P072: Preventing emergency department visits among patients with cancer: a scoping review

Introduction: Patients frequently present to the Emergency Department (ED) with predictable complications associated with radiation and chemotherapy for active cancer. Care alternatives have been proposed to reduce ED visits; however, no systematic review related to ED presentations has been completed. The objective of this scoping review was to examine the effectiveness of interventions designed to reduce ED visits among patients receiving active cancer treatment. Methods: A comprehensive literature search involving nine electronic databases and the grey literature was completed. Inclusion criteria considered studies assessing the impact of any intervention to reduce ED utilization among patients with active cancer. Two reviewers independently assessed relevance and inclusion; disagreements were resolved through third party adjudication. Dichotomous and continuous outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model, wherever appropriate. Results: From 3303 citations, a total of 25 studies were included. Interventions identified in these studies comprised: routine and symptom-based patient follow-up, oncology outpatient clinics, early symptom detection, comprehensive inpatient management, hospital at home, and patient navigators. Six out of eight studies assessing oncology outpatient clinics reported a decrease in the proportion of patients presenting to the ED. A meta-analysis of three of these studies did not demonstrate reduction in ED utilization (RR 0.78; 95% CI: 0.56 to 1.08; I2 = 77%) when comparing oncology outpatient clinics to standard care; however, sensitivity analysis removing one study reporting rare events supported a decrease in ED visits (RR 0.86; 95% CI: 0.74 to 0.99; I2 = 47%). Three studies assessing patient follow-up interventions showed no difference in ED utilization (RR 0.69; 95% CI: 0.38 to 1.25; I2 = 86%). Conclusion: A variety of interventions designed to mitigate ED presentations by patients receiving active cancer treatment have been developed and evaluated. Limited evidence suggests that an oncology outpatient clinic may be an effective strategy to reduce ED utilization; however, additional high-quality studies are needed.</jats:p

LO30: Assessing screening tools to identify patients with palliative care needs in the emergency department: a systematic review

Introduction: With an increasing proportion of patients in need of end-of-life (EOL) care presenting to the emergency department (ED), many of these patients may benefit from early palliative care (PC) referral. In fact, early PC referral is one of the Choosing Wisely ED recommendations in the USA. As such, there is a potential benefit to identifying patients with advanced or end-stage illness with PC needs. The objective of this systematic review is to identify and synthesize the available evidence regarding the existence and psychometric properties of screening tools to identify patients with advanced or end-stage illness and PC needs presenting to EDs. Methods: A comprehensive search of eight electronic databases and the grey literature was conducted. Studies assessing the ability of a screening instrument to identify ED patients with advanced or end-stage illness in need of PC were eligible for inclusion. Two independent reviewers completed study selection, quality assessment, and data extraction. Disagreements were resolved through third-party adjudication. Due to the significant heterogeneity, as well as inconsistent outcome reporting, a descriptive summary of the results was completed. Results: Once duplicates were removed, the title and abstracts of 3516 studies were screened, of which, 15 studies were included. Overall, 10 unique screening instruments were assessed across the studies. The most commonly assessed screening tool was the use of the modified surprise question (SQ), in which physicians were asked if they would be surprised if the patient died within a specified period of time. Only four of the included studies assessed the diagnostic or psychometric properties of the screening tools. One study reported that the modified SQ predicted PC consultation with 35% sensitivity, 89% specificity, and a negative predictive value of 97%. The proportion of patients identified with PC needs ranged from 12% to 73%, with studies utilizing the SQ reporting a range of 12% to 33%. Conclusion: A variety of screening tools are available to identify ED patients with advanced or end-stage illness who would benefit from a referral for PC. While the modified SQ was the most common instrument assessed and appears to be simple to implement, it is unclear if the diagnostic and psychometric properties of this tool are sufficiently robust to warrant widespread implementation.</jats:p

P072: Comparing met vs. unmet palliative care needs in patients with end-stage conditions presenting to two Canadian emergency departments

Introduction: Patients with end-stage conditions require integrated physical, spiritual, psychological and social care. Despite efforts to provide comprehensive community care, those with severe symptoms often present to emergency departments (EDs) with palliative care (PC) needs. The objective of this study was to identify patients with end-stage diagnoses presenting to EDs, and to document and compare their PC needs. Methods: A four-month prospective cohort study was conducted in two Canadian EDs. Using a modified PC screening tool, volunteer emergency physicians identified adult patients with end-stage illnesses and documented their PC needs. This tool has the ability to classify patients as having met vs. unmet PC needs based on the documentation of risk factors. Research assistants documented demographic information, severity at presentation (Canadian Triage and Acuity Scale {CTAS}), disposition and revisits from an electronic repository. Bivariate comparisons between patients with met vs. unmet PC needs were completed. Results: Overall, 663 patients were enrolled, of which 78% (n = 518/663) were identified as having unmet PC needs according to the screening tool. Cancer was the most prevalent condition in each group (43% unmet needs, 37% met needs). There was no significant difference between the two groups in terms of age, sex or CTAS score. The unmet PC needs group was more likely to be admitted (68% vs. 50%; p = 0.0001) when compared to patients with PC needs assessed as being met. No significant difference was noted in terms of time to physician assessment or ED length of stay. The two groups did not significantly differ in the proportion of return visits within 30 days (34% vs. 32%) or the average number of return visits (3 vs. 2 visits). A higher proportion of patients with unmet PC needs made at least one visit to the ED in the 6 months prior to their index visit compared to patients with met PC needs (74% vs. 51%, p &amp;lt; 0.001); yet, the average number of ED visits was similar between the groups (3 visits). Conclusion: This study revealed that patients with end-stage diagnoses, especially cancer, commonly have unmet PC needs. They are also more likely to present to the ED and to require hospitalization than patients in whom PC needs have been met. Further investigations into their clinical profile and health care utilization may clarify the impact of their unmet PC needs on the healthcare system.</jats:p

MP08: The frequency of emergency departments visits for patients with end-of-life conditions: a call for action

Introduction: An increasing number of patients with end-stage diseases present to emergency departments (EDs) for physical, spiritual, psychological and social care. The objective of this study was to identify patients with end-stage diseases with palliative care (PC) needs and document their frequency of ED visits. Methods: This prospective cohort study was conducted in two Canadian EDs. Using a modified palliative care screening tool, volunteer ED physicians were asked to identify adult patients with end-stage, chronic conditions including cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), heart failure (HF), cirrhosis, dementia and/or progressive central nervous system (PCNS) disease. Demographic data were collected from these tools and data regarding patients’ visits in both the 6 months prior to and 30 days following their index visits were collected from the ED Information System. Bivariate analyses were completed using Student's t and chi-square test. Results: A total of 663 patients with end-stage illness were identified; 338 (51%) were female and the median age was 76 (IQR: 63, 85). Cancer was the most common presentation (41%), followed by dementia (23%), COPD (16%), HF (9%), CKD (9%), PCNS disease (9%) and cirrhosis (7%). These patients made a total of 1277 visits in the 6 months prior to and 288 in the 30 days following the index visit. Patients presenting to the EDs with cancer (p = 0.001), cirrhosis (p = 0.005) and CKD (p = 0.03) were more likely to visit an ED in the 6 months prior to their index visit. In contrast, patients presenting with dementia (p &amp;lt; 0.0001) and PCNS disease (p = 0.02) were significantly less likely to present to an ED in the 6 months prior to their index visit. Patients presenting with cirrhosis or CKD had the highest average number of ED visits in the 6 months prior to their index visit (cirrhosis: 4.59 visits, SD: 3.8, p &amp;lt; 0.0001; CKD: 4.39 visits, SD: 3.8, p = 0.0001). Of these patients, those presenting with end-stage cirrhosis were significantly more likely to make a return visit to an ED within 30 days after their index visit (p = 0.014). Conclusion: Cancer is the most common condition for patients with end-stage, chronic illnesses in these EDs. Those presenting with cirrhosis or CKD are at a significantly higher risk of repeat visits to the EDs. This study has identified potential deficits in care and can serve as a baseline for future intervention studies.</jats:p

Impact of hip fracture on health-related quality of life and activities of daily living: the SPARE-HIP prospective cohort study

There is a scarcity of prospectively collected data on functional and patient-reported outcomes following hip fracture. We therefore aimed to measure health-related quality of life (HRQoL) and activities of daily living activities (ADL) before, during index admission for a hip/proximal femur fracture, and at 1 and 4 months later

Multicentre randomised controlled trial comparing Bankart repair with remplissage and Latarjet procedure in shoulder instability with subcritical bone loss (STABLE): study protocol

Introduction Recurrent shoulder dislocations often cause attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management for patients with shoulder instability with subcritical bone loss remains unknown and current clinical practice is highly varied.Methods and analysis The Shoulder instability Trial comparing Arthroscopic stabilisation Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multicentre, randomised controlled trial of 114 patients diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss (10%–20%, measured on 3D CT using circle of best fit technique). Patients are randomised either arthroscopic capsuloligamentous repair (Bankart repair+remplissage) or open or arthroscopic coracoid transfer (Latarjet procedure). The primary outcome of this trial will be the between-group difference in the change from baseline to 24 months postintervention in Western Ontario Shoulder Instability Index scores. Secondary outcomes include: (1) rates of recurrent shoulder dislocations and symptoms of instability up to 24 months’ postsurgery; (2) clinical outcomes measured by American Shoulder and Elbow Society score, Shoulder Activity Scale, EQ-5D and Patient Satisfaction Scale; (3) physical examination (range of motion, stability); (4) return to previous level of activity/sport; (5) rate of shoulder-related complications and serious adverse events.Ethics and dissemination This protocol has been reviewed and approved by the Hamilton Integrated Research Ethics Board (HiREB; project number 15998) prior to commencement of the trial. Results from the study will be submitted for publication in a peer-reviewed journal regardless of whether there are statistically significant findings.Trial registration number NCT05705479; this study was prospectively registered on clinicaltrials.gov

A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Abstract Introduction Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied. Methods and analysis The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively. Conclusions This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability. Trial registration This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&amp;draw=2&amp;rank=1. Ethics and dissemination This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability. </jats:sec

Accelerated surgery versus standard care in hip fracture (HIP ATTACK) : an international, randomised, controlled trial

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4\u20139) in the accelerated-surgery group and 24 h (10\u201342) in the standard-care group (p&lt;0\ub70001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0\ub791 (95% CI 0\ub772 to 1\ub714) and absolute risk reduction (ARR) of 1% ( 121 to 3; p=0\ub740). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0\ub797 (0\ub783 to 1\ub713) and an ARR of 1% ( 122 to 4; p=0\ub771). Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Funding: Canadian Institutes of Health Research