Poster Number-15 - Effect of outpatient provider type on the rate of emergency department visits for patients with malignant pain

Effect of outpatient provider type on the rate of emergency department visits for patients with malignant pain

Purpose: Opioids are an integral element of end-of-life care and are considered a mainstay of cancer pain (CP)management. A national decrease in morphine milligram equivalents (MME) for the treatment of CP has been associated with an increased rate of emergency department visits for pain in patients with advanced cancer. CP has historically been managed by oncologists, however the role of outpatient palliative care for symptom management has expanded. Previous studies compare prescribing trends between oncologists and all other provider types, but have failed to evaluate the potential utility of palliative care providers. This study compares CP related outcomes between oncologist and palliative care providers by determining the average MME per opioid regimen prescribed and the rate of emergency department visits for CP in cancer patients.

Methods: A retrospective chart review was performed to assess outcomes related to CP management provided by oncologists and palliative care providers. Patients included in this study were ≥18 years of age, had a diagnosis of active cancer, and received ≥ 75% of their prescribed opioid medications from an outpatient oncology or palliative care clinic. Patients without active cancer, or receiving buprenorphine or tramadol were excluded. The primary outcome was the incidence of patient emergency department visits related to pain per provider type. Secondary outcomes included average MME per prescribed opioid regimen and incidence of patient emergency department visits related to constipation per provider type.

Results: Overall, 80 patients were included: 40 managed by palliative care and 40 managed by oncology. Baseline characteristics including age, sex, weight, and stage of cancer were distributed equally between groups. Cancer type differed between groups at baseline. The most common cancer type for patients managed by oncology included breast (40%) whereas digestive/gastrointestinal cancer was the most common cancer type for patients managed by palliative care (35%) (p = < .01). In terms of the primary endpoint, patients managed by palliative care had a 15% lower incidence of emergency department visits related to pain compared to patients managed by oncology (10% vs 25% respectively, p = .03). Conversely, patients managed by palliative care received an average of 7.5 MMEs more per opioid regimen for the treatment of CP than patients managed by oncology (67.5vs 60 respectively, p = < .01). Rates of patient emergency department visits for constipation did not differ between the palliative care or oncology group (5% vs 7.5% respectively, p = .50).

Conclusion: Overall, cancer patients treated for CP received higher doses of opioids and had a lower rate of emergency department visits for pain when managed by palliative care physicians rather than oncologists. Larger studies are needed to confirm the association between lower MME containing pain regimens and emergency department visits for CP and adjust for confounding factors such as cancer type.

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