Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments

Jeffrey M. Caterino, David Adler, Danielle D. Durham, Sai Ching Jim Yeung, Matthew F. Hudson, Aveh Bastani, Steven L. Bernstein, Christopher W. Baugh, Christopher J. Coyne, Corita R. Grudzen, Daniel J. Henning, Adam Klotz, Troy E. Madsen, Daniel J. Pallin, Cielito C. Reyes-Gibby, Juan Felipe Rico, Richard J. Ryan, Nathan I. Shapiro, Robert Swor, Arvind Venkat & 4 others Jason Wilson, Charles Thomas, Jason J. Bischof, Gary H. Lyman

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Abstract

Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

Original languageEnglish (US)
Pages (from-to)e190979
JournalJAMA network open
Volume2
Issue number3
DOIs
StatePublished - Mar 1 2019

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Patient Admission
Hospital Emergency Service
Neoplasms
Pain
Length of Stay
Outpatients
Anti-Bacterial Agents
Nausea
Opioid Analgesics
Emergencies
Prospective Studies
Benchmarking
Antiemetics
Emergency Treatment
Emergency Medical Services

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Caterino, J. M., Adler, D., Durham, D. D., Yeung, S. C. J., Hudson, M. F., Bastani, A., ... Lyman, G. H. (2019). Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. JAMA network open, 2(3), e190979. https://doi.org/10.1001/jamanetworkopen.2019.0979

Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. / Caterino, Jeffrey M.; Adler, David; Durham, Danielle D.; Yeung, Sai Ching Jim; Hudson, Matthew F.; Bastani, Aveh; Bernstein, Steven L.; Baugh, Christopher W.; Coyne, Christopher J.; Grudzen, Corita R.; Henning, Daniel J.; Klotz, Adam; Madsen, Troy E.; Pallin, Daniel J.; Reyes-Gibby, Cielito C.; Rico, Juan Felipe; Ryan, Richard J.; Shapiro, Nathan I.; Swor, Robert; Venkat, Arvind; Wilson, Jason; Thomas, Charles; Bischof, Jason J.; Lyman, Gary H.

In: JAMA network open, Vol. 2, No. 3, 01.03.2019, p. e190979.

Research output: Contribution to journalArticle

Caterino, JM, Adler, D, Durham, DD, Yeung, SCJ, Hudson, MF, Bastani, A, Bernstein, SL, Baugh, CW, Coyne, CJ, Grudzen, CR, Henning, DJ, Klotz, A, Madsen, TE, Pallin, DJ, Reyes-Gibby, CC, Rico, JF, Ryan, RJ, Shapiro, NI, Swor, R, Venkat, A, Wilson, J, Thomas, C, Bischof, JJ & Lyman, GH 2019, 'Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments', JAMA network open, vol. 2, no. 3, pp. e190979. https://doi.org/10.1001/jamanetworkopen.2019.0979
Caterino, Jeffrey M. ; Adler, David ; Durham, Danielle D. ; Yeung, Sai Ching Jim ; Hudson, Matthew F. ; Bastani, Aveh ; Bernstein, Steven L. ; Baugh, Christopher W. ; Coyne, Christopher J. ; Grudzen, Corita R. ; Henning, Daniel J. ; Klotz, Adam ; Madsen, Troy E. ; Pallin, Daniel J. ; Reyes-Gibby, Cielito C. ; Rico, Juan Felipe ; Ryan, Richard J. ; Shapiro, Nathan I. ; Swor, Robert ; Venkat, Arvind ; Wilson, Jason ; Thomas, Charles ; Bischof, Jason J. ; Lyman, Gary H. / Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments. In: JAMA network open. 2019 ; Vol. 2, No. 3. pp. e190979.
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title = "Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments",
abstract = "Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8{\%} were female. Seven hundred ninety-four participants (73.9{\%}; 95{\%} CI, 71.1{\%}-76.5{\%}) had undergone cancer treatment in the preceding 30 days; 674 (62.7{\%}; 95{\%} CI, 59.7{\%}-65.6{\%}) had advanced or metastatic cancer; and 505 (47.0{\%}; 95{\%} CI, 43.9{\%}-50.0{\%}) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6{\%}; 95{\%} CI, 6.1{\%}-9.4{\%}) were placed in observation and 615 (57.2{\%}; 95{\%} CI, 54.2{\%}-60.2{\%}) were admitted; 154 of 615 admissions (25.0{\%}; 95{\%} CI, 21.7{\%}-28.7{\%}) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1{\%}; 95{\%} CI, 59.2{\%}-65.0{\%}; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2{\%}) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1{\%}; 95{\%} CI, 18.8{\%}-23.8{\%}) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4{\%}; 95{\%} CI, 3.14{\%}-37.2{\%}) of those with pre-ED pain, including 244 of 428 (57.0{\%}; 95{\%} CI, 52.2{\%}-61.8{\%}) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3{\%}; 95{\%} CI, 28.5{\%}-34.1{\%}); of these, 160 (47.6{\%}; 95{\%} CI, 12.8{\%}-17.1{\%}) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5{\%}; 95{\%} CI, 23.9{\%}-29.2{\%}). Of these, 209 patients (73.3{\%}; 95{\%} CI, 17.1{\%}-21.9{\%}) were admitted compared with 427 of 790 (54.1{\%}; 95{\%} CI, 50.5{\%}-57.6{\%}) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.",
author = "Caterino, {Jeffrey M.} and David Adler and Durham, {Danielle D.} and Yeung, {Sai Ching Jim} and Hudson, {Matthew F.} and Aveh Bastani and Bernstein, {Steven L.} and Baugh, {Christopher W.} and Coyne, {Christopher J.} and Grudzen, {Corita R.} and Henning, {Daniel J.} and Adam Klotz and Madsen, {Troy E.} and Pallin, {Daniel J.} and Reyes-Gibby, {Cielito C.} and Rico, {Juan Felipe} and Ryan, {Richard J.} and Shapiro, {Nathan I.} and Robert Swor and Arvind Venkat and Jason Wilson and Charles Thomas and Bischof, {Jason J.} and Lyman, {Gary H.}",
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TY - JOUR

T1 - Analysis of Diagnoses, Symptoms, Medications, and Admissions Among Patients With Cancer Presenting to Emergency Departments

AU - Caterino, Jeffrey M.

AU - Adler, David

AU - Durham, Danielle D.

AU - Yeung, Sai Ching Jim

AU - Hudson, Matthew F.

AU - Bastani, Aveh

AU - Bernstein, Steven L.

AU - Baugh, Christopher W.

AU - Coyne, Christopher J.

AU - Grudzen, Corita R.

AU - Henning, Daniel J.

AU - Klotz, Adam

AU - Madsen, Troy E.

AU - Pallin, Daniel J.

AU - Reyes-Gibby, Cielito C.

AU - Rico, Juan Felipe

AU - Ryan, Richard J.

AU - Shapiro, Nathan I.

AU - Swor, Robert

AU - Venkat, Arvind

AU - Wilson, Jason

AU - Thomas, Charles

AU - Bischof, Jason J.

AU - Lyman, Gary H.

PY - 2019/3/1

Y1 - 2019/3/1

N2 - Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

AB - Importance: Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective: To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants: This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures: The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results: Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance: This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.

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