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Outcomes After Referral for Acute Inpatient Rehabilitation in Hospitalized Patients With Cancer
Vol. 50 No. 4 October 2015
Journal of Pain and Symptom Management
e1
Letter
Outcomes After Referral for Acute Inpatient Rehabilitation in Hospitalized Patients With Cancer To the Editor: Patients with cancer suffer declines in functional status for a variety of reasons, including progression of disease, exacerbations of noncancer conditions, and adverse effects of treatment, which can lead to hospitalization for acute care.1 When this occurs, cancer treatment plans often must be adjusted as risks of further decline may outweigh the benefits of ongoing therapy. Providers often refer patients for intensive rehabilitation services, such as acute inpatient rehabilitation, to help them improve function, independence, and quality of life, and to potentially allow for further cancer treatment.2 These services can be valuable for selected patients with good prognosis and clear precipitating factors for functional decline that can be addressed.3 However, for patients with cancer who are approaching the end of life, a decline in functional status may be a natural part of the dying process. For those who only have limited time left, spending that time focused on the unrealistic goal of improving function, especially if rehabilitation care is provided in a facility, may cause unnecessary burden and discomfort and impede other important goals, such as improving comfort and spending time at home and with family. Physicians often do not discuss prognosis or overestimate prognosis with patients,4 and because decreased performance status is associated with ineligibility for chemotherapy, physicians often discuss rehabilitation as the mechanism for obtaining future chemotherapy. The outcomes of referrals from inpatient medical oncology units to acute inpatient rehabilitation, particularly the likelihood that a patient will achieve the goal of continued chemotherapy, and the survival of patients who are referred to these services, have not been previously evaluated. The objectives of this study were to evaluate the frequency of administration of further chemotherapy and the mortality at 180 days among patients with Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
cancer referred for acute inpatient rehabilitation from an inpatient oncology unit. The goal of this work was to delineate outcomes of acute inpatient rehabilitation so that referring providers and patients can be better informed about the likelihood of benefits of rehabilitation care.
Methods We conducted a retrospective study of outcomes of medical oncology referrals to acute inpatient rehabilitation. The Patient and Family Services department tracks referrals for placement in an acute rehabilitation unit for inpatients on the medical oncology service at the Weinberg Cancer Center at Johns Hopkins. We reviewed electronic medical records for patients referred during calendar year 2012 with follow-up through March 2014, 15 months after the end of the data accrual period. For patients who had multiple referrals, only data from the first referral were used. We collected data on age, sex, race, cancer diagnosis, documentation of chemotherapy treatment at Johns Hopkins after referral for acute rehabilitation, and date of death. Mortality at 180 days was calculated from the date of acute rehabilitation referral. We conducted descriptive analyses of all variables.
Results A total of 43 individual patients were referred for acute rehabilitation in 2012. Of these, 33 (76.7%) were actually discharged to an acute rehabilitation facility. Nine (20.9%) were discharged home, and one (2.3%) died in the hospital before discharge (Fig. 1). Characteristics for all patients referred were median age 65 years; 30 (69.8%) were male; 32 (74.4%) were whites, nine (20.9%) were blacks, two (4.7%) had race listed as other; 26 (60.5%) had a hematologic malignancy, and 17 (39.5%) had a solid tumor, five (11.6%) of which were primary brain tumors (excluding central nervous system lymphoma, which is included with the hematologic malignancies). Of the patients who completed a course of acute rehabilitation, 17 (51.5%) received further chemotherapy 0885-3924/$ - see front matter
e2
Letter
Vol. 50 No. 4 October 2015
Fig. 1. Outcomes for patients with cancer referred for acute rehabilitation from an inpatient medical oncology unit.
after their acute rehabilitation and 16 (48.5%) did not receive any further chemotherapy. Mortality at 180 days for this group overall was 54.5% (18 of 33). For patients who received chemotherapy, mortality at 180 days was 29.4% (5 of 17). For patients who did not receive chemotherapy, mortality at 180 days was 81.3% (13 of 16) (Fig. 1).
Discussion Hospitalized medical oncology patients who are referred for acute inpatient rehabilitation are felt to be strong enough to complete a minimum of three hours of physical therapy, occupational therapy, or speech therapy (or some combination of these) per day, with the expectation that they will be returning home after their course of treatment. In this mixed population of patients admitted to an inpatient oncology unit during the course of treatment for malignancy who were considered for acute inpatient rehabilitation, approximately 75% were actually transferred to an inpatient rehabilitation unit. Of these, roughly 50% received further chemotherapy after their rehabilitation treatment. As a comparison, we previously found at our cancer center that, after a course of subacute rehabilitation, only 4% (one of 25) received further chemotherapy.5 Mortality at 180 days for the acute rehabilitation group overall was also roughly 50%. (If this prognosis had been clear at the time of that decision, it would have made them eligible for hospice enrollment.) Although hematologic malignancy patients had slightly lower mortality than those with solid tumor disease (35% at 180 days), there was still a large proportion of patients
who would have benefited from a discussion of palliative care or hospice at the time of referral. Rehabilitation care is not contraindicated in those patients who choose to forgo further antineoplastic treatment in favor of symptom management under the auspices of palliative care or hospice. For some patients, an improvement in functional status will confer an improved quality of life and an ability to remain at home at the end of life, which is exactly in line with the goals of hospice and palliative care. It is important for patients to explicitly understand the goals of their acute inpatient rehabilitation care so that they may participate fully in the decision about which treatment to undergo. Any time that the course of a patient’s illness changes, which is often marked by a change in the venue in which they are receiving care, a discussion of goals, prognosis, and options is appropriate. If these discussions are held regularly from the time of the initial diagnosis of a potentially life limiting illness, it is easier to revisit and review patients’ understanding of where they are in the course of their disease and where they expect to be next.
Limitations The limitations of a small retrospective study are many. In particular, because data were not consistently available in the medical record, we could not include the functional status of patients at various times during their illness, whether the intent of the chemotherapy (curative versus palliative) was explicitly discussed, or the patients’ understanding of this information. Also, without consistent documentation of conversations about the goals of acute rehabilitation, we could not determine what patients and
Vol. 50 No. 4 October 2015
Letter
physicians understood about this choice and whether further chemotherapy was an explicit goal.
e3
Sydney M. Dy, MD, MSc Johns Hopkins School of Public Health Baltimore, Maryland, USA http://dx.doi.org/10.1016/j.jpainsymman.2015.07.006
Conclusions In this retrospective study, patients with cancer referred for acute inpatient rehabilitation during admission to a medical oncology unit had a high rate of mortality at 180 days, and only half received further chemotherapy. When referrals to inpatient rehabilitation are made, discussions about palliative care and hospice are appropriate and should be considered. Future research should explore predictors of outcomes after acute inpatient rehabilitation and also evaluate the patient-therapist-physician communication and decision-making process, to evaluate how those patients who chose to have acute rehabilitation (and their oncologists) were expecting to benefit by improved survival, the ability to receive further chemotherapy, and/or an improvement in functional status so that they might return home at the end of life. Isaac M. Bromberg, MD Baystate Medical Center Springfield, Massachusetts, USA E-mail: [email protected] Louise Knight, MSW, LCSW-C, OSW-C Sidney Kimmel Cancer Center Johns Hopkins Hospital Baltimore, Maryland, USA
Disclosures and Acknowledgments This research received no specific funding grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest.
References 1. Hoppe S, Rainfray M, Fonck M, et al. Functional decline in older patients with cancer receiving first-line chemotherapy. J Clin Oncol 2013;31:3877e3882. 2. Shin KY, Gou Y, Konzen B, et al. Inpatient cancer rehabilitation: the experience of a National Comprehensive Cancer Center. Am J Phys Med Rehabil 2011;90: S63eS68. 3. Swenson KK, Nissen MJ, Knippenberg K, et al. Cancer rehabilitation: outcome evaluation of a strengthening and conditioning program. Cancer Nurs 2014;37:162e169. 4. Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 2001;134:1096e1105. 5. Dy SM, List DJ, Barbe C, Knight L. A quality improvement initiative for improving appropriateness of referrals from a cancer center to subacute rehabilitation. J Pain Symptom Manage 2013;48:127e131.
Journal of Pain and Symptom Management
e1
Letter
Outcomes After Referral for Acute Inpatient Rehabilitation in Hospitalized Patients With Cancer To the Editor: Patients with cancer suffer declines in functional status for a variety of reasons, including progression of disease, exacerbations of noncancer conditions, and adverse effects of treatment, which can lead to hospitalization for acute care.1 When this occurs, cancer treatment plans often must be adjusted as risks of further decline may outweigh the benefits of ongoing therapy. Providers often refer patients for intensive rehabilitation services, such as acute inpatient rehabilitation, to help them improve function, independence, and quality of life, and to potentially allow for further cancer treatment.2 These services can be valuable for selected patients with good prognosis and clear precipitating factors for functional decline that can be addressed.3 However, for patients with cancer who are approaching the end of life, a decline in functional status may be a natural part of the dying process. For those who only have limited time left, spending that time focused on the unrealistic goal of improving function, especially if rehabilitation care is provided in a facility, may cause unnecessary burden and discomfort and impede other important goals, such as improving comfort and spending time at home and with family. Physicians often do not discuss prognosis or overestimate prognosis with patients,4 and because decreased performance status is associated with ineligibility for chemotherapy, physicians often discuss rehabilitation as the mechanism for obtaining future chemotherapy. The outcomes of referrals from inpatient medical oncology units to acute inpatient rehabilitation, particularly the likelihood that a patient will achieve the goal of continued chemotherapy, and the survival of patients who are referred to these services, have not been previously evaluated. The objectives of this study were to evaluate the frequency of administration of further chemotherapy and the mortality at 180 days among patients with Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
cancer referred for acute inpatient rehabilitation from an inpatient oncology unit. The goal of this work was to delineate outcomes of acute inpatient rehabilitation so that referring providers and patients can be better informed about the likelihood of benefits of rehabilitation care.
Methods We conducted a retrospective study of outcomes of medical oncology referrals to acute inpatient rehabilitation. The Patient and Family Services department tracks referrals for placement in an acute rehabilitation unit for inpatients on the medical oncology service at the Weinberg Cancer Center at Johns Hopkins. We reviewed electronic medical records for patients referred during calendar year 2012 with follow-up through March 2014, 15 months after the end of the data accrual period. For patients who had multiple referrals, only data from the first referral were used. We collected data on age, sex, race, cancer diagnosis, documentation of chemotherapy treatment at Johns Hopkins after referral for acute rehabilitation, and date of death. Mortality at 180 days was calculated from the date of acute rehabilitation referral. We conducted descriptive analyses of all variables.
Results A total of 43 individual patients were referred for acute rehabilitation in 2012. Of these, 33 (76.7%) were actually discharged to an acute rehabilitation facility. Nine (20.9%) were discharged home, and one (2.3%) died in the hospital before discharge (Fig. 1). Characteristics for all patients referred were median age 65 years; 30 (69.8%) were male; 32 (74.4%) were whites, nine (20.9%) were blacks, two (4.7%) had race listed as other; 26 (60.5%) had a hematologic malignancy, and 17 (39.5%) had a solid tumor, five (11.6%) of which were primary brain tumors (excluding central nervous system lymphoma, which is included with the hematologic malignancies). Of the patients who completed a course of acute rehabilitation, 17 (51.5%) received further chemotherapy 0885-3924/$ - see front matter
e2
Letter
Vol. 50 No. 4 October 2015
Fig. 1. Outcomes for patients with cancer referred for acute rehabilitation from an inpatient medical oncology unit.
after their acute rehabilitation and 16 (48.5%) did not receive any further chemotherapy. Mortality at 180 days for this group overall was 54.5% (18 of 33). For patients who received chemotherapy, mortality at 180 days was 29.4% (5 of 17). For patients who did not receive chemotherapy, mortality at 180 days was 81.3% (13 of 16) (Fig. 1).
Discussion Hospitalized medical oncology patients who are referred for acute inpatient rehabilitation are felt to be strong enough to complete a minimum of three hours of physical therapy, occupational therapy, or speech therapy (or some combination of these) per day, with the expectation that they will be returning home after their course of treatment. In this mixed population of patients admitted to an inpatient oncology unit during the course of treatment for malignancy who were considered for acute inpatient rehabilitation, approximately 75% were actually transferred to an inpatient rehabilitation unit. Of these, roughly 50% received further chemotherapy after their rehabilitation treatment. As a comparison, we previously found at our cancer center that, after a course of subacute rehabilitation, only 4% (one of 25) received further chemotherapy.5 Mortality at 180 days for the acute rehabilitation group overall was also roughly 50%. (If this prognosis had been clear at the time of that decision, it would have made them eligible for hospice enrollment.) Although hematologic malignancy patients had slightly lower mortality than those with solid tumor disease (35% at 180 days), there was still a large proportion of patients
who would have benefited from a discussion of palliative care or hospice at the time of referral. Rehabilitation care is not contraindicated in those patients who choose to forgo further antineoplastic treatment in favor of symptom management under the auspices of palliative care or hospice. For some patients, an improvement in functional status will confer an improved quality of life and an ability to remain at home at the end of life, which is exactly in line with the goals of hospice and palliative care. It is important for patients to explicitly understand the goals of their acute inpatient rehabilitation care so that they may participate fully in the decision about which treatment to undergo. Any time that the course of a patient’s illness changes, which is often marked by a change in the venue in which they are receiving care, a discussion of goals, prognosis, and options is appropriate. If these discussions are held regularly from the time of the initial diagnosis of a potentially life limiting illness, it is easier to revisit and review patients’ understanding of where they are in the course of their disease and where they expect to be next.
Limitations The limitations of a small retrospective study are many. In particular, because data were not consistently available in the medical record, we could not include the functional status of patients at various times during their illness, whether the intent of the chemotherapy (curative versus palliative) was explicitly discussed, or the patients’ understanding of this information. Also, without consistent documentation of conversations about the goals of acute rehabilitation, we could not determine what patients and
Vol. 50 No. 4 October 2015
Letter
physicians understood about this choice and whether further chemotherapy was an explicit goal.
e3
Sydney M. Dy, MD, MSc Johns Hopkins School of Public Health Baltimore, Maryland, USA http://dx.doi.org/10.1016/j.jpainsymman.2015.07.006
Conclusions In this retrospective study, patients with cancer referred for acute inpatient rehabilitation during admission to a medical oncology unit had a high rate of mortality at 180 days, and only half received further chemotherapy. When referrals to inpatient rehabilitation are made, discussions about palliative care and hospice are appropriate and should be considered. Future research should explore predictors of outcomes after acute inpatient rehabilitation and also evaluate the patient-therapist-physician communication and decision-making process, to evaluate how those patients who chose to have acute rehabilitation (and their oncologists) were expecting to benefit by improved survival, the ability to receive further chemotherapy, and/or an improvement in functional status so that they might return home at the end of life. Isaac M. Bromberg, MD Baystate Medical Center Springfield, Massachusetts, USA E-mail: [email protected] Louise Knight, MSW, LCSW-C, OSW-C Sidney Kimmel Cancer Center Johns Hopkins Hospital Baltimore, Maryland, USA
Disclosures and Acknowledgments This research received no specific funding grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest.
References 1. Hoppe S, Rainfray M, Fonck M, et al. Functional decline in older patients with cancer receiving first-line chemotherapy. J Clin Oncol 2013;31:3877e3882. 2. Shin KY, Gou Y, Konzen B, et al. Inpatient cancer rehabilitation: the experience of a National Comprehensive Cancer Center. Am J Phys Med Rehabil 2011;90: S63eS68. 3. Swenson KK, Nissen MJ, Knippenberg K, et al. Cancer rehabilitation: outcome evaluation of a strengthening and conditioning program. Cancer Nurs 2014;37:162e169. 4. Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 2001;134:1096e1105. 5. Dy SM, List DJ, Barbe C, Knight L. A quality improvement initiative for improving appropriateness of referrals from a cancer center to subacute rehabilitation. J Pain Symptom Manage 2013;48:127e131.