Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer

2021 ◽  
pp. OP.20.00617
Author(s):  
Arthur S. Hong ◽  
Hannah Chang ◽  
D. Mark Courtney ◽  
Hannah Fullington ◽  
Simon J. Craddock Lee ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Emergency Department Visits ◽  
University Hospital ◽  
Urgent Care ◽  
Telephone Triage ◽  
Patients With Cancer ◽  
Oncology Care ◽  
Ed Visits ◽  
The University

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

A solution to reducing avoidable emergency department visits: Implementation of an outpatient oncology acute care clinic.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e13517-e13517
Author(s):  
Sadaf Charania ◽  
Judy Devlin ◽  
Edie Brucker ◽  
Shayna Simon ◽  
Christine Hong ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cancer Treatment ◽  
Acute Care ◽  
The United States ◽  
Emergency Department Visits ◽  
Urgent Care ◽  
Outpatient Basis ◽  
Oncology Patients ◽  
Care Clinic ◽  
Ed Visits

e13517 Background: Emergency Department (ED) utilization by oncology patients accounts for more than 4.5 million visits in the United States annually, leading to hospitalization four times the rate of the general population.1,2 Many ED visits are the result of symptoms related to cancer or cancer treatment that can be managed on an outpatient basis. Unnecessary admissions lead to possible delays in cancer treatment and increased burden on healthcare resources.3 Simmons Acute Care (SAC), an advanced practice provider (APP)-led clinic, was established in August 2020 to provide an alternative model of oncology care to address these issues. Methods: A multidisciplinary team of key stakeholders was formed to develop an action plan. Institutional data was reviewed to identify the timing and volume of ED visits by oncology patients. Clinic hours were set Monday through Friday, 7:00am – 7:00pm, and referrals were made from primary oncology providers. Evidence-based clinical pathways were developed to standardize patient management, and a data collection plan was implemented to measure outcomes. Internal communications to patients and presentations at staff and faculty meetings occurred to inform patients and clinical staff/providers. Results: From August to December 2020, 165 patient visits were completed in SAC, 141 patients discharged home, 14 patients directly admitted to the hospital, and 10 patients transferred to the ED for a higher level of care. Based on data from 2020, the average cost of an ED visit for an oncology patient was $5,500 and increased to $28,500 if the patient is admitted. Patients with hematologic and gastrointestinal malignancies represented approximately 30% of all visits. Gastrointestinal symptoms were the most frequent presenting chief complaint. Conclusions: Supporting oncology patients in the ambulatory setting provided a reduction in admissions and unnecessary ED visits, leading to cost savings/avoidance to the patient and health system. Based on internal cost analyses, there are potential savings of over $2 million to the organization during this 5-month period. Additional studies are underway to assess patient satisfaction, as well as the economic impact for patients. 1. Rui PKK. National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf 2. Hong AS, Froehlich T, Clayton Hobbs S, Lee SJC, Halm EA. Impact of a Cancer Urgent Care Clinic on Regional Emergency Department Visits. J Oncol Pract. 2019;15(6):e501-e509. doi:10.1200/JOP.18.00743 3. Roy M, Halbert B, Devlin S, Chiu D, Graue R, Zerillo JA. From metrics to practice: identifying preventable emergency department visits for patients with cancer. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. Published online November 7, 2020. doi:10.1007/s00520-020-05874-3

Identification of patients at high risk for preventable emergency department visits and inpatient admissions after starting chemotherapy: Machine learning applied to comprehensive electronic health record data.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 1511-1511
Author(s):  
Dylan J. Peterson ◽  
Nicolai P. Ostberg ◽  
Douglas W. Blayney ◽  
James D. Brooks ◽  
Tina Hernandez-Boussard
Keyword(s):  
Machine Learning ◽  
Emergency Department ◽  
Electronic Health Record ◽  
Acute Care ◽  
Cancer Care ◽  
Model Performance ◽  
Emergency Department Visits ◽  
Health Record ◽  
Patients At Risk ◽  
Ed Visits

1511 Background: Acute care use is one of the largest drivers of cancer care costs. OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy is a CMS quality measure that will affect reimbursement based on unplanned inpatient admissions (IP) and emergency department (ED) visits. Targeted measures can reduce preventable acute care use but identifying which patients might benefit remains challenging. Prior predictive models have made use of a limited subset of the data available in the Electronic Health Record (EHR). We hypothesized dense, structured EHR data could be used to train machine learning algorithms to predict risk of preventable ED and IP visits. Methods: Patients treated at Stanford Health Care and affiliated community care sites between 2013 and 2015 who met inclusion criteria for OP-35 were selected from our EHR. Preventable ED or IP visits were identified using OP-35 criteria. Demographic, diagnosis, procedure, medication, laboratory, vital sign, and healthcare utilization data generated prior to chemotherapy treatment were obtained. A random split of 80% of the cohort was used to train a logistic regression with least absolute shrinkage and selection operator regularization (LASSO) model to predict risk for acute care events within the first 180 days of chemotherapy. The remaining 20% were used to measure model performance by the Area Under the Receiver Operator Curve (AUROC). Results: 8,439 patients were included, of whom 35% had one or more preventable event within 180 days of starting chemotherapy. Our LASSO model classified patients at risk for preventable ED or IP visits with an AUROC of 0.783 (95% CI: 0.761-0.806). Model performance was better for identifying risk for IP visits than ED visits. LASSO selected 125 of 760 possible features to use when classifying patients. These included prior acute care visits, cancer stage, race, laboratory values, and a diagnosis of depression. Key features for the model are shown in the table. Conclusions: Machine learning models trained on a large number of routinely collected clinical variables can identify patients at risk for acute care events with promising accuracy. These models have the potential to improve cancer care outcomes, patient experience, and costs by allowing for targeted preventative interventions. Future work will include prospective and external validation in other healthcare systems.[Table: see text]

Prior Frequent Emergency Department Use as a Predictor of Emergency Department Visits After a New Cancer Diagnosis

2021 ◽  
pp. OP.20.00889
Author(s):  
Arthur S. Hong ◽  
Danh Q. Nguyen ◽  
Simon Craddock Lee ◽  
D. Mark Courtney ◽  
John W. Sweetenham ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cancer Diagnosis ◽  
Negative Binomial ◽  
Academic Medical Center ◽  
Safety Net ◽  
Emergency Department Visits ◽  
Patients With Cancer ◽  
Safety Net Hospital ◽  
Ed Visits ◽  
After Cancer

PURPOSE: To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis. METHODS: This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics. RESULTS: Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48). CONCLUSION: The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

scholarly journals Emergency Department Visits for Opioid Overdoses Among Patients With Cancer

2019 ◽  
Vol 112 (9) ◽  
pp. 938-943 ◽  
Author(s):  
Vikram Jairam ◽  
Daniel X Yang ◽  
James B Yu ◽  
Henry S Park
Keyword(s):  
At Risk ◽  
Emergency Department ◽  
Statistical Tests ◽  
Temporal Trends ◽  
The United States ◽  
Emergency Department Visits ◽  
Multivariable Logistic Regression Analysis ◽  
Opioid Overdose ◽  
Patients With Cancer ◽  
Ed Visits

Abstract Background Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. Methods The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. Results Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. Conclusions Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.

scholarly journals Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits

2020 ◽  
Vol 11 ◽  
pp. 215013272092627
Author(s):  
Julia Ellbrant ◽  
Jonas Åkeson ◽  
Helena Sletten ◽  
Jenny Eckner ◽  
Pia Karlsland Åkeson
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Patient Characteristics ◽  
Pediatric Emergency ◽  
Emergency Department Visits ◽  
University Hospital ◽  
Pediatric Emergency Department ◽  
Hospital Data ◽  
Cross Sectional ◽  
Ed Visits

Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P < .001), visits in the lowest triage group (36% lower; P < .001), patients presenting with fever ( P = .001) or ear pain ( P < .001), and nonadmitted ED patients ( P = .033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 ( P < .001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits.

Emergency department visits for prescription and synthetic opioid overdoses among patients with cancer.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 6579-6579
Author(s):  
Vikram Jairam ◽  
Daniel X. Yang ◽  
James B. Yu ◽  
Henry S. Park
Keyword(s):  
Cervical Cancer ◽  
Emergency Department ◽  
Cancer Patients ◽  
The United States ◽  
Emergency Department Visits ◽  
Cancer Site ◽  
Opioid Overdose ◽  
Patients With Cancer ◽  
Rate Of Increase ◽  
Ed Visits

6579 Background: Patients with cancer may be at high risk of opioid dependence due to physical and psychosocial factors, although little data exists to inform providers and policymakers. Our aim is to examine overdoses from prescription and synthetic opiates leading to emergency department (ED) visits among patients with cancer in the United States. Methods: The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS) was queried for all patient visits with a primary diagnosis of prescription or synthetic opioid overdose between 2006 and 2015. Baseline differences between patients with and without cancer were assessed using chi-square and ANOVA testing. Overdose rates by primary cancer site were normalized using prevalence data from the Surveillance, Epidemiology, and End Results (SEER) Program. Weighted frequencies were used to create national estimates for all data analyses. Results: There were 682,820 weighted ED visits for synthetic opioid overdose, among which 34,547 (5.1%) visits were also associated with a diagnosis of cancer. During this timeframe, ED visits for opioid overdose among patients with cancer increased 2.5-fold, compared to 1.7-fold among those without cancer. 16.5% of patients with cancer had metastatic disease. Patients with cancer presenting for opioid overdose had higher risk of hospital admission (74.8% vs 49.6%), respiratory intubation (13.2% vs 12.2%), mortality (2.1% vs 1.1%), and cost-of-hospital-stay ($32,665 vs $31,824) compared to their non-cancer counterparts (all P < 0.05). Primary cancers with the highest normalized overdose rates (ED visits per 10,000 patients) were esophagus (134), liver & intrahepatic bile duct (124), and cervical cancer (124). Other common cancers had the following normalized overdose rates: lung (105), head and neck (70), and breast (26). Conclusions: Approximately 5% of all ED visits due to prescription and synthetic opioid overdose are among patients with cancer. The rate of increase in ED visits due to opioid overdose from cancer patients was nearly 50% higher than that from non-cancer patients over the 10-year study period. Patients with esophageal, liver, and cervical cancer may be at highest risk.

The association between hospitals’ risk-adjusted emergency department visits and survival and costs in kidney cancer patients.

2019 ◽  
Vol 37 (7_suppl) ◽  
pp. 609-609
Author(s):  
Joel E Segel ◽  
Eric W. Schaefer ◽  
Jay D. Raman ◽  
Christopher S. Hollenbeak
Keyword(s):  
Emergency Department ◽  
Cancer Patients ◽  
Kidney Cancer ◽  
Mortality Rates ◽  
Emergency Department Visits ◽  
Medicare Data ◽  
Initial Surgery ◽  
Oncology Care ◽  
Ed Visits ◽  
The Cost

609 Background: As payers turn to alternative payment models, including the CMS Oncology Care Model, risk-adjusted emergency department (ED) visits are being incorporated as a quality. Yet little is know about this metric compares to existing metrics such as risk-adjusted mortality rates and costs. Methods: Using 2007-2012 SEER-Medicare data, we used logistic regression to model occurrence of an ED visit within 30 and 365 days for all kidney cancer patients receiving initial surgery. Our model controlled for demographics, stage, histology, systemic targeted therapy, and comorbidities. Based on model predictions, we created a ratio of actual versus predicted ED visits for hospitals to identify hospitals with higher and lower than predicted ED visit rates. We estimated the association between the hospitals’ ED visit ratio and hospitals’ risk-adjusted 365-day mortality rates, and 6- and 12-month total costs and total costs (less ED visits). Results: In our sample of 6,078 patients, 15.5% had an ED visit within 30 days of surgery and 43.5% within 365 days. For hospitals with ≥10 patients, we found no statistically significant association between 30-day or 365-day risk-adjusted ED visit rate and their 365-day risk-adjusted mortality rate. While hospitals’ 30-day ED visit rates were significantly associated with 6- and 12-month costs, the association was largely driven by the cost of the ED visit itself. Conversely, hospitals’ 365-day ED visit rates were significantly associated with 12-month costs after excluding the cost of the ED visit. Conclusions: Our results suggest hospitals’ risk-adjusted ED visit rates capture a qualitatively different measure of quality than the more commonly reported mortality rates and is significantly associated with patient cost.

Frontline oncology care team primary palliative symptom guideline education, the oncology care model, and emergency department visits.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 143-143 ◽  
Author(s):  
Susan McInnes ◽  
Cheryl M Carrino ◽  
Laura Shoemaker
Keyword(s):  
Emergency Department ◽  
Cancer Patients ◽  
Cleveland Clinic ◽  
Care Quality ◽  
Emergency Department Visits ◽  
Care Model ◽  
Main Campus ◽  
Palliative Care Teams ◽  
Oncology Care ◽  
Ed Visits

143 Background: The Oncology Care Model (OCM) is a novel 5-year quality-based Oncology payment and care delivery program established by the Centers for Medicare & Medicaid Service in 2016. OCM prioritizes high-quality, coordinated care for patients undergoing chemotherapy (chemo pts.) Participating centers provide augmented services to enhance care and meet quality goals. Challenging symptoms (sxs) are common among chemo pts and may lead to hospitalization and decreased quality of life. Specialist palliative care teams are not able to see all chemo pts with active sxs. Front line oncology care teams (FLC) need education on primary palliative sx management. Methods: Cleveland Clinic Taussig Cancer Institute is one of 181 practices voluntarily participating in OCM. Locations include main campus and 5 regional cancer offices with 100 oncologists caring for about 4,000 chemotherapy patients annually. Our OCM team engaged Oncology (Onc) and Palliative Medicine (PM) providers to standardize sx management. Education was provided to FLC of all disciplines. Electronic record analytics were used to determine emergency department (ED) utilization. Results: A multidisciplinary team of Onc and PM experts developed guidelines for 4 common sxs (chemotherapy-induced neuropathy, persistent cancer pain, nausea/vomiting and constipation. Guidelines were approved by key Onc and PM staff and made available to all providers online. There were 4 educational sessions for FLCs to all sites in 2017. Urgent sx outpatient appointment slots were created in oncology offices to address uncontrolled sx. From Dec 2017 to May 2018, ED visits for all cancer patients at main campus decreased from 500/month to 453/month (9.4%.) Reductions in ED visits were also seen at 2 hospitals adjacent to regional cancer centers (16% and 6%.) Conclusions: OCM participation provided an opportunity to improve care quality at our institution. Primary palliative sx guidelines were successfully developed by an interdisciplinary team and disseminated to FLC. Urgent sx management appointments were made available in oncology offices. These interventions coincided with a reduction in ED visits for all cancer patients.

Palliative home care and emergency department visits in the last 30 and 90 days of life: a retrospective cohort study of patients with cancer

2021 ◽  
pp. bmjspcare-2021-002889
Author(s):  
Jennifer Mracek ◽  
Madalene Earp ◽  
Aynharan Sinnarajah
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Home Care ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Emergency Department Visits ◽  
Palliative Home Care ◽  
Patients With Cancer ◽  
Diagnosis Of Cancer ◽  
Ed Visits

ObjectivesEvaluate the association of specialist palliative home care (HC) on emergency department (ED) visits in the 30 and 90 days prior to death.MethodsThis retrospective cohort study using administrative data identified 6976 adults deceased from cancer between 2008 and 2015, living ≥180 days after diagnosis of cancer, and residing in the urban Calgary Zone of Alberta Health Services. All palliative HC and generalist HC services were examined. Regression analyses examined the relationships of HC type to ED visits in the last 30 or 90 days of life.ResultsIn the last 30 days of life, compared with patients receiving palliative HC, patients receiving only generalist HC, or no HC, were more likely to visit the ED (OR)generalist-HC 1.19; 95% CI 1.06 to 1.34; ORno-HC 1.54; 95% CI 1.31 to 1.82). In the last 90 days of life, compared with patients receiving palliative HC, those receiving generalist HC (OR 1.48; 95% CI 1.32 to 1.67) and no HC (OR 1.66; 95% CI 1.39 to 1.99) had increased odds of visiting the ED.ConclusionsReceiving generalist HC and no HC was associated with increased odds of visiting the ED in the last 30 and 90 days of life, when compared with patients receiving palliative HC. Improving access to palliative HC for patients at high risk of visiting the ED may reduce ED visits and acute care costs and improve quality of life in the last 90 days of life.

scholarly journals Best Practices for Reducing Unplanned Acute Care for Patients With Cancer

2018 ◽  
Vol 14 (5) ◽  
pp. 306-313 ◽  
Author(s):  
Nathan R. Handley ◽  
Lynn M. Schuchter ◽  
Justin E. Bekelman
Keyword(s):  
Emergency Department ◽  
Best Practices ◽  
Acute Care ◽  
Clinical Pathways ◽  
Optimal Strategies ◽  
Emergency Department Visits ◽  
Professional Organizations ◽  
Early Palliative Care ◽  
Patients With Cancer ◽  
Unplanned Admissions

Variation and cost in oncology care represent a large and growing burden for the US health care system, and acute hospital care is one of the single largest drivers. Reduction of unplanned acute care is a major priority for clinical transformation in oncology; proposed changes to Medicare reimbursement for patients with cancer who suffer unplanned admissions while receiving chemotherapy heighten the need. We conducted a review of best practices to reduce unplanned acute care for patients with cancer. We searched PubMed for articles published between 2000 and 2017 and reviewed guidelines published by professional organizations. We identified five strategies to reduce unplanned acute care for patients with cancer: (1) identify patients at high risk for unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new loci for urgent cancer care; and (5) use early palliative care. We assessed each strategy on the basis of specific outcomes: reduction in emergency department visits, reduction in hospitalizations, and reduction in rehospitalizations within 30 days. For each, we define gaps in knowledge and identify areas for future effort. These five strategies can be implemented separately or, with possibly more success, as an integrated program to reduce unplanned acute care for patients with cancer. Because of the large investment required and the limited data on effectiveness, there should be further research and evaluation to identify the optimal strategies to reduce emergency department visits, hospitalizations, and rehospitalizations. Proposed reimbursement changes amplify the need for cancer programs to focus on this issue.

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