July 8, 2019 Read Advisory Board's take: 6 ways to keep cancer patients out of the ED

Urgent care centers specifically designed for patients with cancer might reduce patients' ED utilization in the first six months of diagnosis, helping them avoid the risks associated with a hospital visit and lowering the overall cost of care, according to a study recently published in the Journal of Oncology Practice.

The birth of the cancer urgent care center

Adult cancer patients typically generate a high volume of unplanned ED visits for pain, nausea, and other issues during the first six months of their diagnosis, Christopher Cheney reports for HealthLeaders Media. In many of these cases, patients are hospitalized, which can disrupt their daily schedule and expose them to the risks of a hospital stay, Cheney reports. The visits also increase cancer care expenditures.

In an effort to improve care for cancer patients, a small number of hospitals, including University of Texas (UT) Southwestern Medical Center, have launched cancer-specific urgent care centers, according to Arthur Hong, lead author of the study and an assistant professor of internal medicine and clinical sciences at UT Southwestern.  

For the study, Hong and his colleagues sought to determine whether UT Southwestern's cancer-specific urgent care center, which launched in 2012, helped to reduced ED visits among 33,000 adult cancer patients who were diagnosed with cancer at a comprehensive cancer center between 2009 and 2016. The researchers looked at visits within 180 days of diagnosis.

Key findings

The researchers found that after the urgent care center opened, weekday ED visits among cancer patients dropped from 0.43 visits per 1,000 patient-months to 0.19 visits per 1,000 patient-months.

The researchers noted that while there was a drop in ED visits among cancer patients on weekdays, when the urgent care center was open, the trend did not hold true on weekends, when the urgent care center was closed. "This increases our confidence that the urgent care clinic was associated with a real reduction in ED visits when the clinic was open," the researchers wrote.

Discussion

"What patients really want is a trusted resource and an alternative to the ED because—anywhere you go in the country—there are untold hours you could wait at an ED," Hong said. "Patients also may be worried about being exposed to the dangerous infections that people have in an ED. An urgent care center checks off a lot of boxes in terms of what cancer patients are looking for."

For health systems that are thinking of launching a cancer urgent care, Hong said leaders should assess their patient population to see which services would be most helpful in an urgent care setting (Cheney, HealthLeaders Media, 7/1; Hong et al., PubMed.gov, accessed 7/3).

Advisory Board's take

6 ways to keep cancer patients out of the ED

Cancer programs across the country are growing increasingly focused on keeping patients out of the ED. Between reducing avoidable costs and delivering high-quality care, there are many reasons to do so. Even CMS is now tracking chemotherapy patients' use of the ED and hospital for ten specific symptoms as part of the Outpatient Quality Reporting Program.

However, success can often be elusive. To be able to manage patients' symptoms outside the ED, providers must know about them. Unfortunately, many patients are hesitant to report their symptoms or wait until they need immediate help because they don't know when or how to report these issues or, even more commonly, don't want to be seen as a "bad patient." Organizations have made symptom reporting easier for patients through:

  • Remote symptom monitoring: Allowing patients to self-report symptoms through online platforms or apps can dramatically decrease utilization and has even been shown to improve survival;
  • Standardized phone triage: Programs often tell patients to call with their symptoms, but must also be prepared to answer those calls and triage issues appropriately; and
  • Proactive support for high-risk patients: Providers can implement proactive support to the patients who need it most (rather than waiting until urgent needs arise) by understanding which physical, social, economic, behavioral, and treatment-related factors increase a patient's risk of winding up in the ED.

Even if programs focus on all of the above, there will still be times patients require immediate attention and may end up going to the ED. Therefore, it's critical that programs also prepare an urgent care strategy. To begin, programs should analyze their data to understand how many cancer patients go the ED, why they go, and when they go. Not all programs will have the volumes or resources to justify opening a dedicated clinic. But, there are various options for better managing urgent symptoms:

  • Flexible scheduling in which oncologists and/or advanced practitioners block a set amount of time in their schedules to see urgent add-on patients rather than scheduled patients;
  • Dedicated urgent need providers, often an advanced practitioner, who is dedicated at least part-time to treating patients with urgent needs; and
  • Urgent care centers in which organizations invest in dedicated space and providers to treat patients with urgent needs. Often, organizations repurpose underutilized inpatient space and start with limited hours to build the case for additional investment and resources.

No matter which strategy providers choose, they need to make sure there is clear messaging to both patients and clinicians about the benefits of managing symptoms outside the ED, and guidance on how to triage patient needs effectively. As shown by the UT Southwestern story, when done right, a proactive urgent care strategy can have an outsized impact on costs, quality, and patient experience.

To learn more, Oncology Roundtable members can download our research brief on How to Keep Your Cancer Patients Out of the ED.

Then all members should read our insight covering "Three successful models of emergency cancer care."

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