Clinician Perspectives on Potentially Avoidable Hospitalizations in Patients With Cancer

Acute hospitalizations in patients with cancer are a major driver of the cost of cancer care, accounting for nearly one-half of advanced cancer spending.¹ Reducing acute hospitalizations is a potentially important strategy for improving the quality, value, and patient-centeredness of cancer care. The Agency for Healthcare Research and Quality² has endorsed a set of administrative measures to identify potentially avoidable hospitalizations; however, these measures do not apply to patients with cancer. We sought to evaluate the proportion of hospitalizations in patients with cancer that are viewed as potentially avoidable by clinicians directly involved in patient care.

The study was approved by the Dana-Farber/Harvard Cancer Center institutional review board. We studied patients with solid-tumor malignant neoplasms who were admitted to the medical oncology service at the Brigham and Women’s Hospital between May 2013 and January 2014. Eligible patients were aged 18 years or older and had 2 or more outpatient visits with a medical oncologist in the 6 months preceding hospitalization.

For each hospitalization, we conducted semistructured interviews with 3 clinicians from the patient’s medical care team, including the outpatient medical oncologist, the inpatient attending physician (also a medical oncologist), and the admitting resident physician or physician assistant. Clinicians gave oral consent for participation. Clinician interviews were required to be completed within 30 days of hospital admission, and the majority were completed within 14 days. Clinicians answered 2 questions regarding the avoidability of hospitalization: (1) On the day of admission, could the patient have been safely and effectively managed as an outpatient? and (2) Was hospitalization preventable with different medical management over the 30 days prior to admission? Responses of “probably” or “definitely” for either question were used to identify potentially avoidable hospitalizations. Interviewees answered additional questions about factors leading to hospitalization and patient psychosocial attributes.

The primary study outcome was the proportion of hospitalizations identified as potentially avoidable by 2 or more evaluators. Secondary analysis compared characteristics of patients who experienced potentially avoidable hospitalization with those who did not using the χ² test or the Wilcoxon nonparametric test.

Complete interview data from 3 clinician interviewees were obtained for 103 eligible hospitalizations. Eighty-one patients (79%) had metastatic cancer, and additional patient characteristics are shown in the Table. Twenty-four hospitalizations (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).

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 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.

Corresponding Author: Gabriel A. Brooks, MD, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 (gabriel_brooks@dfci.harvard.edu).

Published Online: February 12, 2015. doi:10.1001/jamaoncol.2014.155.

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.