title: Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care.
abstract: BACKGROUND
  Admissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable.
  
  
  OBJECTIVE
  To determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs).
  
  
  METHODS
  We randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED.
  
  
  RESULTS
  Forty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99).
  
  
  CONCLUSIONS
  Nearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA. Electronic address: marvin.delgado@mdanderson.org.
authors.forename: Marvin Omar
authors.initials: MO
authors.lastname: Delgado-Guay
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA; Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
authors.forename: Yu Jung
authors.initials: YJ
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, College of Medicine, Kosin University, Busan, Republic of Korea.
authors.forename: Seong Hoon
authors.initials: SH
authors.lastname: Shin
authors.affiliation: Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: Chisholm
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Janet
authors.initials: J
authors.lastname: Williams
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Julio
authors.initials: J
authors.lastname: Allo
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
mesh_terms: D000553:Ambulatory Care / Q000379:methods / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000628:therapy*; D010045:Outpatients / Q000706:statistics & numerical data*; D010166:Palliative Care / Q000379:methods / Q000706:statistics & numerical data*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*
keywords: Supportive care; advanced cancer; emergency department; palliative care outpatient