Characterization of avoidable hospital admissions in patients with lung cancer in the immunotherapy and targeted therapy era.
Authors: Lander Eric Michael , Huang Li-Ching , Cass Amanda , Skotte Emily A. , Whisenant Jennifer G. , Iams Wade Thomas , Lovly Christine M. , Osterman Travis John , Lewis Jennifer A. , York Sally J. , Shyr Yu , Horn Leora 
Published: June 2022

e21133 Background: Hospitalization is the second largest contributor of cancer care spending, and over 50% of lung cancer patients are admitted to the hospital while receiving treatment. Patients who avoid hospital admission have reduced health care costs with a higher quality of life. This is the first study that characterizes the risk factors and outcomes for avoidable hospital admissions of lung cancer patients. It is the first to examine the extent to which hospitalizations from immunotherapy and targeted therapy could be avoided. Methods: A retrospective chart review of lung cancer patients admitted January 2018 through December 2018 was conducted. Demographics, disease and treatment history, admission characteristics, outcomes, and end-of-life care utilization were recorded. Following a multidisciplinary consensus review, hospitalizations were determined “avoidable” or “unavoidable.” Generalized estimating equation logistic regression models analyzed risks and outcomes associated with avoidable admissions. Kaplan-Meier estimators examined the median overall survival (mOS) between patients with and without avoidable admissions. Results: We evaluated 319 admissions from 188 patients with a median age of 66 and 16%/84% SCLC/NSCLC. Cancer-related symptoms accounted for 66% of hospitalizations; pneumonia and other infections comprised 34%, and 32% were due to cancer-related pain, vomiting, or failure to thrive (FTT). Common causes of unavoidable hospitalizations were unexpected disease progression causing symptoms, COPD exacerbation, and infection. Of the 47 hospitalizations identified as avoidable (15%), the mOS was 1.6 months; the mOS of unavoidable hospitalizations was 9.7 months (HR 2.07; 95% CI 1.34-3.19; p < 0.001). Significant reasons for avoidable admissions included cancer-related pain (p = 0.021), hypervolemia (p = 0.033), patient desire to initiate hospice services (p = 0.011), and errors in medication reconciliation or distribution (p < 0.001). Errors in medication management caused 26% of the avoidable hospitalizations. Of admissions in patients on immunotherapy (n = 102) or targeted therapy (n = 44), 9% were due to adverse effects of treatment. Patients on immunotherapy and targeted therapy were not more likely to have avoidable hospitalizations compared to patients not on the treatments (p = 0.323 and 0.133, respectively). Patients with avoidable admissions were 3.02 times more likely to enroll in hospice within 30 days of hospitalization compared to unavoidable admissions (95% CI 1.54-5.92; p = 0.001). Conclusions: Patients on immunotherapy or targeted therapy were only rarely admitted due to side effects of treatment. Hospitalizations may be avoided with more aggressive outpatient symptom management, earlier hospice discussion with at-risk patients, and outpatient pharmacist review of medications following hospital discharge.