Nearly half of all intensive care unit hospitalizations among terminal oncology patients in a retrospective case review were identified as potentially avoidable.
The findings suggest a need for strategies to prospectively identify patients at risk for ICU admission and to formulate interventions to improve end-of-life care, wrote Bobby Daly, MD, and colleagues at the University of Chicago. The report was published in the Journal of Oncology Practice.
Dr. Bobby Daly
Of 72 terminal oncology patients who received care in a 600-bed academic medical center’s ambulatory oncology practice and died in an ICU between July 1, 2012, and June 30, 2013, within a week of transfer, 72% were men, 71% had solid tumor malignancies, and 51% had poor performance status (score of 2 or greater). The majority had multiple encounters with the health care system, but only 25% had a documented advance directive, the investigators found.
During a median ICU length of stay of 4 days, 82% of patients had a central line, 81% were intubated, 44% received a feeding tube, 39% received cardiopulmonary resuscitation, 22% began hemodialysis, and 8% received chemotherapy, while 6% had an inpatient palliative care consult, the researchers noted.
Notably, 47% of the ICU hospitalizations were determined to be potentially avoidable by at least two of three reviewers – an oncologist, an intensivist, and a hospitalist – and agreement between the reviewers was fair (kappa statistic, 0.24). Factors independently associated with avoidable hospitalizations on multivariable analysis were worse performance status prior to admission (median score, 2 vs. 1), worse Charlson comorbidity score (median, 8.5 vs. 7.0), number of hospitalizations in the previous 12 months (median, 2 vs. 1), and fewer days since the last outpatient oncology clinic visit (median 21 vs. 41 days). Having chemotherapy as the most recent treatment and cancer symptoms as the reason for hospitalization were also associated with potentially avoidable hospitalization (J Oncol Pract. 2016 Sep. doi: 10.1200/jop.2016.012823).
The findings are important because part of the reason for the increasing cost of cancer care in the United States, which is projected to increase by 27% over 2010 costs to $158 billion by 2020, is the increasingly aggressive care provided at the end of life, the investigators noted.
“Critically ill patients with cancer constitute a large percentage of ICU admissions, 25% of Medicare cancer beneficiaries receive ICU care in the last month of life, and 8% of patients with cancer die there,” they wrote.
Further, high-intensity end-of-life care has been shown in prior studies to improve neither survival nor quality of life for cancer patients.
In fact, the National Quality Forum “endorses ICU admissions in the last 30 days of life as a marker of poor-quality cancer care,” and other groups consider the proportion of patients with advanced cancer dying in the ICU as a quality-of-care metric, they said.
The current study was designed to explore the characteristics of oncology patients who expire in the ICU and the potential avoidability of their deaths there, and although the findings are limited by the single-center retrospective design and use of “subjective majority-driven medical record review,” they “serve to highlight terminal ICU hospitalization as an area of focus to improve the quality and value of cancer care,” the researchers wrote.
The findings also underscore the need for improved advance care planning, they added.
“Beyond the issues of cost and resource scarcity, these ICU deaths often create a traumatic experience for patients and families,” they wrote.
“Understanding these hospitalizations will contribute to the design of interventions aimed at avoiding unnecessary aggressive end-of-life care.”
Dr. Daly reported a leadership role with Quadrant Holdings and financial relationships with Quadrant Holdings, CVS Health, Johnson & Johnson, McKesson, and Walgreens Boots Alliance. Detailed disclosures for all authors are available with the full text of the article at jop.ascopubs.org.