No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations.
Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs.



This was a retrospective case series of patients cared for in an academic medical center's ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient's electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations.



Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05).



Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Bobby
B
Daly
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Andrew
A
Hantel
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Kristen
K
Wroblewski
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Jay S
JS
Balachandran
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Selina
S
Chow
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Rebecca
R
DeBoer
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Gini F
GF
Fleming
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Olwen M
OM
Hahn
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Justin
J
Kline
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Hongtao
H
Liu
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Bhakti K
BK
Patel
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Anshu
A
Verma
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Leah J
LJ
Witt
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Mayumi
M
Fukui
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Aditi
A
Kumar
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Michael D
MD
Howell
University of Chicago Medicine; and University of Chicago, Chicago, IL.
Blase N
BN
Polite
D000368:Aged; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D013727:Terminal Care