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Emergency Department Visits in the Last 30 Days of Life

Key findings

In 2018, the percentage of people with cancer who visited the emergency department (ED) in the last 30 days of life ranged from 38% to 61% across the 4 hematologic cancers (acute lymphocytic leukemia, acute myeloid leukemia, diffuse large B-cell lymphoma and multiple myeloma). Further study is required to understand the appropriate use of the emergency department by these patients.

Why is this important to Ontarians?

This indicator is a measure of effective and person-centred end-of-life care.

  • The last 30 days of life is a period of a high healthcare use for many. This measure can monitor the ongoing effectiveness of palliative services that can mitigate hospitalization and emergency department visits.
  • Palliative care is an approach to care that aims to relieve suffering and improve the quality of living and dying for people with cancer and other serious illnesses.
  • High-quality, person-centred end-of-life care incorporates the key principles of palliative care during the last few months of life.
  • As people near the end of life, their healthcare providers should begin proactive goals of care discussions to understand their patients’ needs and preferences. This includes identifying the supports a person needs to live, manage symptoms and die in the setting of their choice.
  • The emergency department may be the most appropriate setting for the care a patient needs near the end of life. But the need for emergency care may be minimized if symptoms and treatment-related side-effects can be managed at home. This is possible when high-quality and accessible palliative and end-of-life supports and resources are available.
  • Earlier access to both palliative care services — especially near the end of life — and options for care outside the emergency department is important for making the best use of acute care services and improving the quality of end-of-life care for patients.

See Emergency Department Visits in the Last 30 Days of Life Methodology for technical information.

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Data Table 1. Percentage of people with acute lymphocytic leukemia who visited the emergency department at least once in the last 30 days of life, 2014 to 2018
Year of death Percentage of Patients with ED visits (%)
2014 (N=71) 59.2
2015 (N=67) 55.2
2016 (N=88) 54.5
2017 (N=70) 52.9
2018 (N=74) 37.8

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Data Table 2. Percentage of people with acute myeloid leukemia who visited the emergency department at least once in the last 30 days of life, 2014 to 2018
Year of death Percentage of Patients with ED visits (%)
2014 (N=584) 62.8
2015 (N=511) 63.4
2016 (N=633) 64.1
2017 (N=598) 61.7
2018 (N=546) 60.6

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Data Table 3. Percentage of people with diffuse large B-cell lymphoma who visited the emergency department at least once in the last 30 days of life, 2014 to 2018
Year of death Percentage of Patients with ED visits (%)
2014 (N=817) 59.9
2015 (N=914) 58.6
2016 (N=844) 56.5
2017 (N=907) 57.6
2018 (N=908) 55.6

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Data Table 4. Percentage of people with multiple myeloma who visited the emergency department at least once in the last 30 days of life, 2014 to 2018
Year of death Percentage of Patients with ED visits (%)
2014 (N=887) 60.1
2015 (N=880) 59.3
2016 (N=937) 58.4
2017 (N=988) 55.9
2018 (N=957) 58.3

Report date: August 2020
Data sources: Ontario Cancer Registry (OCR), Registered Persons Database (RPDB), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS)
Prepared by: Quality Measurement and Evaluation (QME), Ontario Health (Cancer Care Ontario)

Results

  • The percentage of people with acute lymphocytic leukemia who visited the emergency department in the last 30 days of life decreased from 59% in 2014 to 38% in 2018. However, small volumes and resulting variability should be noted.
  • From 2014 to 2018, the proportion of people with diffuse large B-cell lymphoma, multiple myeloma and acute myeloid leukemia who visited the emergency department in the last 30 days of life remained stable at about 60%.
  • It is not known where in the trajectory of their illness or treatment these patients are who visit the emergency department in the last 30 days of life.
  • Emergency departments are intended to provide care in emergency and life-threatening situations, to offer urgent medical attention for serious conditions and injuries, and to provide access to a wide range of healthcare specialists and diagnostic equipment. For some patients a visit to the emergency department may be appropriate depending on their goals of care, the severity of their symptoms or both.

Opportunities

  • More work is needed to understand why people with hematologic malignancies visit the emergency department, and whether that use is appropriate. This will inform future efforts to enable access to the most appropriate care at the right time.
  • Palliative care services may need to be provided earlier in the disease to improve the person’s quality of life. It has been suggested that the use of hospice services is lower for patients with hematologic cancers than those with solid tumours. This may be attributable to the common use of transfusions to improve symptoms for hematologic cancers, but this needs to be explored further.

References

  1. Egan PC, LeBlanc TW, Olszewski AJ. End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies. Blood Adv [Internet]. 2020 [Cited 2020 Sept 14];4:3606-3614. Available from: https://www.ashclinicalnews.org/news/from-the-blood-journals/blood-advances/study-supports-earlier-frequent-use-hospice-older-patients-hematologic-malignancies/