SIOG 2015

Impact of a dedicated geriatric oncology service on rate of unplanned hospital admissions

Dr Muhammad Adnan Khattak - Fiona Stanley Hospital, Perth, Australia

You are looking at the impact of what’s called a dedicated geriatric oncology service. Let me ask you, first of all, because you’ve done a study on this, how common is it that there is a dedicated service for older patients with cancer?

At least in the Australian setting a dedicated geriatric oncology service does not exist in the majority of the hospitals. So the Royal Adelaide Hospital was the pioneer institute in Adelaide in Australia where geriatric oncology services were laid out for the first time and have been gradually expanded to two or three other institutions as well. The Royal Perth Hospital is one of the institutions in Western Australia where we did this study. In terms of what a dedicated geriatric oncology clinic means is that we sent out a comprehensive screening questionnaire to the patients which was posted out to them at the time of their first appointment and they filled it in with the help of their family and friends and brought it to their first clinical appointment to give us more comprehensive information about their functional status which assisted us in our ability to make informed decisions which are rational and to avoid over-treatment or under-treatment of older cancer patients.

So in practical terms, then, there was a questionnaire, what else did you have to do to execute this study?

Once the questionnaire is brought to us by the patient at the time of first consultation, they go through it, so that’s one part of the assessment. Then they go through the cancer assessment part of it then try to join them together to get an idea of what the disease for this patient is and what is the functional status of this patient and try to look at the patient as well as the disease and try to make a better informed decision about the ability to undergo anti-cancer therapy, whether we should treat this patient or not.

And why should that be crucially different for older patients as compared with their younger counterparts?

Older patients have got complex care needs and an age bias exists amongst physicians. But we know that older patients, it’s quite a heterogeneous group of patients in terms of their functional status and in terms of their comorbidities so every 80 year old is not the same 80 year old - we see relatively fit 80 year old patients and we see very frail 70, even 60 year old patients as well in the clinic. So with the help of a comprehensive geriatric assessment we’re trying to identify which we will not identify on routine history and physical examination in a general medical oncology clinic whereas in contrast in a geriatric oncology clinic we get a more comprehensive picture of the functional status of the patient, their comorbidities, the medication they are on and try to rationalise everything.

So that’s the theory, it should be good, it should be worth doing, what in fact did you find?

A lot of studies have been done looking at what type of geriatric assessment can be done. There are a lot of different tools available so essentially as long as some shape of geriatric assessment is done that’s reasonable and it’s recommended by NCCN and SIOG for every patient who is age 65 and above. So in this study what we’ve looked at is to assess its impact because that’s the question, when you’re trying to roll out a geriatric oncology service, the first question when you apply for funding for such a service from the administrative authorities is, ‘OK, what difference will it make?’ Obviously so far we haven’t been able to come up with a plausible explanation what difference will it make. The thing which is more appealing for the overall health system is what impact comprehensive geriatric assessment will have in an individual patient and overall onto the health system in terms of cost saving. So we looked specifically at the number of unplanned hospital admissions as well as the mean in-patient length of stay of these patients and then tried to find out whether there was any difference in contrast to patients seen at the same time in the same hospital but through a general medical oncology clinic who did not undergo geriatric assessment.

In a nutshell, what was the difference between the rates of unplanned hospital admissions and the length of stay, depending on whether you had a geriatric assessment or not?

This is a pilot study, it’s a small sample size and there a lot of caveats and limitations of this study which I will elaborate in my talk later today as well. But essentially what we found was that the rate of unplanned hospital admissions was much higher in patients who were seen through a general medical oncology clinic in contrast to a geriatric oncology clinic. So roughly about 37% of the patients did not have any admission who were seen through a general medical oncology clinic. In contrast, patients who were seen through a dedicated geriatric oncology clinic 67% of the patients did not have any admissions at all. Then also patients who had at least one, two, three or four admissions, the number was higher in patients who did not undergo geriatric assessment.

Does this mean that there is a saving overall, not only in terms of cost but also patient morbidity?

Yes, in terms of patient morbidity, which is a secondary endpoint of the study, which we present the data sometime next year but in terms of the primary data there was a reduction in the rate of unplanned hospital admissions. And in terms of the cost savings the average in-patient hospital stay was about 5.5 days for those seen through a dedicated geriatric oncology service in contrast to 11 days for patients who were not seen through this dedicated geriatric oncology service. Putting it in perspective, the numbers are very crude and very vague but just to give you some idea, an average in-patient bed stay for a hospital in the Australian health system costs about AUS$2,000 and we’re looking at the cumulative length of stay between the two groups was 334 days versus 665 days between the two groups, that’s the difference of about 339 days. If you multiply it by AUS$2,000 it roughly equates to about AUS$668,000 or €443,000 saving to the health system. Now these are very rough figures, there are a lot of pros and cons in terms of how to interpret this data but it gives you some impression that we can save a lot to the health system and also avoid morbidity to the patient by making a rational decision if we know our patients very well.

It’s a massive impact, in other words, from your small study, relatively small study, but a huge difference. So the significance is quite [?? 6:41] established.

Yes, this is a pilot study and what we are trying to do is subject to funding which we applied for. We are trying to do a randomised study of about 270 patients in which we randomise these patients. In the pilot study we looked at all the different tumour types which confounds the data, makes the interpretation a bit difficult, whereas in the randomised study potentially we’ll include patients with major tumour types like lung cancer, bowel cancer, prostate and breast cancer and then randomise them 135 patients to each arm and then follow them up for a period of twelve months and see if there’s any difference in terms of the rate of unplanned hospital admissions, the length of stay in the hospital, treatment related adverse events and then short-term survival as well at six and twelve months to give us a better idea of what this is all about.

In a nutshell, then, how would you sum up the importance of what you’re saying or the key messages coming out of this for cancer doctors?

I think the key message is that we should not be biased against older cancer patients. We should make treatment decisions more rationally once we are much more informed through these older cancer patients because they’ve got complex care needs. We should assess them more thoroughly through a comprehensive geriatric assessment. Once we identify any deficiencies, any of the domains of the comprehensive geriatric assessment, we should try to address it through a multidisciplinary team meeting and try make a proper referral to try to address them, to refer a patient for a physiotherapy assessment if they’re having repeated falls or refer them to a dietician, particularly in the context of gastrointestinal cancer. Then overall this will avoid over-treatment of frail patients and under-treatment of relatively fitter older cancer patients. Then overall this will lead to a huge cost saving to the health system.