Unplanned Hospitalizations and Readmissions among Elderly Patients with GI Cancer

Transcription

1 Unplanned Hospitalizations and Readmissions among Elderly Patients with GI Cancer September 19, 2014 Joanna-Grace M. Manzano, MD Assistant Professor Department of General Internal Medicine UT MD Anderson Cancer Center

2 Cancer-Related Hospitalizations Common - In 2009, 4.7M adult hospitalizations were cancer-related Costly - Cost of cancer-related hospital stays total $58.6 billion in 2009 $16,400 versus $10,700 per stay $3,300 versus $2,800 per day Longer LOS for hospitalizations principally for cancer were 1.6 days longer than other conditions 6.6 days versus 5.0 days The elderly are particularly vulnerable Cancer hospitalization rates among those 65 and older are 16 times higher than among year olds (Anhang Price, Agency for Healthcare Research and Quality, AHRQ 2012)

3 Hospitalizations among Elderly Texas data shows that elderly hospitalizations are Common (28.5%) Costly (mean charge per stay = $56,717 vs $33,687) Longer LOS (6.5 vs 4.8 days) Admission thru Emergency Department (53.4%) (Source: Texas Hospital Inpatient Discharge Public Use Data File (PUDF), 2009)

4 Elderly Cancer Patients In a cohort of elderly cancer patients: 50-75% of cancer costs were from hospitalizations during the initial phase for most cancers. >70% of costs were attributable to hospitalizations for nearly all cancer sites studied in the last year of life GI cancers have some of the highest proportions attributable to hospitalizations (Yabroff et al, J Natl Cancer Inst 2008;100: )

5 Proportion of net cancer care costs from hospitalizations in the initial phase of care (1 st 12 months post diagnosis) colorectal esophagus gastric liver pancreas 50-75% of cancer costs were from hospitalizations during the initial phase for most cancers. Source: (Yabroff et al, J Natl Cancer Inst 2008;100: )

6 Proportion of net cancer care costs from hospitalizations in the last year of life (final 12 months of life) gastric colorectal esophagus liver pancreas >70% of costs were attributable to hospitalizations for nearly all cancer sites studied in the last year of life Source: (Yabroff et al, J Natl Cancer Inst 2008;100: )

7 Knowledge gap What drives the high hospitalization rate among cancer patients? Are these hospitalizations planned or unplanned? What are the reasons for unplanned hospitalization? What are the risk factors for unplanned hospitalization?

8 Patterns and Predictors of Unplanned Hospitalization in a Population-Based Cohort of Elderly Patients with GI Cancer

9 Study Team Dr. Maria E. Suarez-Almazor Dr. Linda S. Elting Dr. Ruili Luo Dr. Marina C. George

10 Study Objectives 1. To describe the patterns of unplanned hospitalization among elderly GI cancer patients 2. To identify risk factors for unplanned hospitalizations among patients with GI cancer

11 Methodology Study Design: Population- based Retrospective cohort study Linked Texas Cancer Registry-Medicare Claims Study Period: Up to 2 years post cancer diagnosis Units of Analysis: Patient Level Claims Level

12 Data sources 1. The Texas Cancer Registry Data file fields: -patient demographics -cancer identification -stage Identification of cases 2. Medicare data Data files: -Enrollment database (Part A/Part B) -MEDPAR (inpatient claims) -NCH/carrier files -Outpatient Analysis of Claims

13 Selection of Study Cohort GI Cancer diagnosed between , N=71,792 Texas resident N=66,542 Age > 66y N=50,687 First cancer, & histology confirmed N=39,698 Uninterrupted Medicare coverage, non- HMO N=30,387 Exclude: (N=188) - diagnosed at autopsy or at death (6) - uncommon histology (172) - incomplete data (10) N=30,199 patients

14 Outcome Variable UNPLANNED HOSPITALIZATION 1.Admission Type = Emergent or Urgent in MedPAR claims data 2. IF admission type is unknown, and emergency room charge is greater than 0$, then the admission will be considered unplanned 3. MUST NOT have a principal diagnosis of chemo/radiation encounter for cancer i.e. ICD 9 codes V58.0, V58.1, V58.11, V MUST not be an admission for in-patient rehabilitation services ICD9 code V57.xx 5. MUST NOT be an admission to a skilled nursing facility Hospitalizations that do not meet criteria for unplanned were classified as Other

15 Study variables Patient Characteristics Age Gender Race Area of Residence Census Tract %Poverty Level Dual eligibility for MC/MCaid Tumor Characteristics Tumor Type Tumor Stage at Diagnosis Comorbidity Charlson Comorbidity Index (CCI)

16 Study timeline CLAIM 2 Claim = hospitaliza*on event CLAIM 1 CLAIM 3 CLAIM 4 YR - 1 YR 0 YR 1 YR 2 Prior ComorbidiHes Comorbidity Index Cancer Diagnosis Collect PaHent and Tumor CharacterisHcs YR 0 to YR 2 collect all in- pahent claims data (UNPLANNED HOSPITALIZATION VS. OTHER)

17 Descriptive Analysis Unplanned hospitalization rate # of all unplanned hospitalization events Total person-time for the whole cohort LOS of unplanned vs other hospitalizations Proportion of unplanned hospitalization preceded within 30 days by a treatment procedure

18 Statistical Analysis Predictors of unplanned hospitalization Cox proportional hazards modeling First unplanned hospitalization as dependent event (time to event analysis) Censored at date of death or end of observation period if they had not experienced the event

19 Patient Demographics Table of baseline demographic characteristics for N=30199 Variable Category N(%) Age group (18.4%) (24.2%) (23.8%) (33.6%) Gender Female (50.2%) Male (49.8%) Residence Big Metro (47.2%) Metro 8817 (29.2%) Urban 2148 (7.1%) Urban less 4340 (14.4%) Rural 628 (2.1%)

20 Patient Demographics Table of Baseline characteristics for N=30199 Variable Category N(%) Race White (82%) Hispanic 1848 (6.1%) Black 2921 (9.7%) American Indian 47 (0.2%) Census Tract by %Poverty Other 633 (2.0%) % 7562 (25%) 7.49%- 13.3% 7547 (25%) 13.31% % 7551 (25%) % 7539 (25%)

21 Tumor Characteristics Table of baseline clinical characteristics for N=30199 Variable Category N(%) Tumor Type Colon (48.2%) Esophagus 1695 (5.6%) Liver + IntrahepaHc ducts 2059 (6.8%) Pancreas 4085 (13.5%) Rectum and Anus 4979 (16.5%) Tumor Stage at diagnosis Stomach 2833 (9.4%) Localized (33.1%) Regional (33.4%) Distant 6652 (22%) Unknown 3464 (11.5%)

22 Comorbidities Table of baseline clinical characteristics for N=30199 Variable Category N(%) Charlson Comorbidity Index (64.3%) (19.3%) (8.5%) (7.9%) CCI

23 Pre-existing Comorbidities Frequency of comorbidi:es (%) Diabetes (without complicahons) Chronic pulmonary disease CongesHve Heart Failure Cerebrovascular disease (except hemiplegia Peripheral vascular disease Diabetes with end organ damage Myocardial infarct Moderate or severe renal disease Ulcer disease Mild liver disease DemenHa ConnecHve Hssue disease Moderate or severe liver disease Hemiplegia AIDS Frequency of comorbidihes (%)

24 Claims Analysis 30,199 PaHents 5,515 pahents with zero InpaHent claims or only had SNF claims 24,684 pahents had 60,837 inpa:ent claims 25501, 42% 35336, 58% Unplanned Other

25 Unplanned hospitalization Unplanned hospitalization rate = # of all unplanned hospitalization events Total person-time for the whole cohort = 93 events/100 person-years Event rate by year of diagnosis à 89 to 97 events/100 py; p =.362 LOS(unplanned) 7.4 days < LOS(other) 8.9 days; p<.001

26 59% had 1 Unplanned Hospitalization (n=17482) Mean time to first unplanned hospitalization = 2.2 months Mean # of unplanned hospitalization events = % had either chemo, radio or surgery in preceding 30 days of the first unplanned hospitalization 6.9% chemo 12% surg 2.5% radio 9.4% had an ER visit in preceding 30 days

27 Reasons for Unplanned Hospitalization Top 10 non-cancer reasons for unplanned hospitalization N (%) 1. Fluid and electrolyte disorders 2944 (8.33) 2. Intestinal obstruction without hernia 1871 (5.29) 3. Pneumonia 1572 (4.45) 4. Congestive heart failure 1547 (4.38) 5. Complications of surgical procedures and medical care 1504 (4.26) 6. Septicemia 1450 (4.10) 7. Gastrointestinal hemorrhage 1330 (3.76) 8. Deficiency and other anemia 1074 (3.04) 9. COPD and bronchiectasis 1032 (2.92) 10. Urinary Tract infections 1030 (2.91) *State of Texas Potentially Preventable Hospitalizations, Texas Department of State Health Services

28 Adjusted Multivariable Analysis Risk Factors for First Unplanned Hospitalization 95% confidence Coefficient Variable Hazard raho interval p Age (vs years) years years years <.001 Sex: female (vs. male) Ethnicity (vs white) Hispanic Black American Indian Other Cancer type (vs colon) Esophageal <.001 Liver or intrahepahc ductal PancreaHc Anorectal Gastric <.001 Disease stage (vs localized) Regional <.001 Distant <.001 Unknown Area of residence a (vs big metro) Metro Urban Urban less Rural Census tract poverty level a (vs Q1) Q Q Q <.001 Charlson comorbidity index (vs 0) < < <.001 State buy in a (vs none) <.001

29 Risk Factors for Unplanned Hospitalization AGE: 75+ compared to age group RACE: Black compared to white CANCER TYPE: Esophageal > gastric > pancreatic compared to colon ca CANCER STAGE: More advanced disease stages c/w localized CENSUS TRACT POVERTY LEVEL: Q3-Q4 census tr c/w Q1(most affluent neighborhood) COMORBIDITY: Increasing CCI DUAL ELIGIBILITY: State buy in vs none

30 Summary of findings Unplanned Hospitalizations among elderly GI cancer patients are common (93 events per 100 py) Top reasons for unplanned hospitalization were both cancerrelated and non-cancer related Comorbidities e.g. congestive heart failure and chronic pulmonary disease are among the top reasons for unplanned hospitalization 5 out of the top 10 non-cancer reasons for unplanned hospitalization are considered potentially preventable by the Agency for Healthcare Research and Quality (AHRQ)

31 Unplanned 30-day Readmissions among Elderly Patients with Gastrointestinal Cancer

32 Readmissions Timeline 2007 Medicare Payment Advisory Commission (MedPAC), proposed a payment policy for inpatient readmissions (penalty vs. reward+penalty) 2008 MedPAC recommends public reporting of readmission rates, payment reforms to encourage care coordination 2009 Jencks study: almost one-fifth (19.6%)of 11,855,702 Medicare (MC) beneficiaries were readmitted within 30 days of a hospital discharge (based on data from ) 2010 Congress enacted Hospital Readmissions Reduction Program (HRRP) under PPCA Penalty for hospitals with above-average readmissions from (July 2008-June 2011) 3 conditions: AMI + heart failure + pneumonia 2011 small decline in all-cause readmission rates 0.3% decrease (15.3%) 12.3% of all MC admissions were followed by a potentially preventable readmission 2012 CMS implemented HRRP, reduces payment to hospitals w/ excess readmissions. Total penalty capped at 1% of base operating payments in 2013 à 2% in 2014 à 3% in HRRP will expand to include COPD, CABG surgery, PTCA and other vascular conditions as well as other conditions the Secretary deems appropriate

33 Readmissions Defined A readmission is a rehospitalization to an acute care hospital following a prior admission from an acute care hospital. Quality metric Indicator of poor care Failure of care transition Medicare annual cost is 17 billion dollars for readmissions Hospitals are being penalized for high readmission rates

34 Readmissions in Cancer 14% 30-day all cause readmission rate in a Canadian study (Hong et al, CIHI) Post cancer surgery readmission rates à 6-39% Common in GI cancer, lung cancer, lymphoma (Hong et al, CIHI)

35 Study Objectives 1. To describe patterns of 30-day readmission among Medicare beneficiaries with GI cancer in Texas 2. To identify risk factors for readmission

36 Methodology Study Design: Population- based retrospective cohort study Data Source: Linked Texas Cancer Registry-Medicare Claims ( ) Study Period: 2 years Unit of Analysis: an episode of care/hospitalization event

37 Outcome Variable A hospitalization was assigned an outcome of UNPLANNED READMISSION if: 1. followed by a readmission within 30 days of discharge AND 2. readmission was unplanned - emergent or urgent admission AND - not an encounter for chemotherapy, radiation or in-patient rehabilitation

38 Study timeline <30 days >30 days Event = hospitalization UNPLANNED EVENT 2 EVENT 1 EVENT 3 YR -1 YR 0 YR 1 YR 2 Comorbidity Index Cancer Diagnosis Patient and Tumor Characteristics YR 0 to YR 2 review all inpatient claims data (UNPLANNED READMISSION)

39 Independent Variables Patient Characteristics Age Gender Ethnicity Population size of area of residence Census tract poverty level Tumor Characteristics Type Stage Comorbidity Hospitalization Characteristics Prior treatment within 30 days of a hospitalization radiotherapy chemotherapy surgery Prior ER visit Prior outpatient visit Unplanned hospitalization ICU stay Surgical procedure Length of stay Charlson comorbidity index

40 GI Cancer diagnosed between , N=71,792 Texas resident age > 66y, first cancer, & histology confirmed N=39,698 Uninterrupted Medicare coverage, non-hmo N=30,387 Not diagnosed at autopsy or at death, excluding uncommon histology N=30,199 patients / / After cohort selection 30,199 patients Exclude long term and skilled nursing facility stays (acute stays only) Exclude hospitalizations that could not be followed for 30 days after discharge: -discharges after Nov (3) -Transfers (2041) -Inpatient deaths (3499) -Outpatient death w/in 30 days (4646) -Bad data (7 misclassified as acute stay) 24,343 patients 21,292 patients 70,254 hospitalizations 56,650 Hospitalizations 46,454 hospitalizations Additional Exclusion criteria for CLAIMS analysis Final Study Cohort: 21,292 patients 46,454 hospitalizations

41 Patient Demographics (N=21,292)

42 Patient Demographics (N=21,292)

43 Clinical Characteristics (N=21,292)

44 Claims Analysis 8109, 17% 46,454 acute hospitalizations 38345, 83% Readmission Rate Unplanned Readmission = Yes = 17% Unplanned Readmission = No Unplanned Readmission Rate after MEDICAL hospitalizations = 21% SURGICAL hospitalizations = 13%

45 Time to Readmission Mean Median Minimum Maximum 12.3 days 11 days 1 30 frequency days

46 Non-Cancer Reasons for Unplanned Readmission Medical visits ICD- 9 Principal Diagnosis N (%) 1. CHF 257 (4.6) 2. Volume deplehon 250 (4.5) 3. Pneumonia 188 (3.4) 4. SepHcemia 175 (3.2) 5. UTI 149 (2.7) 6. Acute kidney failure 123 (2.2) 7. GI Hemorrhage 101 (1.8) 8. DehydraHon 98 (1.8) 9. Pulmonary embolism 86 (1.6) 10. Acute respiratory failure 82 (1.5) Surgical visits ICD- 9 Principal Diagnosis N (%) 1. PostoperaHve infechon 146 (5.7) 2. DigesHve system complicahons 133 (5.2) 3. Volume deplehon 100 (3.9) 4. Pneumonia 83 (3.2) 5. CHF 81 (3.1) 6. SepHcemia 65 (2.5) 7. UTI 62 (2.4) 8. Pulmonary embolism 55 (2.1) 9. IntesHnal obstruchon 55 (2.1) 10. DehydraHon 51 (2.0)

47 Risk Factors for Unplanned Readmission after Medical Hospitalizations Mul:variate Category OR CI Tumor Type Esophagus Ref: Colon Liver + IHD Pancreas Stomach Stage Regional Ref: Localized Distant Unknown Comorbidity Ref: Zero Census Tract Poverty level > 21% Prior ER visit Yes Unplanned Index HospitalizaHon Yes

48 Risk Factors for Unplanned Readmission after Surgical Hospitalizations Mul:variate Category OR CI Age Ref:66-69 Age > Tumor Type Ref: Colon Esophagus Liver + IHD Pancreas Anorectal Stomach Stage Ref: Localized Distant Comorbidity Ref: Zero Prior ER visit Yes Unplanned Index HospitalizaHon Yes ICU stay Yes

49 Summary of Findings Unplanned Readmissions are common among GI cancer patients = 17% readmission rate Median time to readmission 11 days Post-acute care interventions targeted towards the first week of discharge Some of the top reasons are potentially preventable Need to define preventable in cancer population Opportunities for improvement

50 Summary of Findings Risk factors identified Multimorbidity Distant metastases Unplanned hospitalization ER visit within 30 days of a hospitalization

51 Unplanned Hospitalizations and Readmissions among Elderly Patients with GI Cancer CONCLUSIONS

52 Study Conclusions Unplanned Hospitalizations and Readmissions are common in our study cohort Multimorbidity chronic disease management Role for Risk Stratification Coordination of Care Primary care involvement Transitions of Care Discharge process Findings should inform efforts for standardizing metrics especially for cancer patients

53 Limitations Use of administrative data subject to deficiencies of coding e.g. inconsistencies in use of coding system Aggregated data for 6 GI cancers Regional variation in unplanned hospitalization and readmission, may not be generalizable outside of Texas à need to compare

54 Generated Questions Are patterns specific to Texas only? Regional variations? What are the cost implications of these unplanned hospitalizations/readmissions? Are socioeconomic disparities related to healthcare access? Other cancers? Who are recurrently hospitalized/readmitted?

55 Unplanned Hospitalizations and Readmissions among Elderly Patients with GI Cancer NEXT STEPS

56 Research Proposal Research Question: What are the risk factors for recurrent unplanned hospitalization among elderly patients with caner? Data Source: TCR + SEER-Medicare Outcome: Recurrent Hospitalization defined as unplanned hospitalization rate > 1

57 Research Proposal Include cost data Focus on 1 cancer only? Explore other variables Stents/catheters/ostomies Outpatient visits/er visits Geographic regions