidable
Hospitalizations Considered Potentially Avoidable, %
50
Gabriel A. Brooks, MD Joseph O. Jacobson, MD Deborah Schrag, MD, MPH
40
30
Author Affiliations: Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (Brooks, Jacobson); Harvard Medical School, Boston, Massachusetts (Schrag).
20
10
0
Corresponding Author: Gabriel A. Brooks, MD, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 ([email protected]). Published Online: February 12, 2015. doi:10.1001/jamaoncol.2014.155. AP R/PA O
By Clinical Role
0
1
2
3
By No. of Evaluators
The y-axis shows the percentage of the 103 hospitalizations that were considered to be potentially avoidable. AP indicates inpatient attending physician; R/PA, resident and/or physician assistant; and O, outpatient oncologist.
izations (23%) were identified as potentially avoidable by 2 or more clinicians, meeting the study definition of potentially avoidable hospitalization. The Figure shows the proportion of hospitalizations rated as potentially avoidable, stratified by clinical role and by the number of concurring clinicians. We tested the association between potentially avoidable hospitalization and social support, illness coping skills, and illness understanding, finding no significant associations (Table). However, clinician identification of psychosocial factors as contributing to the reason for hospitalization was significantly associated with potentially avoidable hospitalization (P = .003) (Table). Anxiety and/or depression and inadequate home support were the 2 psychosocial factors most commonly identified as contributing to hospitalization (both overall and among hospitalizations perceived as potentially avoidable) in an exploratory qualitative analysis. Potentially avoidable hospitalization was associated with shorter length of stay but not 30-day readmissions or mortality (Table). Discussion | Direct identification of avoidable or preventable hospitalizations in patients with cancer is challenging, and administrative measures are lacking. In a prior study, retrospective medical record review identified 19% of hospitalizations in patients with gastrointestinal cancer as potentially avoidable. 3 Herein we demonstrate that clinicians directly involved in caring for patients with cancer agree that nearly 1 in 4 hospitalizations (23%) are potentially avoidable. Anxiety and/or depression and inadequate home support were frequently identified as triggers of potentially avoidable hospitalization. Still, all 3 clinicians agreed about the avoidability of hospitalization only 51% of the time, demonstrating that clinician perspectives are subjective and may vary by clinical role. Future efforts to study avoidable
110
Author Contributions: Dr Brooks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Brooks, Schrag. Drafting of the manuscript: Brooks, Schrag. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Brooks. Obtained funding: Jacobson. Study supervision: Schrag. Conflict of Interest Disclosures: None reported. Funding/Support: Dr Brooks was supported by a Young Investigator Award from the Conquer Cancer Foundation of the American Society of Clinical Oncology and by a program grant from the National Cancer Institute of the National Institutes of Health (R25CA09220). Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The contents of this publication are the sole responsibility of the authors, and do not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, or the American Society of Clinical Oncology. 1. Brooks GA, Li L, Uno H, Hassett MJ, Landon BE, Schrag D. Acute hospital care is the chief driver of regional spending variation in Medicare patients with advanced cancer. Health Aff (Millwood). 2014;33(10):1793-1800. 2. Agency for Healthcare Research and Quality. Prevention Quality Indicators Overview. http://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx. Accessed October 2, 2014. 3. Brooks GA, Abrams TA, Meyerhardt JA, et al. Identification of potentially avoidable hospitalizations in patients with GI cancer. J Clin Oncol. 2014;32(6): 496-503.
CORRECTION Error in Byline: In the Original Investigation titled “Hereditary Diffuse Gastric Cancer Syndrome: CDH1 Mutations and Beyond” by Hansford et al, published online February 12, 2015, in JAMA Oncology (doi:10.1001/jamaoncol.2014.168), one of the author’s names in the byline was misspelled. The name should have appeared as Carla Oliveira, PhD. The error also occurred in the Author Affiliations and the Author Contributions. This article was corrected online.
Incorrect and Incomplete Table Headings: In the Original Investigation titled “Use of Electric Power Morcellation and Prevalence of Underlying Cancer in Women Who Undergo Myomectomy” posted online first in the February 19, 2015, issue of JAMA Oncology (doi:10.1001/jamaoncol.2014.206), headings were formatted incorrectly and incompletely in Table 1. The corrected second column heading, spanning 2 subcolumns, reads “Electric Power Morcellatora,” and its 2 subcolumn headings read, from left to right, “Not Used” and “Used.”
JAMA Oncology April 2015 Volume 1, Number 1 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a Florida Atlantic University User on 03/12/2016
jamaoncology.com
hospitalizations in patients with cancer should test specific interventions to enhance the delivery of outpatient cancer care, evaluating the effect of these interventions on hospitalization rates.
Figure. Percentage of Hospitalizations Considered to Be Potentially Avoidable
Hospitalizations Considered Potentially Avoidable, %
50
Gabriel A. Brooks, MD Joseph O. Jacobson, MD Deborah Schrag, MD, MPH
40
30
Author Affiliations: Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts (Brooks, Jacobson); Harvard Medical School, Boston, Massachusetts (Schrag).
20
10
0
Corresponding Author: Gabriel A. Brooks, MD, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 ([email protected]). Published Online: February 12, 2015. doi:10.1001/jamaoncol.2014.155. AP R/PA O
By Clinical Role
0
1
2
3
By No. of Evaluators
The y-axis shows the percentage of the 103 hospitalizations that were considered to be potentially avoidable. AP indicates inpatient attending physician; R/PA, resident and/or physician assistant; and O, outpatient oncologist.
izations (23%) were identified as potentially avoidable by 2 or more clinicians, meeting the study definition of potentially avoidable hospitalization. The Figure shows the proportion of hospitalizations rated as potentially avoidable, stratified by clinical role and by the number of concurring clinicians. We tested the association between potentially avoidable hospitalization and social support, illness coping skills, and illness understanding, finding no significant associations (Table). However, clinician identification of psychosocial factors as contributing to the reason for hospitalization was significantly associated with potentially avoidable hospitalization (P = .003) (Table). Anxiety and/or depression and inadequate home support were the 2 psychosocial factors most commonly identified as contributing to hospitalization (both overall and among hospitalizations perceived as potentially avoidable) in an exploratory qualitative analysis. Potentially avoidable hospitalization was associated with shorter length of stay but not 30-day readmissions or mortality (Table). Discussion | Direct identification of avoidable or preventable hospitalizations in patients with cancer is challenging, and administrative measures are lacking. In a prior study, retrospective medical record review identified 19% of hospitalizations in patients with gastrointestinal cancer as potentially avoidable. 3 Herein we demonstrate that clinicians directly involved in caring for patients with cancer agree that nearly 1 in 4 hospitalizations (23%) are potentially avoidable. Anxiety and/or depression and inadequate home support were frequently identified as triggers of potentially avoidable hospitalization. Still, all 3 clinicians agreed about the avoidability of hospitalization only 51% of the time, demonstrating that clinician perspectives are subjective and may vary by clinical role. Future efforts to study avoidable
110
Author Contributions: Dr Brooks had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: Brooks, Schrag. Drafting of the manuscript: Brooks, Schrag. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Brooks. Obtained funding: Jacobson. Study supervision: Schrag. Conflict of Interest Disclosures: None reported. Funding/Support: Dr Brooks was supported by a Young Investigator Award from the Conquer Cancer Foundation of the American Society of Clinical Oncology and by a program grant from the National Cancer Institute of the National Institutes of Health (R25CA09220). Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The contents of this publication are the sole responsibility of the authors, and do not necessarily represent the official views of the National Cancer Institute, the National Institutes of Health, or the American Society of Clinical Oncology. 1. Brooks GA, Li L, Uno H, Hassett MJ, Landon BE, Schrag D. Acute hospital care is the chief driver of regional spending variation in Medicare patients with advanced cancer. Health Aff (Millwood). 2014;33(10):1793-1800. 2. Agency for Healthcare Research and Quality. Prevention Quality Indicators Overview. http://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx. Accessed October 2, 2014. 3. Brooks GA, Abrams TA, Meyerhardt JA, et al. Identification of potentially avoidable hospitalizations in patients with GI cancer. J Clin Oncol. 2014;32(6): 496-503.
CORRECTION Error in Byline: In the Original Investigation titled “Hereditary Diffuse Gastric Cancer Syndrome: CDH1 Mutations and Beyond” by Hansford et al, published online February 12, 2015, in JAMA Oncology (doi:10.1001/jamaoncol.2014.168), one of the author’s names in the byline was misspelled. The name should have appeared as Carla Oliveira, PhD. The error also occurred in the Author Affiliations and the Author Contributions. This article was corrected online.
Incorrect and Incomplete Table Headings: In the Original Investigation titled “Use of Electric Power Morcellation and Prevalence of Underlying Cancer in Women Who Undergo Myomectomy” posted online first in the February 19, 2015, issue of JAMA Oncology (doi:10.1001/jamaoncol.2014.206), headings were formatted incorrectly and incompletely in Table 1. The corrected second column heading, spanning 2 subcolumns, reads “Electric Power Morcellatora,” and its 2 subcolumn headings read, from left to right, “Not Used” and “Used.”
JAMA Oncology April 2015 Volume 1, Number 1 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://oncology.jamanetwork.com/ by a Florida Atlantic University User on 03/12/2016
jamaoncology.com
