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PURPOSE: There is limited understanding of the role of postdischarge medical oncology follow-up during care transition periods. Our study describes the care transition patterns and the association between postdischarge medical oncology appointments and downstream health care use at a tertiary academic center. METHODS: We conducted a retrospective cohort study of 25,135 medical oncology admissions between 2018 and 2020 at Yale New Haven Hospital. We examined the association between postdischarge medical oncology appointment timing with 30-day all-cause readmissions and emergency department (ED) visits using multivariable logistic regression models and propensity score-matched analyses. RESULTS: Compared with admissions without appointment within 30 days, admissions with postdischarge medical oncology appointment within 30 days were associated with lower rates of all-cause 30-day readmission (odds ratio [OR] = 0.56, 95% CI, 0.52 to 0.59; P < .001) and ED visit (OR = 0.56, 95% CI, 0.52 to 0.59; P < .001). Admissions with appointment ≤ 14 days were associated with lower rates of 30-day readmission (OR = 0.28, 95% CI, 0.25 to 0.32; P < .001) and ED visit (OR = 0.56, 95% CI, 0.52 to 0.63; P < .001) compared with those with appointment within 15-30 days. Similar patterns in health care use were seen with propensity score matching. Subgroup analyses of cancer types with the most admissions observed similar trends between 30-day readmission and ED visits with appointment timing. CONCLUSION: Timely postdischarge medical oncology appointments were associated with significantly lower likelihood of 30-day readmission and ED visits, suggesting a potential role for postdischarge follow-up as an intervention to decrease health care use.
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Cuidados Posteriores , Alta del Paciente , Atención a la Salud , Estudios de Seguimiento , Humanos , Oncología Médica , Estudios RetrospectivosRESUMEN
PURPOSE: Acute care imposes a significant burden on patients and cancer care costs. We examined whether an advanced practice provider-driven, cancer-specific urgent care center embedded within a large tertiary academic center decreased acute care use among oncology patients on active therapy. MATERIALS AND METHODS: We conducted a quasi-experimental study anchored around the Oncology Extended Care Clinic (OECC) opening date. We evaluated two parallel 4-month periods: a post-OECC period that followed a 5-month run-in phase, and the identical calendar period 1 year earlier. Our primary outcomes included all emergency department (ED) presentations and hospital admissions during the 3-month window following the index provider visit. We used Poisson models to calculate absolute pre-OECC v post-OECC rate differences. RESULTS: Our cohort included 2,095 patients in the pre-OECC period and 2,188 in the post-OECC period. We identified 32.6 ED visits/100 patients and 41.2 hospitalizations/100 patients in the pre-OECC period, versus 28.2 ED visits/100 patients and 26.1 hospitalizations/100 patients post-OECC. After adjusting for age, sex, race and ethnicity, and practice location, we observed a significant decrease of 4.6 ED visits/100 patients during the post-OECC period (95% CI, -8.92/100 to -0.28/100; P = .04) compared with the pre-OECC period. There was no significant association between the OECC opening and hospitalization rate (rate difference: -3.29 admissions/100 patients; 95% CI, -8.24/100 to 1.67/100; P = .19). CONCLUSION: Establishing a cancer-specific urgent care center was significantly associated with a modest decrease in emergency room utilization but not with hospitalization rate. Barriers included clinic capacity, patient awareness, and physician comfort with advanced practice provider autonomy. Optimizing workflow and standardizing clinical pathways can create benchmarks useful for value-based payments.
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Instituciones de Atención Ambulatoria , Neoplasias , Servicio de Urgencia en Hospital , Hospitalización , Humanos , Oncología Médica , Neoplasias/terapiaRESUMEN
The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented disruption in health care delivery around the world. In an effort to prevent hospital-acquired COVID-19 infections, most hospitals have severely curtailed elective surgery, performing only surgeries if the patient's survival or permanent function would be compromised by a delay in surgery. As hospitals emerge from the pandemic, it will be necessary to progressively increase surgical activity at a time when hospitals continue to care for COVID-19 patients. In an attempt to mitigate the risk of nosocomial infection, we have created a patient care pathway designed to minimize risk of exposure of patients coming into the hospital for scheduled procedures. The COVID-minimal surgery pathway is a predetermined patient flow, which dictates the locations, personnel, and materials that come in contact with our cancer surgery population, designed to minimize risk for virus transmission. We outline the approach that allowed a large academic medical center to create a COVID-minimal cancer surgery pathway within 7 days of initiating discussions. Although the pathway represents a combination of recommended practices, there are no data to support its efficacy. We share the pathway concept and our experience so that others wishing to similarly align staff and resources toward the protection of patients may have an easier time navigating the process.
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Infecciones por Coronavirus/epidemiología , Vías Clínicas/organización & administración , Procedimientos Quirúrgicos Mínimamente Invasivos , Neoplasias/cirugía , Neumonía Viral/epidemiología , Oncología Quirúrgica/organización & administración , Betacoronavirus , COVID-19 , Procedimientos Quirúrgicos Electivos , Humanos , Pandemias , SARS-CoV-2RESUMEN
OBJECTIVE: To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients. METHODS: A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications. RESULTS: Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent. DISCUSSION: This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years. IMPLICATIONS FOR PRACTICE: Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.