Evaluation of unplanned 30-day readmission

and emergency department utilization of

post- chemotherapy treated patients in a
community teaching hospital
Si-Ing Chen, Pharm.D.
PGY-1 Pharmacy Resident
Indiana University Health Ball Memorial Hospital
Muncie, IN
Great Lakes Pharmacy Resident Conference
April 23-24, 2019
The speaker has no actual or potential conflict of
interest in relation to this presentation.

2
Indiana University Health Ball Memorial Hospital

https://hoosiercancer.org/our-network/site/002/
Historical Background
Hospital readmissions and unplanned Emergency Department (ED) visits impose a
significant cost
2011
3.3 million hospital readmissions occurred
$41.3 billion
2012
The Affordable Care Act asked for the establishment of Hospital Readmissions
Reduction Program (HRRP)
Cancer patients have historically been excluded from HRRP
Hines et al, 2011; 4
CMS. Hospital Readmissions Reduction Program
Historical Background (continued)
2017
Chemotherapy measures were added to the Hospital Outpatient Quality
Reporting Program
2020
Payment determination will be calculated based on eligible patients during
calendar year of 2018

CMS. Details for title: CMS-1656-FC ) 5

QualityNet. Chemotherapy Measure (OP-35).
2018 CMS Measure Update and Specification
Report: Outcomes
Inpatient admissions and unplanned ED visits within 30 days of chemotherapy in
an outpatient setting with any of the following 10 conditions:
Chemotherapy Measure (OP-35)
Anemia Dehydration
Diarrhea Emesis
Fever Nausea
Neutropenia Pain
Pneumonia Sepsis
QualityNet. Chemotherapy Measure (OP-35) 6
2018 Measure Updates and Specifications Report:
Definition
Outcome timeframe
30 days following chemotherapy, including day of treatment
Multiple event consideration
Only 1 qualifying event within the 30 day period

QualityNet. Chemotherapy Measure (OP-35). 7

2018 Measure Updates and Specifications Report:
Inclusion & Exclusion Criteria
Inclusion Criteria Exclusion Criteria
Medicare patients (A & B) Leukemia diagnosis
Age > 18 Bone marrow transplant
Cancer Diagnosis Organ Transplant
Receiving chemotherapy in an Planned Inpatient Chemotherapy
outpatient infusion setting
Rehabilitation care

QualityNet. Chemotherapy Measure (OP-35) 8

Primary Outcome
30-day hospital readmission and unplanned ED visits to Ball Memorial Hospital
after chemotherapy due to any of the 10 measures

Chemotherapy Measure (OP-35)

Anemia Dehydration
Diarrhea Emesis
Fever Nausea
Neutropenia Pain
Pneumonia Sepsis
9
Secondary Outcomes
Mean time to event from last chemo received
Average length of stay (LOS)
Total charge (to patients/insurance)
Total cost (to hospital)
Percentage of prior clinic communication
Percent of inpatient oncologist consultations
Percentage of inpatient palliative care and hospice consultations
Most prevalent supportive care measures taken prior to and during events

10
Methods
IRB exempt
Study period: June 1, 2017 to May 31, 2018
Inclusion/Exclusion Criteria as defined by CMS 2018 Measure Updates and
Specifications Report

11
Data Collection
Retrospective chart review
Data collection points
Reason for ED visit or readmission
Patient demographics
Cancer specific factors
Chemotherapy received
Salvage measures taken before readmission or ED visits
Re-admission data
Financial information
12
Statistical analysis: descriptive statistics
Results: Primary Outcome
64 Unplanned Events
Unplanned ED visits: 8 (12.5%)
Hospital readmission: 56 (87.5%)

308 total cancer patients received chemotherapy between June 2017- May 2018
Unplanned ED visit rate: 2.5%
Readmission rate: 18%

13
Results: Patient Demographics
Sex: 50% female Most Prevalent Cancer Type (%)
25
Age: 20%
20 17%
Mean: 73 years-old

Percent (%)
15
Range: 42-97 years-old 12%
10 9%
Cancer stage distribution
5
Stage II: 3 (5%)
0
Small Cell Lung None Small Cell Non-Hodgkin Breast Cancer
Stage III: 11 (17%) Cancer Lung cancer Lymphoma
Cancer Type
Stage IV: 50 (78%)
14
 N %
Primary Reason For Event
Sepsis 15 23
Neutropenia 14 22
Pain 12 19
Pneumonia 9 14
Anemia 5 8
Emesis 4 6
Dehydration 3 5
Nausea 1 1
Diarrhea 1 1
Fever 1 1
15
Classes of Cancer Treatment Used
Hormonal Biotherapy
therapy 9%
2%

Immunotherapy Cytotoxic
20% chemotherapy
60%

Cytotoxic +
Biotherapy
9% 16
Results: Event Related Data
Outcomes Results

Time to event from Mean: 14.1 days

chemotherapy Range: 1- 30 days
Length of stay Mean: 7.4 days
Range: 0-28 days
Total charge (to Mean: $57,003
insurance/patient) Range: $5,809- $356,493
Total cost (to hospital) Mean: $11,937
Range: $953- $78,485
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 Result: Event Related Data
Outcomes N %
Prior clinic communication 24 40

Oncologist inpatient 30 50
consultation
Palliative care consultation 13 20

Hospice consultation 13 20

Most common pre-event ED referral (n=14) 22

salvage measure
Most common measures Antibiotic (n=17) 27
taken during ED visit/
18
readmission
National Data
Estimated national 30 day all-cause Top causes of unplanned readmission
readmission in cancer patient in the overall
United States
Septicemia (8.5%)
20.2%
Complication of surgical procedure/
⎻ January to November 2013 medical care (5%)
⎻ After excluding elective Congestive heart failure (4.6%)
readmissions
Pneumonia (4.1%)
Total cost of unplanned 30 day
Complication of device/ graft (3.3%)
readmissions in cancer patients
$14.4 billion for 2013
19
Mehta et al, 2016 (Abstract retried from Clinical Oncology Online)
Limitations
Retrospective analysis subject to available data in electronic medical record
Patients often presented with multiple readmission measures
Potential bias may be introduced with subjective chart-review

20
Conclusions and Discussion
Unplanned 30-day ED visits/ hospital readmission imposed significant financial
burden
Risk factors identified
Strategies to mitigate these risk factors and decrease event rates are
warranted
⎻ LOS: Increase inpatient oncology consults?
⎻ 20% Palliative care/hospice consults: Hospitalist education/Grand Rounds?
⎻ 40% Clinic communication: Re-educate patients
⎻ Chemotherapy follow-up calls by NP; Supportive care clinic for same day visits
21
Future Directions
Collect data from a comprehensive list that incorporates all cancer patients
Evaluate risk stratifications
Identify risk factors for 30 unplanned ED visits/ hospital admissions
Propose plans to better manage patients, mitigate risks and events, as well as
reduce events
Definition of sepsis? Initial diagnosis codes vs. meeting actual criteria?

22
Self-Assessment Question 1
Which of the following reasons for admissions would be considered as potentially
preventable causes of unplanned 30-day ED visits/ hospital readmission in
cancer patients receiving chemotherapy by CMS?

A. Bone fracture, constipation , dehydration, nausea

B. Pain, emesis, thrombocytopenia, neutropenia
C. Anemia, dehydration, diarrhea, emesis
D. Nausea, emesis, cardiac arrest, anemia

23
Self-Assessment Question 1
Which of the following reasons for admissions would be considered as potentially
preventable causes of unplanned 30-day ED visits/ hospital readmission in
cancer patients receiving chemotherapy by CMS?

A. Bone fracture, constipation , dehydration, nausea

B. Pain, emesis, thrombocytopenia, neutropenia
C. Anemia, dehydration, diarrhea, emesis
D. Nausea, emesis, cardiac arrest, anemia

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Self-Assessment Question 2
Which of the following would be considered as qualifying events of unplanned 30-
day ED visits/ hospital readmissions for cancer patients receiving chemotherapy
due to potentially preventable causes?

A. The hospital admission due to sepsis 25 days after patient received carboplatin
and pemetrexed during a previous inpatient stay
B. The hospital admission due to sepsis 2 days after patient being discharged from
the hospital due to fall 14 days after receiving outpatient nivolumab
C. The hospital admission for bone marrow transplant for a leukemia patient
D. The hospital admission due to fatigue/ anemia 25 days after patient receiving
outpatient zoledronic acid from an outpatient infusion center 25
Self-Assessment Question 2
Which of the following would be considered as qualifying events of unplanned 30-
day ED visits/ hospital readmissions for cancer patients receiving chemotherapy
due to potentially preventable causes?

A. The hospital admission due to sepsis 25 days after patient received carboplatin
and pemetrexed during a previous inpatient stay
B. The hospital admission due to sepsis 2 days after patient being discharged from
the hospital due to fall 14 days after receiving outpatient nivolumab
C. The hospital admission for bone marrow transplant for a leukemia patient
D. The hospital admission due to fatigue/ anemia 25 days after patient receiving
outpatient zoledronic acid from an outpatient infusion center 26
Acknowledgement/ Special Thanks!
Statistical support Information support
Munni Begum, Ph.D. Nhung Thai, MSHI, RHIA
Professor, Department of Mathematical Sr Data Analyst - Business/Clinical
Sciences Intelligence
Ball State University Decision Support & Analytics
Muncie, IN Indiana University Health
Indianapolis, IN

27
References
1. Hines, AL, Barrett, ML, Jiang, HJ, Steiner, CA. Conditions With the Largest Number of Adult Hospital
Readmissions by Payer. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs . Edition 2011;
2. Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program (HRRP). Available at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-
Programs/HRRP/Hospital-Readmission-Reduction-Program.html. Accessed March 28th, 2019
3. Centers for Medicare & Medicaid Services. Details for title: CMS-1656-FC (Hospital Outpatient Prospective
Payment - Final Rule with Comment and Final CY2017 Payment Rates). Available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-
Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html. Accessed March 28th, 2019
4. QualityNet. Chemotherapy Measure (OP-35). Available at:
http://www.qualitynet.org/dcs/ContentServer?cid=1228776191711&pagename=QnetPublic%2FPage%2F
QnetTier3& c=Page. Accessed March 28th, 2019

28
References
5. Saunders ND, Nichols SD, Antiporda MA, Johnson K, Walker K, Nilsson R, Graham L, Old M, Klisovic RB,
Penza S, Schmidt CR. Examination of unplanned 30-day readmissions to a comprehensive cancer
hospital. J Oncol Pract. 2015 Mar;11(2):e177-81
6. Mehta, K, Jacobs, BL., Wang, H., etal. 30 Day Readmissions in Cancer Patient in United States. J Clin
Oncol 34, no. 15_suppl (May 20 2016) 6577-6577. Abstract retried from Clinical Oncology Online

29
Evaluation of unplanned 30-day readmission
and ED utilization of post- chemotherapy
treated patients in a community teaching
hospital
Si-Ing Chen, Pharm.D.
PGY-1 Pharmacy Resident
Indiana University Health Ball Memorial Hospital
Muncie, IN
Great Lakes Pharmacy Resident Conference
April 23-24, 2019
schen6@iuhealth.org