Focus on Quality
Original Contribution
Are Patients With Thoracic Malignancies at Risk for Uncontrolled Symptoms?
Stanford University; Stanford Hospitals and Clinics, Stanford; and University of California Los Angeles, Los Angeles, CA
contact their oncologists and care teams after normal clinic operating hours. Better understanding of these after-hours telephone calls can inform efforts to improve cancer care and to reduce health care spending. We sought to evaluate after-hours calls at Stanford Cancer Institute (SCI) Thoracic Oncology Clinic.
241 telephone calls for analysis. The majority of calls occurred between 5 PM to 11 PM (n ⫽ 175 [73%]; P ⬍ .001), followed by daytime calls on weekends (n ⫽ 157 [65%]; P ⬍ .001). Common symptoms were cough (28%) and dyspnea (27%). Of the calls, 62% (150 patients) resulted in emergency department (ED) referral, and 77% of patients (115 of 150) evaluated in the ED were admitted to the hospital.
Methods: We retrospectively analyzed content of telephone
Conclusion: Most after-hours telephone calls from pa-
call notes made to SCI during weekends and from 5 PM to 8 AM on weekdays. Chief complaint, caller and patient demographics, patient diagnosis, advice given, and disposition were analyzed. 2 tests were used to analyze differences in proportions.
tients with lung cancer are related to symptoms. Many patients were referred to the ED and subsequently required hospitalization. Analysis of call content and prior events leading to after-hours calls may predict hospital admissions in this group of patients and can inform development of proactive interventions to improve quality of care and patient-centered outcomes.
Abstract Purpose: Patients with cancer often develop symptoms and
Results: There were a total of 263 after-hours telephone calls during the 6 months of the study. After exclusions, there were
Introduction Lung cancer, although decreasing in incidence, remains a major cause of death and morbidity in the United States.1 Secular trends—increasing incidence among women, survival rates, and chronically administered oral therapies—are changing the way lung cancer treatment is delivered.1-3 The shift from inpatient to outpatient care has made telephonic access increasingly important for quality cancer care delivery. Specifically, access to telephonic after-hours medical advice and triage when outpatient oncology clinics are closed or otherwise not available because of distance is now standard of care for many patients and their caregivers.4-10 Despite the increasing reliance on telephonic access to medical advice after hours, little is known about the nature of telephone calls made by patients with lung cancer when clinics are closed. Studies in nononcology settings have revealed that telephone-based care has been used by patients as a way to seek emergent relief and avoid copays associated with visits during the day and associated absenteeism from work.11,12 For patients with cancer, one institution-based study revealed that pain was the most common symptom reported in after-hours calls.13 Other studies of oncology patients have suggested advice on oral chemotherapy is a common reason for calls, given the limitations of adaptations of oncology systems to oral chemotherapy plan delivery.14 Additionally, other studies have revealed that poor delivery of after-hours care can result in increased use of health care resources, specifically, unplanned hospitalizations and emergency department (ED) visits.15,16 e98
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Understanding the nature of after-hours calls for patients with lung cancer may help to inform more proactive interventions for patients during or after clinic hours. Better understanding of reasons why patients call and of disposition can lead to the development of programs that improve quality of afterhours care delivery for patients with lung cancer and potentially reduce health care use. We studied a consecutive sample of after-hours telephone calls initiated by patients with lung cancer at the Stanford Cancer Institute (SCI) to better understand reasons for calls and resolution and to determine if there are opportunities to improve care delivery.
Methods The study was a retrospective analysis of 6 months of afterhours telephone calls made by patients with lung cancer who were cared for by a large academic cancer institute. In our institution, all patients who are seen by treating oncologists are given a central telephone number to call if questions arise at any point during the course of their care. This includes any patient who is under active treatment or follow-up for his or her lung cancer diagnosis. During the day, dedicated oncology-trained nurses track and triage calls to the appropriate staff. After business hours, from 5 PM to 8 AM on weekdays and from 5 PM on Friday to 8 AM on Monday, as well as all day on holidays, the calls are routed to trained on-call oncology physicians (fellows who have finished their clinical training and/or junior faculty), who are paid to specifically to provide this service. Physicians respond to the patient, provide advice, and contemporaneously
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at University of Manchester Library on June 2, 2015 from 130.88.90.140 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
By Manali I. Patel, MD, MPH, Donna C. Williams, RN, Carla Wohlforth, George Fisher, MD, PhD, Heather A. Wakelee, MD, and Douglas W. Blayney, MD
Analysis of Telephone Calls Made After Hours
Table 1. Cohort Demographics (N ⫽ 225) Characteristic
No.
%
Age, years Mean
56.6
Range
30-90
Sex Male
103
46
Female
122
54
Race/ethnicity 193
86
African American
White
5
2
Hispanic
5
2
22
10
Patient
113
50
Caregiver
112
50
Asian Caller
cycle of chemotherapy. The distribution of the 241 telephone calls across time of day is shown in Figure 1. Seventy-three percent of weeknight calls occurred between the hours of 5 PM and 11 PM. On weekends and holidays, 65% percent of calls occurred between the hours of 8 AM and 5 PM. The number of patients, along with the proportion of calls, referred to the ED and subsequently hospitalized is shown in Figure 2. Many calls concerned more than one complaint
A 27%
73%
Results Overall, there were a total of 263 after-hours telephone calls initiated to our institution regarding symptoms for 225 unique patients (Table 1). There were 34 patients (15%) who initiated more than one after-hours call: 30 patients (13%) initiated two calls, and four patients (2%) initiated three calls. After excluding 22 telephone calls (8.5%) for missing data, there were 241 telephone calls (92%) for analysis initiated by or for 225 unique patients. For reference only—to compare the size of our clinic with other lung cancer subspecialty clinics— during the study period, our institution had 436 unique patients with 468 new patient visits (some new patients in our multidisciplinary clinic saw ⬎ one provider); we also had 2,148 return visits and 1,011 visits for infusion services. The person who initiated the call was the patient (50%) or the caregiver or relative (50%). The majority of telephone calls were made in regard to the care of female patients (54%). The highest age distribution was patients age 50 to 59 years (29%). Of the 225 patients who called, 18% were undergoing their first Copyright © 2014 by American Society of Clinical Oncology
5 pm–11 pm 11 pm–8 am
B 10%
25% 65% 8 am–5 pm 5 pm–11 pm 11 pm–8 am
Figure 1. Distribution of calls by time. (A) Weekdays; (B) weekends and holidays.
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document the encounter as a telephone note in the electronic health record (EHR). Information documented by the on-call physicians includes date and time of the call, the caller’s identity (eg, patient, spouse, other family member, and so on), the patient’s chief complaint, the advice given, and the disposition. Patient age, sex, diagnosis, and primary oncologist are available in the EHR for the on-call physician’s use. The telephone note is then routed to the patient’s primary oncologist and the triage nurse for follow-up on the following business day. The triage nurse transfers the documentation from the EHR into a separate deidentified database (ie, triage nurse database). This database is updated daily by the daytime triage nurses and includes all information documented in the EHR by the after-hours on-call physicians: date and time of call, caller’s identify, chief complaint, and review of symptoms, disposition, age, sex, and diagnosis. The nurses also review the medical record for clinical care the following day and report the patient’s ultimate disposition (ie, ED visit, hospitalization, or medication refills). The triage nurse database is used for follow-up of patient calls and for quality-improvement purposes. We analyzed the triage nurse database for after-hours calls from patients cared for in the lung cancer clinic. Specifically, we analyzed documentation from calls made by patients and their caregivers over the weekends, on holidays, and during the hours from 5 PM to 8 AM on weekdays from January 1, 2013, to July 1, 2013. We analyzed the reasons for the telephone calls and the ultimate advice given and disposition. We verified the numbers of calls recorded in the triage nurse database during the study period with hospital operator records. We excluded calls with missing information regarding reason for call, advice given, or ultimate disposition. Differences in proportions were analyzed by 2 test using SAS software (version 9.2; SAS Institute, Cary, NC). A twosided P value less than .05 was considered significant. The Stanford Institutional Review Board reviewed and approved this study as a quality-improvement exercise.
Patel et al
70 Hospitalizations ED visits Calls
60
Percent
50 40 30
10
au
N
Sh o
rt
ne
ss
Co u
g of P h br ain e se a/ F ath vo ev m er i Fa tin M tig g ed ic u at Ra e io n O sh H que the e r Co mo stio A lte ns pt n re tip ys d i m D at s Bl en iar ion t r N oo al he as d s a al p tat co res us ng su M est re uc io o n U rin Ta An siti ar ch xi s y yc et fr a y eq rd ue ia nc y
0
Figure 2. Subjects of calls and disposition proportion. ED, emergency department.
(30%); however, after reviewing all symptoms documented in the database, almost all calls (95%) concerned more than one symptom (P ⬍ .001), with a high percentage of these additional symptoms uncovered on review of systems (76%). The main symptoms reported were cough (28%) and shortness of breath (2%). Disposition proportions for ED and hospitalizations are shown by symptom in Figure 2; all dispositions are shown in Figure 3. Among the 241 calls, 30% resulted in the patient being provided with telephonic advice (reassurance, 20%; treatment advice, 10%); in 5%, the patient was provided with medication (refill or new prescription); in 62% (150 telephone calls; P ⫽ .01), the patient was referred to ED. Of the 150 patients referred to the ED, the primary symptoms for referral were: fever more than 100.4°F (n ⫽ 30; 20%), shortness of breath (n ⫽ 30; 20%), nausea/vomiting (n ⫽ 22; 15%), diarrhea (n ⫽ 18; 12%), pain (n ⫽ 16; 11%), fatigue (n ⫽ 15; 10%), mucositis (n ⫽ 10; 7%), and constipation (n ⫽ 7; 5%; Figure 2). Of those calls in which the patient was referred to the ED, 77% (115 of 150 calls) resulted in hospital admission (P ⫽ .001). Hospital admissions were more common among patients with fever (n ⫽ 33; 29%); vomiting (n ⫽ 17; 15%), shortness of breath (n ⫽ 16; 14%), pain (n ⫽ 15; 13%), fatigue (n ⫽ 13;
3% 5%
30% 62% Other Medication question/refill Telephone advice ED
Figure 3. All dispositions. ED, emergency department.
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Discussion During the study period, there were a total of 263 afterhours telephone calls regarding the care of patients with lung cancer. Our study is the first to our knowledge to focus on the nature of after-hours calls for patients with lung cancer. Understanding the reasons why patients initiate telephone calls after hours is important because it can represent an opportunity to improve the current knowledge of symptoms experienced by patients with lung cancer. Additionally, the characteristics and timing of patient calls can help inform staffing needs for after-hours care. Furthermore, an afterhours call may represent a high-risk condition for a subsequent unplanned hospitalization. In agreement with other studies in the oncology and nononcology settings, we found that patient calls were initiated in similar proportions by patients and their caregivers.6,7,17 Although our lung cancer clinic demographics comprise equal proportions of men and women, we found that the majority of after-hours calls were made regarding care for a female patient, consistent with previous studies17-19; this may represent the changing demographics of lung cancer or the inherent nature of women to seek medical care being more likely than that of men.20,21 Similar to other studies in private practice, we found that large volumes of calls were initiated in the early evenings on weeknights and during the day on weekends.6,18,19,22 In our study, few telephone calls occurred in the late evening or early morning hours, perhaps revealing that calls may be more acute if they are made during a time that disrupts the sleep of the patient, caregiver, and provider. This potential temporal association requires further investigation. Notably, there was also a wide interval between the time when a provider last saw the patient (mean, 34.2 days; range, 0 to 330 days). This wide interval warrants further investigation to determine whether there are actionable metrics to prevent after-hours use. In contrast to the few other studies of after-hours oncology calls, we found that most telephone calls were initiated for more than one symptom that required intervention.13,23 This may be because our system of after-hours telephone calls requires triage by physicians who are trained to consistently report on the full review of systems, whereas other
V O L . 11, I S S U E 1
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20
11%), constipation (n ⫽ 7; 6%), tachycardia (n ⫽ 6; 5%), cough (n ⫽ 5; 4%), and low blood pressure (n ⫽ 3; 3%) represented the other symptoms that resulted in hospital admission. Of the 34 patients who called more than once, there were 27 (79%) who called for the same symptom. Of these patients, 10 (37%) called consecutively (2 nights in a row) for the same symptom (five with shortness of breath, three with vomiting, and two with fatigue). All of these patients were referred to the ED and subsequently admitted to the hospital. To analyze for exclusion bias, we found that of the 8.5% of telephone calls excluded because of missing documentation, there were similar but nonstatistically significantly lower rates of ED use (56%; P ⫽ .51) and admissions (65%; P ⫽ .48) compared to the analytic cohort.
Analysis of Telephone Calls Made After Hours
Copyright © 2014 by American Society of Clinical Oncology
ance, or proximity to treating hospital). These factors may influence after-hours use or nonuse of our after-hours call system and are important considerations for future analyses. Because the scope of the study focused on understanding reasons patients and caregivers initiate calls, our sample reflects the patient population most at risk for experiencing after-hours unmet needs. Our study, however, highlights that the development of a program dedicated to proactive symptom management should also be applied to patients who do not call after hours to further reduce likelihood of under-reported symptoms in this patient population. These findings reveal highly prevalent and pervasive patient concerns after hours. This study was limited to telephone calls, and therefore, we were unable to capture patient-initiated e-mails sent to physicians or e-mails sent through the EHR patient portal. The exclusion of these e-mails may be a source of bias; however, there are a small number of e-mails sent to physicians (approximately zero to one per week), and per the thoracic oncology providers, these e-mails are unlikely to be a significant source of bias during the time of this study, because they are usually dedicated to non–symptom-related issues. Future studies should comprehensively evaluate needs of patients who do not initiate calls after hours and further investigate other sources of patient contact with medical providers. Additionally, because this study was a pilot evaluation, we only obtained information on patients with lung cancer, given the changing demographics and increased use of oral chemotherapeutics in this patient population. A future evaluation is planned for the larger cohort of disease groups. Despite the limitations of our study, our work has important implications. Understanding after-hours calls for patients with cancer can provide insight into patient needs and patterns of symptom reporting. This study can also help us develop interventions that improve access to care and high-value cancer care delivery through protocol development, patient education, and proactive symptom management. In conclusion, proactive, high-value cancer care delivery requires a better understanding of patient and caregiver needs. Understanding the reasons patients call after hours can reveal opportunities for interventions dedicated to improving patient and caregiver experiences. The implications of our study on current practice are important, because the results reveal the need to provide more proactive symptom management for patients during clinic and in between clinic visits. Proactive approaches to improving after-hours care may prevent use of health care resources while improving patient and caregiver quality of life and satisfaction with care. Acknowledgment Presented at the American Society of Clinical Oncology Quality Care Symposium, San Diego, CA, November 1-2, 2013 (Abstract Merit Award winner).
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studies were conducted in settings where nonphysician staff answered the calls.8,13 The high number of symptoms uncovered on review of systems corroborates previous findings of under-reported symptoms by patients with cancer.24 This finding also reveals the opportunities to routinely conduct proactive symptom assessments. Additionally, in contrast to other studies, we revealed a striking observation that a majority of calls were regarding chief complaints of common symptoms, such as cough and shortness of breath, as opposed to pain.13,23,25,26 Although pain emerged as a common complaint, it was less prevalent than in other reported studies in the non–thoracic oncology setting5,7,13 and was uncovered on the physicians’ documented review of systems. These findings may be because of practice differences in pain management or the nature of symptoms patients with lung cancer may experience.25 We also found a wide range of other less common complaints, such as rash and medication refill, concerns that may be managed during clinic hours. Many telephone calls led to subsequent ED visits and unplanned hospitalization, similar to findings in nononcology settings, where physicians felt compelled to refer simple patient cases to the ED for further management, and/or patient cases were acute enough to require evaluation.7,19 In our study, a striking finding was that the patients who called more than once consecutively for the same symptom were subsequently admitted to the hospital for that chief complaint. Although we did not analyze the numbers of referrals made to the ED during the day, these findings, specifically the more commonly reported symptoms, along with the numbers of calls initiated more than once by the same patient, represent opportunities to decrease use of after-hours care through proactive early interventions guided by evidence-based symptom treatment algorithms. Our study has some limitations. First, our evaluation was a retrospective analysis of existing data on telephone calls made to a single institution after hours. We included calls only with physician-documented encounters that were abstracted by daytime triage nurses the opening clinic day after the calls were initiated. We had not previously verified this system, which could have introduced error; however, during the study period, we verified, with Stanford Hospital operator records, that daytime nurses documented 100% of afterhours calls. Because the study was retrospective, we limited our analysis to previously collected data and calls with no missing documentation. Retrospective record reviews are limited by poor and missing documentation. Despite exclusions for missing data, we were able to analyze a significant proportion of after-hours telephone calls. Of those telephone calls with missing data, we found ED use and hospital admission rates similar to those in our analytic cohort. Additionally, because of lack of patient identification and limited documentation, we were unable to analyze stage of disease or treatment type, nor could we examine other covariates such as individual-level factors (ie, education, insur-
Patel et al
Manuscript writing: All authors
Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Final approval of manuscript: All authors Corresponding author: Manali I. Patel, MD, MSPH, 875 Blake Wilbur Dr, Stanford, CA 94305; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001502; published online ahead of print at jop.ascopubs.org on September 30, 2014.
References 1. Centers for Disease Control and Prevention: Lung cancer statistics. www. cdc.gov/cancer/lung/statistics
14. National Comprehensive Cancer Network: NCCN Task Force Report: Oral Chemotherapy. www.nccn.org/JNCCN/PDF/JNSU3_combined_Oral_Chemo_2008.pdf
2. American Cancer Society. www.cancer.org/cancer/lungcancer-non-smallcell/ detailedguide/non-small-cell-lung-cancer-treating-targeted-therapies
15. Wagner-Johnston ND, Carson KA, Grossman SA: High outpatient pain intensity scores predict impending hospital admissions in patients with cancer. J Pain Symptom Manage 39:180-185, 2010
3. National Comprehensive Cancer Network. www.nccn.org/professionals/ physician_gls/pdf/nscl.pdf 4. McCann L, Maguire R, Miller M, et al: Patients’ perceptions and experiences of using a mobile phone-based advanced symptom management system (ASyMS) to monitor and manage chemotherapy related toxicity. Eur J Cancer Care (Engl) 18:156-164, 2009 5. Kroenke K, Theobald D, Norton K, et al: The Indiana Cancer Pain and Depression (INCPAD) trial: Design of a telecare management intervention for cancerrelated symptoms and baseline characteristics of study participants. Gen Hosp Psychiatry 31:240-253, 2009
16. Temel JS, Pirl WF, Lynch TJ: Comprehensive symptom management in patients with advanced-stage non-small-cell lung cancer. Clin Lung Cancer 7:241249, 2006 17. Jacobson BC, Strate L, Baffy G, et al: The nature of after-hours telephone medical practice by GI fellows. Am J Gastroenterol 96:570-573, 2001 18. Radecki SE, Neville RE, Girard RA: Telephone patient management by primary care physicians. Med Care 27:817-822, 1989
6. Flannery M, Phillips SM, Lyons CA: Examining telephone calls in ambulatory oncology. J Oncol Pract 5:57-60, 2009
19. Greenhouse DL, Probst JC: After-hours telephone calls in a family practice residency: Volume, seriousness, and patient satisfaction. Fam Med 27:525-530, 1995
7. Nail LM, Greene D, Jones LS, et al: Nursing care by telephone: Describing practice in an ambulatory oncology center. Oncol Nurs Forum 16:387-395, 1989
20. Bertakis KD, Azari R: Patient gender differences in the prediction of medical expenditures. J Womens Health (Larchmt) 19:1925-1932, 2010
8. Maguire R, McCann L, Miller M, et al: Nurse’s perceptions and experiences of using of a mobile-phone-based Advanced Symptom Management System (ASyMS) to monitor and manage chemotherapy-related toxicity. Eur J Oncol Nurs 12:380-386, 2008
21. Bertakis KD, Azari R, Helms LJ, et al: Gender differences in the utilization of health care services. J Fam Pract 49:147-152, 2000
9. Elnicki DM, Ogden P, Flannery M, et al: Telephone medicine for internists. J Gen Intern Med 15:337-343, 2000 10. Cykert S, Flannery MT, Huber EC, et al: Telephone medical care administered by internal medicine residents: Concerns of program directors and implications for residency training. Am J Med Sci 314:198-202, 1997 11. Brown A, Armstrong D: Telephone consultations in general practice: An additional or alternative service? Br J Gen Pract 45:673-675, 1995 12. Daugird AJ, Spencer DC: Characteristics of patients who highly utilize telephone medical care in a private practice. J Fam Pract 29:59-63, 1989; discussion 63-64 13. Flannery M, McAndrews L, Stein KF: Telephone calls by individuals with cancer. Oncol Nurs Forum 40:464-471, 2013
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22. Pitts J, Whitby M: Out of hours workload of a surburban general practice: Deprivation of expectation. BMJ 300:1113-1115, 1990 23. Reid J, Porter S: Utility, caller, and patient profile of a novel chemotherapy telephone helpline service within a regional cancer centre in Northern Ireland. Cancer Nurs 34:E27-E32, 2011 24. Shoemaker LK, Estfan B, Induru R, et al: Symptom management: An important part of cancer care. Cleve Clin J Med 78:25-34, 2011 25. Tishelman C, Petersson LM, Degner LF, et al: Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death. J Clin Oncol 25:5381-5389, 2007 26. Homsi J, Walsh D, Rivera N, et al: Symptom evaluation in palliative medicine: Patient report vs systematic assessment. Support Care Cancer 14:444-453, 2006
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at University of Manchester Library on June 2, 2015 from 130.88.90.140 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
Author Contributions Conception and design: Manali I. Patel, Douglas W. Blayney Collection and assembly of data: Manali I. Patel, Donna C. Williams, Carla Wohlforth, George Fisher Data analysis and interpretation: Manali I. Patel, George Fisher, Heather A. Wakelee, Douglas W. Blayney
Original Contribution
Are Patients With Thoracic Malignancies at Risk for Uncontrolled Symptoms?
Stanford University; Stanford Hospitals and Clinics, Stanford; and University of California Los Angeles, Los Angeles, CA
contact their oncologists and care teams after normal clinic operating hours. Better understanding of these after-hours telephone calls can inform efforts to improve cancer care and to reduce health care spending. We sought to evaluate after-hours calls at Stanford Cancer Institute (SCI) Thoracic Oncology Clinic.
241 telephone calls for analysis. The majority of calls occurred between 5 PM to 11 PM (n ⫽ 175 [73%]; P ⬍ .001), followed by daytime calls on weekends (n ⫽ 157 [65%]; P ⬍ .001). Common symptoms were cough (28%) and dyspnea (27%). Of the calls, 62% (150 patients) resulted in emergency department (ED) referral, and 77% of patients (115 of 150) evaluated in the ED were admitted to the hospital.
Methods: We retrospectively analyzed content of telephone
Conclusion: Most after-hours telephone calls from pa-
call notes made to SCI during weekends and from 5 PM to 8 AM on weekdays. Chief complaint, caller and patient demographics, patient diagnosis, advice given, and disposition were analyzed. 2 tests were used to analyze differences in proportions.
tients with lung cancer are related to symptoms. Many patients were referred to the ED and subsequently required hospitalization. Analysis of call content and prior events leading to after-hours calls may predict hospital admissions in this group of patients and can inform development of proactive interventions to improve quality of care and patient-centered outcomes.
Abstract Purpose: Patients with cancer often develop symptoms and
Results: There were a total of 263 after-hours telephone calls during the 6 months of the study. After exclusions, there were
Introduction Lung cancer, although decreasing in incidence, remains a major cause of death and morbidity in the United States.1 Secular trends—increasing incidence among women, survival rates, and chronically administered oral therapies—are changing the way lung cancer treatment is delivered.1-3 The shift from inpatient to outpatient care has made telephonic access increasingly important for quality cancer care delivery. Specifically, access to telephonic after-hours medical advice and triage when outpatient oncology clinics are closed or otherwise not available because of distance is now standard of care for many patients and their caregivers.4-10 Despite the increasing reliance on telephonic access to medical advice after hours, little is known about the nature of telephone calls made by patients with lung cancer when clinics are closed. Studies in nononcology settings have revealed that telephone-based care has been used by patients as a way to seek emergent relief and avoid copays associated with visits during the day and associated absenteeism from work.11,12 For patients with cancer, one institution-based study revealed that pain was the most common symptom reported in after-hours calls.13 Other studies of oncology patients have suggested advice on oral chemotherapy is a common reason for calls, given the limitations of adaptations of oncology systems to oral chemotherapy plan delivery.14 Additionally, other studies have revealed that poor delivery of after-hours care can result in increased use of health care resources, specifically, unplanned hospitalizations and emergency department (ED) visits.15,16 e98
JOURNAL
OF
ONCOLOGY PRACTICE
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Understanding the nature of after-hours calls for patients with lung cancer may help to inform more proactive interventions for patients during or after clinic hours. Better understanding of reasons why patients call and of disposition can lead to the development of programs that improve quality of afterhours care delivery for patients with lung cancer and potentially reduce health care use. We studied a consecutive sample of after-hours telephone calls initiated by patients with lung cancer at the Stanford Cancer Institute (SCI) to better understand reasons for calls and resolution and to determine if there are opportunities to improve care delivery.
Methods The study was a retrospective analysis of 6 months of afterhours telephone calls made by patients with lung cancer who were cared for by a large academic cancer institute. In our institution, all patients who are seen by treating oncologists are given a central telephone number to call if questions arise at any point during the course of their care. This includes any patient who is under active treatment or follow-up for his or her lung cancer diagnosis. During the day, dedicated oncology-trained nurses track and triage calls to the appropriate staff. After business hours, from 5 PM to 8 AM on weekdays and from 5 PM on Friday to 8 AM on Monday, as well as all day on holidays, the calls are routed to trained on-call oncology physicians (fellows who have finished their clinical training and/or junior faculty), who are paid to specifically to provide this service. Physicians respond to the patient, provide advice, and contemporaneously
V O L . 11, I S S U E 1
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at University of Manchester Library on June 2, 2015 from 130.88.90.140 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
By Manali I. Patel, MD, MPH, Donna C. Williams, RN, Carla Wohlforth, George Fisher, MD, PhD, Heather A. Wakelee, MD, and Douglas W. Blayney, MD
Analysis of Telephone Calls Made After Hours
Table 1. Cohort Demographics (N ⫽ 225) Characteristic
No.
%
Age, years Mean
56.6
Range
30-90
Sex Male
103
46
Female
122
54
Race/ethnicity 193
86
African American
White
5
2
Hispanic
5
2
22
10
Patient
113
50
Caregiver
112
50
Asian Caller
cycle of chemotherapy. The distribution of the 241 telephone calls across time of day is shown in Figure 1. Seventy-three percent of weeknight calls occurred between the hours of 5 PM and 11 PM. On weekends and holidays, 65% percent of calls occurred between the hours of 8 AM and 5 PM. The number of patients, along with the proportion of calls, referred to the ED and subsequently hospitalized is shown in Figure 2. Many calls concerned more than one complaint
A 27%
73%
Results Overall, there were a total of 263 after-hours telephone calls initiated to our institution regarding symptoms for 225 unique patients (Table 1). There were 34 patients (15%) who initiated more than one after-hours call: 30 patients (13%) initiated two calls, and four patients (2%) initiated three calls. After excluding 22 telephone calls (8.5%) for missing data, there were 241 telephone calls (92%) for analysis initiated by or for 225 unique patients. For reference only—to compare the size of our clinic with other lung cancer subspecialty clinics— during the study period, our institution had 436 unique patients with 468 new patient visits (some new patients in our multidisciplinary clinic saw ⬎ one provider); we also had 2,148 return visits and 1,011 visits for infusion services. The person who initiated the call was the patient (50%) or the caregiver or relative (50%). The majority of telephone calls were made in regard to the care of female patients (54%). The highest age distribution was patients age 50 to 59 years (29%). Of the 225 patients who called, 18% were undergoing their first Copyright © 2014 by American Society of Clinical Oncology
5 pm–11 pm 11 pm–8 am
B 10%
25% 65% 8 am–5 pm 5 pm–11 pm 11 pm–8 am
Figure 1. Distribution of calls by time. (A) Weekdays; (B) weekends and holidays.
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document the encounter as a telephone note in the electronic health record (EHR). Information documented by the on-call physicians includes date and time of the call, the caller’s identity (eg, patient, spouse, other family member, and so on), the patient’s chief complaint, the advice given, and the disposition. Patient age, sex, diagnosis, and primary oncologist are available in the EHR for the on-call physician’s use. The telephone note is then routed to the patient’s primary oncologist and the triage nurse for follow-up on the following business day. The triage nurse transfers the documentation from the EHR into a separate deidentified database (ie, triage nurse database). This database is updated daily by the daytime triage nurses and includes all information documented in the EHR by the after-hours on-call physicians: date and time of call, caller’s identify, chief complaint, and review of symptoms, disposition, age, sex, and diagnosis. The nurses also review the medical record for clinical care the following day and report the patient’s ultimate disposition (ie, ED visit, hospitalization, or medication refills). The triage nurse database is used for follow-up of patient calls and for quality-improvement purposes. We analyzed the triage nurse database for after-hours calls from patients cared for in the lung cancer clinic. Specifically, we analyzed documentation from calls made by patients and their caregivers over the weekends, on holidays, and during the hours from 5 PM to 8 AM on weekdays from January 1, 2013, to July 1, 2013. We analyzed the reasons for the telephone calls and the ultimate advice given and disposition. We verified the numbers of calls recorded in the triage nurse database during the study period with hospital operator records. We excluded calls with missing information regarding reason for call, advice given, or ultimate disposition. Differences in proportions were analyzed by 2 test using SAS software (version 9.2; SAS Institute, Cary, NC). A twosided P value less than .05 was considered significant. The Stanford Institutional Review Board reviewed and approved this study as a quality-improvement exercise.
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70 Hospitalizations ED visits Calls
60
Percent
50 40 30
10
au
N
Sh o
rt
ne
ss
Co u
g of P h br ain e se a/ F ath vo ev m er i Fa tin M tig g ed ic u at Ra e io n O sh H que the e r Co mo stio A lte ns pt n re tip ys d i m D at s Bl en iar ion t r N oo al he as d s a al p tat co res us ng su M est re uc io o n U rin Ta An siti ar ch xi s y yc et fr a y eq rd ue ia nc y
0
Figure 2. Subjects of calls and disposition proportion. ED, emergency department.
(30%); however, after reviewing all symptoms documented in the database, almost all calls (95%) concerned more than one symptom (P ⬍ .001), with a high percentage of these additional symptoms uncovered on review of systems (76%). The main symptoms reported were cough (28%) and shortness of breath (2%). Disposition proportions for ED and hospitalizations are shown by symptom in Figure 2; all dispositions are shown in Figure 3. Among the 241 calls, 30% resulted in the patient being provided with telephonic advice (reassurance, 20%; treatment advice, 10%); in 5%, the patient was provided with medication (refill or new prescription); in 62% (150 telephone calls; P ⫽ .01), the patient was referred to ED. Of the 150 patients referred to the ED, the primary symptoms for referral were: fever more than 100.4°F (n ⫽ 30; 20%), shortness of breath (n ⫽ 30; 20%), nausea/vomiting (n ⫽ 22; 15%), diarrhea (n ⫽ 18; 12%), pain (n ⫽ 16; 11%), fatigue (n ⫽ 15; 10%), mucositis (n ⫽ 10; 7%), and constipation (n ⫽ 7; 5%; Figure 2). Of those calls in which the patient was referred to the ED, 77% (115 of 150 calls) resulted in hospital admission (P ⫽ .001). Hospital admissions were more common among patients with fever (n ⫽ 33; 29%); vomiting (n ⫽ 17; 15%), shortness of breath (n ⫽ 16; 14%), pain (n ⫽ 15; 13%), fatigue (n ⫽ 13;
3% 5%
30% 62% Other Medication question/refill Telephone advice ED
Figure 3. All dispositions. ED, emergency department.
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Discussion During the study period, there were a total of 263 afterhours telephone calls regarding the care of patients with lung cancer. Our study is the first to our knowledge to focus on the nature of after-hours calls for patients with lung cancer. Understanding the reasons why patients initiate telephone calls after hours is important because it can represent an opportunity to improve the current knowledge of symptoms experienced by patients with lung cancer. Additionally, the characteristics and timing of patient calls can help inform staffing needs for after-hours care. Furthermore, an afterhours call may represent a high-risk condition for a subsequent unplanned hospitalization. In agreement with other studies in the oncology and nononcology settings, we found that patient calls were initiated in similar proportions by patients and their caregivers.6,7,17 Although our lung cancer clinic demographics comprise equal proportions of men and women, we found that the majority of after-hours calls were made regarding care for a female patient, consistent with previous studies17-19; this may represent the changing demographics of lung cancer or the inherent nature of women to seek medical care being more likely than that of men.20,21 Similar to other studies in private practice, we found that large volumes of calls were initiated in the early evenings on weeknights and during the day on weekends.6,18,19,22 In our study, few telephone calls occurred in the late evening or early morning hours, perhaps revealing that calls may be more acute if they are made during a time that disrupts the sleep of the patient, caregiver, and provider. This potential temporal association requires further investigation. Notably, there was also a wide interval between the time when a provider last saw the patient (mean, 34.2 days; range, 0 to 330 days). This wide interval warrants further investigation to determine whether there are actionable metrics to prevent after-hours use. In contrast to the few other studies of after-hours oncology calls, we found that most telephone calls were initiated for more than one symptom that required intervention.13,23 This may be because our system of after-hours telephone calls requires triage by physicians who are trained to consistently report on the full review of systems, whereas other
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11%), constipation (n ⫽ 7; 6%), tachycardia (n ⫽ 6; 5%), cough (n ⫽ 5; 4%), and low blood pressure (n ⫽ 3; 3%) represented the other symptoms that resulted in hospital admission. Of the 34 patients who called more than once, there were 27 (79%) who called for the same symptom. Of these patients, 10 (37%) called consecutively (2 nights in a row) for the same symptom (five with shortness of breath, three with vomiting, and two with fatigue). All of these patients were referred to the ED and subsequently admitted to the hospital. To analyze for exclusion bias, we found that of the 8.5% of telephone calls excluded because of missing documentation, there were similar but nonstatistically significantly lower rates of ED use (56%; P ⫽ .51) and admissions (65%; P ⫽ .48) compared to the analytic cohort.
Analysis of Telephone Calls Made After Hours
Copyright © 2014 by American Society of Clinical Oncology
ance, or proximity to treating hospital). These factors may influence after-hours use or nonuse of our after-hours call system and are important considerations for future analyses. Because the scope of the study focused on understanding reasons patients and caregivers initiate calls, our sample reflects the patient population most at risk for experiencing after-hours unmet needs. Our study, however, highlights that the development of a program dedicated to proactive symptom management should also be applied to patients who do not call after hours to further reduce likelihood of under-reported symptoms in this patient population. These findings reveal highly prevalent and pervasive patient concerns after hours. This study was limited to telephone calls, and therefore, we were unable to capture patient-initiated e-mails sent to physicians or e-mails sent through the EHR patient portal. The exclusion of these e-mails may be a source of bias; however, there are a small number of e-mails sent to physicians (approximately zero to one per week), and per the thoracic oncology providers, these e-mails are unlikely to be a significant source of bias during the time of this study, because they are usually dedicated to non–symptom-related issues. Future studies should comprehensively evaluate needs of patients who do not initiate calls after hours and further investigate other sources of patient contact with medical providers. Additionally, because this study was a pilot evaluation, we only obtained information on patients with lung cancer, given the changing demographics and increased use of oral chemotherapeutics in this patient population. A future evaluation is planned for the larger cohort of disease groups. Despite the limitations of our study, our work has important implications. Understanding after-hours calls for patients with cancer can provide insight into patient needs and patterns of symptom reporting. This study can also help us develop interventions that improve access to care and high-value cancer care delivery through protocol development, patient education, and proactive symptom management. In conclusion, proactive, high-value cancer care delivery requires a better understanding of patient and caregiver needs. Understanding the reasons patients call after hours can reveal opportunities for interventions dedicated to improving patient and caregiver experiences. The implications of our study on current practice are important, because the results reveal the need to provide more proactive symptom management for patients during clinic and in between clinic visits. Proactive approaches to improving after-hours care may prevent use of health care resources while improving patient and caregiver quality of life and satisfaction with care. Acknowledgment Presented at the American Society of Clinical Oncology Quality Care Symposium, San Diego, CA, November 1-2, 2013 (Abstract Merit Award winner).
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studies were conducted in settings where nonphysician staff answered the calls.8,13 The high number of symptoms uncovered on review of systems corroborates previous findings of under-reported symptoms by patients with cancer.24 This finding also reveals the opportunities to routinely conduct proactive symptom assessments. Additionally, in contrast to other studies, we revealed a striking observation that a majority of calls were regarding chief complaints of common symptoms, such as cough and shortness of breath, as opposed to pain.13,23,25,26 Although pain emerged as a common complaint, it was less prevalent than in other reported studies in the non–thoracic oncology setting5,7,13 and was uncovered on the physicians’ documented review of systems. These findings may be because of practice differences in pain management or the nature of symptoms patients with lung cancer may experience.25 We also found a wide range of other less common complaints, such as rash and medication refill, concerns that may be managed during clinic hours. Many telephone calls led to subsequent ED visits and unplanned hospitalization, similar to findings in nononcology settings, where physicians felt compelled to refer simple patient cases to the ED for further management, and/or patient cases were acute enough to require evaluation.7,19 In our study, a striking finding was that the patients who called more than once consecutively for the same symptom were subsequently admitted to the hospital for that chief complaint. Although we did not analyze the numbers of referrals made to the ED during the day, these findings, specifically the more commonly reported symptoms, along with the numbers of calls initiated more than once by the same patient, represent opportunities to decrease use of after-hours care through proactive early interventions guided by evidence-based symptom treatment algorithms. Our study has some limitations. First, our evaluation was a retrospective analysis of existing data on telephone calls made to a single institution after hours. We included calls only with physician-documented encounters that were abstracted by daytime triage nurses the opening clinic day after the calls were initiated. We had not previously verified this system, which could have introduced error; however, during the study period, we verified, with Stanford Hospital operator records, that daytime nurses documented 100% of afterhours calls. Because the study was retrospective, we limited our analysis to previously collected data and calls with no missing documentation. Retrospective record reviews are limited by poor and missing documentation. Despite exclusions for missing data, we were able to analyze a significant proportion of after-hours telephone calls. Of those telephone calls with missing data, we found ED use and hospital admission rates similar to those in our analytic cohort. Additionally, because of lack of patient identification and limited documentation, we were unable to analyze stage of disease or treatment type, nor could we examine other covariates such as individual-level factors (ie, education, insur-
Patel et al
Manuscript writing: All authors
Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Final approval of manuscript: All authors Corresponding author: Manali I. Patel, MD, MSPH, 875 Blake Wilbur Dr, Stanford, CA 94305; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001502; published online ahead of print at jop.ascopubs.org on September 30, 2014.
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3. National Comprehensive Cancer Network. www.nccn.org/professionals/ physician_gls/pdf/nscl.pdf 4. McCann L, Maguire R, Miller M, et al: Patients’ perceptions and experiences of using a mobile phone-based advanced symptom management system (ASyMS) to monitor and manage chemotherapy related toxicity. Eur J Cancer Care (Engl) 18:156-164, 2009 5. Kroenke K, Theobald D, Norton K, et al: The Indiana Cancer Pain and Depression (INCPAD) trial: Design of a telecare management intervention for cancerrelated symptoms and baseline characteristics of study participants. Gen Hosp Psychiatry 31:240-253, 2009
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9. Elnicki DM, Ogden P, Flannery M, et al: Telephone medicine for internists. J Gen Intern Med 15:337-343, 2000 10. Cykert S, Flannery MT, Huber EC, et al: Telephone medical care administered by internal medicine residents: Concerns of program directors and implications for residency training. Am J Med Sci 314:198-202, 1997 11. Brown A, Armstrong D: Telephone consultations in general practice: An additional or alternative service? Br J Gen Pract 45:673-675, 1995 12. Daugird AJ, Spencer DC: Characteristics of patients who highly utilize telephone medical care in a private practice. J Fam Pract 29:59-63, 1989; discussion 63-64 13. Flannery M, McAndrews L, Stein KF: Telephone calls by individuals with cancer. Oncol Nurs Forum 40:464-471, 2013
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22. Pitts J, Whitby M: Out of hours workload of a surburban general practice: Deprivation of expectation. BMJ 300:1113-1115, 1990 23. Reid J, Porter S: Utility, caller, and patient profile of a novel chemotherapy telephone helpline service within a regional cancer centre in Northern Ireland. Cancer Nurs 34:E27-E32, 2011 24. Shoemaker LK, Estfan B, Induru R, et al: Symptom management: An important part of cancer care. Cleve Clin J Med 78:25-34, 2011 25. Tishelman C, Petersson LM, Degner LF, et al: Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death. J Clin Oncol 25:5381-5389, 2007 26. Homsi J, Walsh D, Rivera N, et al: Symptom evaluation in palliative medicine: Patient report vs systematic assessment. Support Care Cancer 14:444-453, 2006
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Information downloaded from jop.ascopubs.org and provided by at University of Manchester Library on June 2, 2015 from 130.88.90.140 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
Author Contributions Conception and design: Manali I. Patel, Douglas W. Blayney Collection and assembly of data: Manali I. Patel, Donna C. Williams, Carla Wohlforth, George Fisher Data analysis and interpretation: Manali I. Patel, George Fisher, Heather A. Wakelee, Douglas W. Blayney
