- Email: [email protected]
Characteristics and Outcomes of Patients Admitted to the Acute Palliative Care Unit From the Emergency Center
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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
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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)
<0.0001a
249 (41) 334 (55) 27 (4)
137 (44) 168 (54) 7 (2)
112 (38) 166 (56) 20 (7)
0.0142a
397 82 68 63
196 46 33 37
201 36 35 26
(67) (12) (12) (9)
0.4034a
0.0002b
(65) (13) (11) (10)
(63) (15) (11) (12)
8.0 (7.6e8.4)
8.4 (8.0e8.9)
7.6 (7.0e8.2)
5.1 6.5 2.2 3.3 4.0 4.4 5.6 5.3 3.6 4.5
5.6 6.7 2.7 3.2 4.0 4.7 5.5 5.4 3.4 4.8
4.6 6.1 1.6 3.3 4.0 4.1 5.7 5.1 3.8 4.2
(4.8e5.4) (6.2e6.7) (2.0e2.5) (3.0e3.5) (3.7e4.3) (4.1e4.7) (5.3e5.9) (5.0e5.5) (3.3e3.9) (4.3e4.8)
(5.2e5.9) (6.4e7.0) (2.4e3.1) (2.9e3.6) (3.6e4.4) (4.3e5.0) (5.1e5.9) (5.0e5.7) (3.1e3.8) (4.5e5.2)
(4.2e5.0) (5.8e6.5) (1.3e1.9) (2.9e3.7) (3.5e4.4) (3.7e4.5) (5.2e6.1) (4.6e5.5) (3.3e4.2) (3.8e4.6)
0.0004b 0.0049b <0.0001b 0.9860b 0.7750b 0.0748b 0.6963b 0.1793b 0.3112b 0.0299b
CI ¼ confidence interval; APCU ¼ acute palliative care unit; ESAS ¼ Edmonton Symptom Assessment Scale. Statistically significant results are given in boldface type. a Fisher’s exact test. b Kruskal-Wallis test. c Chi-square test.
A previous study reported significant racial differences in the rates of terminal chemotherapy and late hospice enrollment.26 Nonwhite patients also have been reported to receive more aggressive care than white patients, and to have more EC and intensive care unit admissions, more in-hospital deaths, and lower rates of hospice enrollment.27 Our findings are consistent with those of previous studies (Table 3).
Related to cancer diagnosis, 95% of the patients from the EC had solid tumors and 5% had hematologic malignancies. Growing research evidence indicates that patients with hematologic malignancies are not receiving appropriate or timely referrals to the palliative care system.28e31 In this study, hematologic malignancy was associated with a lower likelihood of admission from the EC. Hematologic
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Fig. 1. Overall survival by product-limit survival estimates with number of subjects at risk. Kaplan-Meier survival curves for patients who were admitted to advanced palliative care unit. The log-rank test was used to compare the survival times between groups. EC ¼ emergency center; IP ¼ inpatient.
malignancy was a significant predictor of inpatient mortality in the univariate analysis and, therefore, was considered in the logistic regression model. However, hematologic malignancy did not reach statistical significance in the multivariate analysis. Decisions regarding the discharge of patients are complex.11 A prospective study of 100 palliative care patients found that younger age, married status, good performance status, and good cognitive status were key determinants of the likelihood of home discharge.32 Our results indicate that admission from an EC may be associated with increased likelihood of home discharge. In another study, 33% of APCU patients died during their stay and the six month survival rate was 22%.11 Our results showed that median survival times from admission to APCU were 35 and 31 days for EC
patients and transferred inpatients, respectively. In multivariate analysis, we found that EC admission, well-being, dyspnea, and delirium were associated with discharge status. The EC admission and delirium were major predictors of status at discharge. A few previous studies reported that delirium was associated with dying in the hospital.13,33 The results of our study showed the same findings. Delirium is a well-established prognostic factor.33 Many patients with delirium require high-dose neuroleptics or palliative sedation and thereby are more likely to die in the hospital. Related to admission source, one possible explanation for the lower percentage of inpatients discharged alive compared with the corresponding percentage of EC patients is that clinical complications may have been treated unsuccessfully by the oncology team before the patients were
Table 2 Final Parsimonious Modela Predicting Status at Discharge Odds Ratio Estimates (c-Statistic ¼ 0.72) Effect Group (EC vs. IP) Delirium (yes vs. no) Well-being (per point increase) Dyspnea (per point increase)
OR
95% Wald Confidence Limits
P-Value
1.8593 0.3942 1.1192 0.8533
1.153e2.996 0.244e0.635 1.023e1.225 0.789e0.921
0.0338 0.0003 0.0160 0.0004
c-statistic ¼ concordance statistic; OR ¼ odds ratio of those alive at discharge as compared with odds ratio of those dead at discharge; EC ¼ emergency center; IP ¼ inpatient transfer. a Adjusted for gender, race, insurance status, and cancer diagnosis.
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Table 3 HR for Variables Predicting Survival After Discharge Alive Based on Multivariate Logistic Regressiona Effect Group (EC vs. IP) Drowsiness (per point increase) Well-being (per point increase) Delirium (yes vs. no)
HR
P-Value (c2)
0.7484 1.0761 0.9486 1.4062
0.0403 0.0014 0.0261 0.0154
HR ¼ hazard ratio; EC ¼ emergency center; IP ¼ inpatient transfer. a Adjusted for gender, race, insurance, and cancer diagnosis.
transferred to the APCU. Possible complications include delirium, hypercalcemia, sepsis, thromboembolic disease, renal failure, and congestive heart failure. In contrast, patients admitted directly from an EC can receive appropriate treatment for the first time in the APCU setting; as a result, the likelihood of meeting the criteria for being discharged alive is higher than that for transferred inpatients. The difference between the discharge rates of the two patient groups needs to be investigated further. In interpreting this study’s findings, several limitations need to be taken into account. First, the retrospective nature of this study limited the data that were collected, and some important clinical variables were not documented clearly for our cohort. Second, the study was confined to a single APCU in a comprehensive cancer center, which serves a unique patient population. Infrastructural and administrative parameters, clinical practices, and patient populations may vary considerably between different APCU facilities. Third, performance status, a particularly important determinant of clinical outcome and survival, was not available in this study. In summary, patients admitted to the APCU from the EC had higher levels of pain, fatigue, nausea, and sleep disturbance and a lower rate of dying in the hospital than rates for transferred inpatients. The APCU was successful at facilitating the discharge of both inpatients and EC patients to the community although the EC patients had more severe symptoms on admission.
Disclosures and Acknowledgments Dr. E. B. is supported in part by National Institutes of Health grants RO1NR010162-01A1, RO1CA122292-01, and RO1CA124481-01. Dr.
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D. H. is supported in part by an institutional start-up grant (#18075582). This study also was supported by the M. D. Anderson Cancer Center Support Grant (CA 016672). The funding sources were not involved in the conduct of the study or development of the submission. The authors declare no conflicts of interest. We thank Arthur Gelmis in the Department of Scientific Publications at M. D. Anderson Cancer Center for his valuable editorial assistance.
References 1. Elsayem A, Smith ML, Parmley L, et al. Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center. J Palliat Med 2006;9:894e902. 2. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA 1998;279: 1877e1882. 3. Jones JM, McPherson CJ, Zimmermann C, et al. Assessing agreement between terminally ill cancer patients’ reports of their quality of life and family caregiver and palliative care physician proxy ratings. J Pain Symptom Manage 2011;42:354e365. 4. Bruera E, Neumann C, Brenneis C, et al. Frequency of symptom distress and poor prognostic indicators in palliative cancer patients admitted to a tertiary palliative care unit, hospices, and acute care hospitals. J Palliat Care 2000;16:16e21. 5. Nakano K, Yoshida T, Furutama J, et al. Quality of end-of-life care for patients with metastatic nonsmall-cell lung cancer in general wards and palliative care units in Japan. Support Care Cancer 2012;20:883e888. 6. Al-Kindi SG, Zeinah GF, Hassan AA. Pattern of hospitalization of patients with cancer in an acute palliative care setting: Qatar’s experience. Am J Hosp Palliat Care 2013;30:25e28. 7. Mercadante S, Porzio G, Valle A, et al. Emergencies in patients with advanced cancer followed at home. J Pain Symptom Manage 2012;44:295e300. 8. Ahn S, Lee YS, Lim KS, et al. Emergency department cancer unit and management of oncologic emergencies: experience in Asan Medical Center. Support Care Cancer 2012;20:2205e2210. 9. Rigby A, Krzyzanowska M, Le LW, et al. Impact of opening an acute palliative care unit on administrative outcomes for a general oncology ward. Cancer 2008;113:3267e3274. 10. Tse DM, Chan KS, Lam WM, et al. The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths. Palliat Med 2007;21:425e433.
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11. Hui D, Elsayem A, Palla S, et al. Discharge outcomes and survival of patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center. J Palliat Med 2010;13:49e57. 12. Bruera E, Hui D. Conceptual models for integrating palliative care at cancer centers. J Palliat Med 2012;15:1261e1269. 13. Mori M, Parsons HA, De la Cruz M, et al. Changes in symptoms and inpatient mortality: a study in advanced cancer patients admitted to an acute palliative care unit in a comprehensive cancer center. J Palliat Med 2011;14:1034e1041. 14. Elsayem A, Calderon BB, Camarines EM, et al. A month in an acute palliative care unit: clinical interventions and financial outcomes. Am J Hosp Palliat Care 2011;28:550e555. 15. Carneiro R, Barbedo I, Costa I, et al. Estudo comparativo dos cuidados prestados a doentes nos u ltimos dias de vida. [Article in Portuguese]. Acta Med Port 2011;24:545e554. 16. Lagman R, Rivera N, Walsh D, et al. Acute inpatient palliative medicine in a cancer center: clinical problems and medical interventionsea prospective study. Am J Hosp Palliat Care 2007;24:20e28. 17. Jones JM, Cohen SR, Zimmermann C, et al. Quality of life and symptom burden in cancer patients admitted to an acute palliative care unit. J Palliat Care 2010;26:94e102. 18. Elsayem A, Mori M, Parsons HA, et al. Predictors of inpatient mortality in an acute palliative care unit at a comprehensive cancer center. Support Care Cancer 2010;18:67e76. 19. Bryson J, Coe G, Swami N, et al. Administrative outcomes five years after opening an acute palliative care unit at a comprehensive cancer center. J Palliat Med 2010;13:559e565.
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22. Lawlor PG, Fainsinger RL, Bruera ED. Delirium at the end of life: critical issues in clinical practice and research. JAMA 2000;284:2427e2429. 23. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med 2000;160:786e794. 24. Lawlor PG, Bruera ED. Delirium in patients with advanced cancer. Hematol Oncol Clin North Am 2002;16:701e714. 25. Bruera E, Bush SH, Willey J, et al. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 2009;115:2004e2012. 26. Miesfeldt S, Murray K, Lucas L, et al. Association of age, gender, and race with intensity of endof-life care for Medicare beneficiaries with cancer. J Palliat Med 2012;15:548e554. 27. Pritchard RS, Fisher ES, Teno JM, et al. Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment. J Am Geriatr Soc 1998;46:1242e1250. 28. McGrath P. Palliative care for patients with hematological malignancieseif not, why not? J Palliat Care 1999;15:24e30. 29. McGrath P, Leahy M. Catastrophic bleeds during end-of-life care in haematology: controversies from Australian research. Support Care Cancer 2009;17:527e537. 30. McGrath P. End-of-life care for hematological malignancies: the ‘technological imperative’ and palliative care. J Palliat Care 2002;18:39e47. 31. McGrath P, Holewa H. Missed opportunities: nursing insights on end-of-life care for haematology patients. Int J Nurs Pract 2006;12:295e301.
20. Fadul N, Elsayem A, Palmer JL, et al. Predictors of access to palliative care services among patients who died at a Comprehensive Cancer Center. J Palliat Med 2007;10:1146e1152.
32. Fainsinger RL, Demoissac D, Cole J, et al. Home versus hospice inpatient care: discharge characteristics of palliative care patients in an acute care hospital. J Palliat Care 2000;16:29e34.
21. Bruera E, Kuehn N, Miller MJ, et al. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7:6e9.
33. Hui D, Kilgore K, Fellman B, et al. Development and cross-validation of the in-hospital mortality prediction in advanced cancer patients score: a preliminary study. J Palliat Med 2012;15:902e909.
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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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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
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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)
<0.0001a
249 (41) 334 (55) 27 (4)
137 (44) 168 (54) 7 (2)
112 (38) 166 (56) 20 (7)
0.0142a
397 82 68 63
196 46 33 37
201 36 35 26
(67) (12) (12) (9)
0.4034a
0.0002b
(65) (13) (11) (10)
(63) (15) (11) (12)
8.0 (7.6e8.4)
8.4 (8.0e8.9)
7.6 (7.0e8.2)
5.1 6.5 2.2 3.3 4.0 4.4 5.6 5.3 3.6 4.5
5.6 6.7 2.7 3.2 4.0 4.7 5.5 5.4 3.4 4.8
4.6 6.1 1.6 3.3 4.0 4.1 5.7 5.1 3.8 4.2
(4.8e5.4) (6.2e6.7) (2.0e2.5) (3.0e3.5) (3.7e4.3) (4.1e4.7) (5.3e5.9) (5.0e5.5) (3.3e3.9) (4.3e4.8)
(5.2e5.9) (6.4e7.0) (2.4e3.1) (2.9e3.6) (3.6e4.4) (4.3e5.0) (5.1e5.9) (5.0e5.7) (3.1e3.8) (4.5e5.2)
(4.2e5.0) (5.8e6.5) (1.3e1.9) (2.9e3.7) (3.5e4.4) (3.7e4.5) (5.2e6.1) (4.6e5.5) (3.3e4.2) (3.8e4.6)
0.0004b 0.0049b <0.0001b 0.9860b 0.7750b 0.0748b 0.6963b 0.1793b 0.3112b 0.0299b
CI ¼ confidence interval; APCU ¼ acute palliative care unit; ESAS ¼ Edmonton Symptom Assessment Scale. Statistically significant results are given in boldface type. a Fisher’s exact test. b Kruskal-Wallis test. c Chi-square test.
A previous study reported significant racial differences in the rates of terminal chemotherapy and late hospice enrollment.26 Nonwhite patients also have been reported to receive more aggressive care than white patients, and to have more EC and intensive care unit admissions, more in-hospital deaths, and lower rates of hospice enrollment.27 Our findings are consistent with those of previous studies (Table 3).
Related to cancer diagnosis, 95% of the patients from the EC had solid tumors and 5% had hematologic malignancies. Growing research evidence indicates that patients with hematologic malignancies are not receiving appropriate or timely referrals to the palliative care system.28e31 In this study, hematologic malignancy was associated with a lower likelihood of admission from the EC. Hematologic
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Fig. 1. Overall survival by product-limit survival estimates with number of subjects at risk. Kaplan-Meier survival curves for patients who were admitted to advanced palliative care unit. The log-rank test was used to compare the survival times between groups. EC ¼ emergency center; IP ¼ inpatient.
malignancy was a significant predictor of inpatient mortality in the univariate analysis and, therefore, was considered in the logistic regression model. However, hematologic malignancy did not reach statistical significance in the multivariate analysis. Decisions regarding the discharge of patients are complex.11 A prospective study of 100 palliative care patients found that younger age, married status, good performance status, and good cognitive status were key determinants of the likelihood of home discharge.32 Our results indicate that admission from an EC may be associated with increased likelihood of home discharge. In another study, 33% of APCU patients died during their stay and the six month survival rate was 22%.11 Our results showed that median survival times from admission to APCU were 35 and 31 days for EC
patients and transferred inpatients, respectively. In multivariate analysis, we found that EC admission, well-being, dyspnea, and delirium were associated with discharge status. The EC admission and delirium were major predictors of status at discharge. A few previous studies reported that delirium was associated with dying in the hospital.13,33 The results of our study showed the same findings. Delirium is a well-established prognostic factor.33 Many patients with delirium require high-dose neuroleptics or palliative sedation and thereby are more likely to die in the hospital. Related to admission source, one possible explanation for the lower percentage of inpatients discharged alive compared with the corresponding percentage of EC patients is that clinical complications may have been treated unsuccessfully by the oncology team before the patients were
Table 2 Final Parsimonious Modela Predicting Status at Discharge Odds Ratio Estimates (c-Statistic ¼ 0.72) Effect Group (EC vs. IP) Delirium (yes vs. no) Well-being (per point increase) Dyspnea (per point increase)
OR
95% Wald Confidence Limits
P-Value
1.8593 0.3942 1.1192 0.8533
1.153e2.996 0.244e0.635 1.023e1.225 0.789e0.921
0.0338 0.0003 0.0160 0.0004
c-statistic ¼ concordance statistic; OR ¼ odds ratio of those alive at discharge as compared with odds ratio of those dead at discharge; EC ¼ emergency center; IP ¼ inpatient transfer. a Adjusted for gender, race, insurance status, and cancer diagnosis.
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Table 3 HR for Variables Predicting Survival After Discharge Alive Based on Multivariate Logistic Regressiona Effect Group (EC vs. IP) Drowsiness (per point increase) Well-being (per point increase) Delirium (yes vs. no)
HR
P-Value (c2)
0.7484 1.0761 0.9486 1.4062
0.0403 0.0014 0.0261 0.0154
HR ¼ hazard ratio; EC ¼ emergency center; IP ¼ inpatient transfer. a Adjusted for gender, race, insurance, and cancer diagnosis.
transferred to the APCU. Possible complications include delirium, hypercalcemia, sepsis, thromboembolic disease, renal failure, and congestive heart failure. In contrast, patients admitted directly from an EC can receive appropriate treatment for the first time in the APCU setting; as a result, the likelihood of meeting the criteria for being discharged alive is higher than that for transferred inpatients. The difference between the discharge rates of the two patient groups needs to be investigated further. In interpreting this study’s findings, several limitations need to be taken into account. First, the retrospective nature of this study limited the data that were collected, and some important clinical variables were not documented clearly for our cohort. Second, the study was confined to a single APCU in a comprehensive cancer center, which serves a unique patient population. Infrastructural and administrative parameters, clinical practices, and patient populations may vary considerably between different APCU facilities. Third, performance status, a particularly important determinant of clinical outcome and survival, was not available in this study. In summary, patients admitted to the APCU from the EC had higher levels of pain, fatigue, nausea, and sleep disturbance and a lower rate of dying in the hospital than rates for transferred inpatients. The APCU was successful at facilitating the discharge of both inpatients and EC patients to the community although the EC patients had more severe symptoms on admission.
Disclosures and Acknowledgments Dr. E. B. is supported in part by National Institutes of Health grants RO1NR010162-01A1, RO1CA122292-01, and RO1CA124481-01. Dr.
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D. H. is supported in part by an institutional start-up grant (#18075582). This study also was supported by the M. D. Anderson Cancer Center Support Grant (CA 016672). The funding sources were not involved in the conduct of the study or development of the submission. The authors declare no conflicts of interest. We thank Arthur Gelmis in the Department of Scientific Publications at M. D. Anderson Cancer Center for his valuable editorial assistance.
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