Robert Michael Daly

Identifying avoidable terminal oncology ICU hospitalizations.

56 Background: Eight percent of cancer patients expire in the ICU. There is no association between spending on aggressive end of life (EOL) care and survival outcomes. This aggressive care is also associated with reduced quality of life for patients and families. The National Quality Forum endorses the number of patients admitted to the ICU in the last 30 days of life as a quality of care measure. Our hypothesis is that a significant number of oncology patients suffer avoidable terminal ICU hospitalizations. METHODS Using data from the University of Chicago (UCM) Cancer Registry, we identified patients who died in UCM adult ICUs in FY2013. Of the 1,388 oncology deaths, 115 were in the ICU. Of those, 72 were established patients having had at least one visit with a UCM oncologist. A physician from oncology, critical care, and hospital medicine directly reviewed the electronic medical record of each patient from 3 months prior to index hospitalization until death. Using a standardized assessment tool, these physicians then determined whether the terminal hospitalization was clinically avoidable through different medical management. The primary outcome was the proportion of terminal oncology ICU hospitalizations identified as potentially avoidable by two or more reviewers. RESULTS Seventy-one percent of this patient population had a solid malignancy and 53% of those had metastatic disease. The ECOG performance status was ≥ 2 prior to admission in 51% of patients. Eighty-two percent had at least one prior hospitalization. During the index hospitalization, 81% were intubated, 39% had resuscitation, and 22% had hemodialysis. Two or more physician reviewers identified 34 (47%) of terminal oncology ICU hospitalizations as clinically avoidable. All three specialty physicians agreed about the avoidability 43% of the time. CONCLUSIONS A review of terminal oncology ICU hospitalizations demonstrates that most of these patients had an advanced malignancy and poor clinical status and underwent aggressive EOL interventions. A significant number of these hospitalizations were identified as clinically avoidable by two or more physician reviewers. By identifying avoidable terminal oncology ICU hospitalizations, we can design interventions to prevent them.

Characterizing terminal oncology ICU hospitalizations.

167 Background: Twenty-five percent of Medicare cancer beneficiaries use the ICU in the last month of life, and 8% of cancer patients expire there. Cancer patients who die in the ICU have worse quality of life compared with those who die at home. Terminal ICU hospitalizations also come at high financial cost, accounting for 80.2% of all terminal hospitalization costs. Our hypothesis is that a significant number of oncology patients suffer avoidable terminal ICU hospitalizations. By better characterizing these hospitalizations, we will provide the knowledge backbone for future interventions. METHODS Using data from the University of Chicago (UC) cancer registry, we identified patients who died in UC adult ICUs in FY2013. Of the 1,388 oncology deaths, 115 were in the ICU. Of those, 73 were established patients having had at least one visit with a UC oncologist. We performed a chart abstraction to identify patient, clinical, and hospitalization characteristics. RESULTS The average age of this patient population was 64 years and 71% were men. Solid and hematologic malignancies comprised 71% and 29%, respectively. Of the solid malignancy patients, 54% had metastatic disease. The average duration of the patient-oncologist relationship was 693 days, and 77% had their last oncology appointment within 2 months of index hospitalization. The ECOG performance status was ≥ 2 prior to admission in 51% of patients. These patients had an average of 3 hospitalizations and 15 outpatient visits in the year prior to death. Eighty-one percent did not have advance directives and 86% did not have an outpatient palliative care consult. The average duration in the ICU was 8 days, during which 95% did not have an inpatient palliative care consult, 79% were intubated, and 38% had resuscitation attempted. CONCLUSIONS Most cancer patients who died in the ICU had an advanced stage malignancy and/or poor clinical status prior to admission. In addition, a significant number received intubation and resuscitation. Despite evidence of adequate interaction with the healthcare system, most patients had not had a palliative care consult or advance directives. This study will allow for further exploration of the avoidability of terminal oncology ICU hospitalizations to inform future interventions.