Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer

Abstract

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

Recognizing the emergency department’s role in oncologic care: a review of the literature on unplanned acute care

“…These rates of multiple visits are substantially higher than in the general patient population where only 6.5% have two or more ED visits in a year [45]. These ED visits are made to a wide range of facilities: patients who are being treated at one health system may only present to that system's ED for roughly one in three visits, underscoring the importance of the data limitations we discussed above [46].…”

“…Although there are often clinician phone line resources available for cancer patients, recent research suggests that patients with cancer do not often call before going to the ED, and even when they call, they are frequently directed to the ED by the clinician [27,46]. A potential explanation of the underuse of these phone-based triage resources is suggested by qualitative work finding that patients feel guilty for bothering providers [27].…”

From Risk Prediction to Delivery Innovation: Envisioning the Path to Personalized Cancer Care Delivery

“…A solution also lies in what might make the more comprehensive delivery reorganizations effective: encouraging the use of a single point of trusted contact to help triage acute issues. It is striking that patients often visit the emergency department without calling their cancer team beforehand, 12 regardless of clinical acuity, but given continued patient desire for such guidance and triage, 13,14 this may reflect inadequate awareness, immediate availability, or integration of existing resources.…”

Applying Hospital Readmissions to Oncology: A Square Peg in a Round Hole?

“…Even when 24-hour telephone support is available, patients with cancer do not regularly call before going to the emergency department. 19 A narrowly focused readmissions program does not make room to understand why some people frequently visit the emergency department, despite enduring long and unpredictable waits in crowded waiting rooms. The fact that a patient's emergency department use before a cancer diagnosis is independently associated with use after a cancer diagnosis 20,21 also suggests deeper care-seeking behaviors that influence use.…”