High Symptom Burden Among Hospitalized Patients with Advanced Cancer Linked to Longer Stays, Risk of Readmission

A heavy physical and psychological symptom burden is experienced by hospitalized patients with advanced cancer; many of their symptoms—which are potentially manageable—are significantly associated with hospital length of stay (LOS) and risk of unplanned readmission within 90 days of discharge, a team of Harvard researchers has found.

“Our work represents the largest study to date highlighting the immense symptom burden of hospitalized patients with advanced cancer,” write the authors of a report published in Cancer, a journal of the American Cancer Society. “To our knowledge, this is the first study to demonstrate the relation between patients’ self-reported physical symptoms and healthcare utilization among hospitalized patients with advanced cancer.”

Patients Want to Remain Home

Currently in the U.S., more than one-half of cancer patients are hospitalized at least once during the last month of life and nearly 10% have a hospital readmission during that period, despite the preference of most patients with advanced cancer to avoid hospitalization and remain at home, the authors note.

Although most research on cancer patients’ symptom prevalence and severity has focused primarily on those in the outpatient setting, hospitalized patients with advanced cancer often experience a higher symptom burden than those in the ambulatory care setting. “There is a critical need to determine the efficacy of supportive care interventions in this population to reduce symptom burden,” write the authors.

Investigators analyzed inpatient symptom-burden questionnaire responses of 1,036 adult patients with advanced cancer not receiving curative treatment who had unplanned hospitalizations between 2014 and 2015. Physical and psychological symptoms of the patients (median age, 63.4 years; male, 50.6%; white, 92.4%) were assessed using the self-administered, revised Edmonton Symptom Assessment System (ESAS-r) and the Patient Health Questionnaire 4 (PHQ-4), respectively.

Overall:

• A large majority of participants reported symptoms of moderate-to-severe fatigue (86.7%), poor well-being (74.2%), drowsiness (71.7%), pain (67.7%) and lack of appetite (67.3%).
• Only 1.7% reported experiencing no moderate/ severe symptoms.
• More than one-quarter of patients had clinically significant symptoms of depression (28.8%) and anxiety (28.0%).
• Mean hospital LOS was 6.3 days.
• Rate of hospital readmission within 90 days was 43.1%.
• 90-day mortality rate was 41.6%.
• Nearly two-thirds (65%) died or were readmitted within 90 days.

After adjusting for potential confounders— including comorbidity, cancer type and time since the diagnosis of advanced cancer—symptom burden remained a significant predictor of healthcare use. “It is important to note that patients’ symptoms represent a potentially modifiable risk factor that, if properly addressed, may improve healthcare quality and delivery,” the authors point out.

Key Findings:

• LOS: Patients’ physical symptoms (P < 0.001), total symptom burden (P < 0.001), total psychological distress (P = 0.040) and symptoms of depression (P = 0.017) were all significantly associated with longer hospital LOS.
• Readmission: Physical symptoms (P < 0.001), total symptom burden (P < 0.001) and anxiety symptoms (P = 0.045) were significantly associated with a higher risk of 90-day readmission.
• 90-day death or readmission: Physical symptoms, total symptom burden, total psychological distress and depression symptoms (all, P = 0.001) were significantly associated with a higher likelihood of death or readmission within 90 days, as were symptoms of anxiety (P = 0.012).

ID and Treat the Patient

“Most, if not all, of the symptoms identified are treatable with intensive supportive care measures that can be feasibly implemented, especially during hospital admissions,” write the authors. “Interventions to identify and treat symptomatic patients hold great potential for improving patients’ experience with their illness, enhancing their quality of life and reducing their healthcare utilization.”

Generalizability of their findings to other populations may be limited by the low rate of socioeconomic diversity in their study sample, note the authors. Nevertheless, “Our investigation provides novel insights to help clinicians and policymakers critically assess the potential contribution of uncontrolled symptoms to excessive and costly cancer care.”

Source: “The Relationship between Physical and Psychological Symptoms and Health Care Utilization in Hospitalized Patients with Advanced Cancer,” Cancer; December 1, 2017; 123(23):4720-4727. Nipp RD, El-Jawahri A, Temel JS, et al; Department of Medicine, Division of Hematology and Oncology; and Department of Medicine, Division of Palliative Care, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston.