In this study, we conducted a retrospective analysis of discharge pattern for patients who were hospitalized with a diagnosis of lung cancer. This study is the first of its kind to describe the services lung cancer patients use after an acute hospitalization.
Despite the known benefits skilled therapy has for cancer patients, only 14% of patients in our study discharged to a post-acute care facility upon discharge. This is a lower percent then what has been previously reported for post-acute care service use from all medical diagnoses. In a recent study of Medicare patients by Werner et al., post-acute care service use was found to be increasing over the last two decades with an estimated 26.3% discharging to a facility in 2015 16. Although, patients in our study were enrolled in private insurance plans, the average age of our patients was 67.2 ± 10.0 years, which is greater than the 65 years of age eligibility requirement for Medicare suggesting that there are likely similarities between the groups as the majority of patients included would be eligible for Medicare. This lower admission rate may be due to a number of factors including under-referral as well as insurance denial of services11. A concern that is often cited in the cancer population is the ability to participate in therapy requirements at post-acute care facilities, which can range from 1–3 hours total per day of physical therapy, occupational therapy or speech therapy17. Despite this postulated apprehension, previous studies have found that cancer patients make significant functional gains during IRF stay, comparable to gains made for stroke, traumatic brain injury and spinal cord injury patients for which IRF is commonly recommended 18–21. Functional gains in the IRF setting is often measured by the functional independence measure (FIM) score. In a study by Mix et al. in 2017, cancer patients of all types including lung cancer patients were found to have a mean total FIM change between admission and discharge of 23.5 ± 16.2 22. A FIM change of 22 has been found to be the minimal clinically important difference that reflect a change in a patient’s management improving independence and decreasing caregiver burden 23. The lower referral rate to IRF in our study may suggest a bias in the utilization of skilled rehabilitation services in lung cancer patients.
In unadjusted analyses, we found that black patients were more likely to discharge to SNF than to other post-acute care settings. This trend remained in adjusted analyses; however, it was no longer statistically significant. Racial differences in post-acute care service use have been previously studied in total knee arthroplasty (TKA) and stroke populations with mixed evidence of service use. In the 2019 study by Singh et al., black patients after TKA were more likely to discharge to IRF or SNF for care as compared to white patients. However, in Kind et al.’s 2010 study of ischemic stroke patients, black patients were less likely to discharge to SNF compared to white patients24. Our findings, in conjunction with what has been previously studied in other populations, suggest that social determinants of health may play a role in how post-acute care services are allocated.
Acute hospitalization length of stay was longer for those who discharged to an IRF, SNF or home with home care as compared to those who discharged to home. This is consistent with what has been previously reported in colorectal cancer patients 25,26. The longer length of stay may be reflective of patients with greater comorbidities and medical complexity. Additionally, a longer length of acute hospitalization suggests that patients may have had a more complex medical course and are likely more deconditioned and therefore likely to benefit from additional rehabilitative services.
Use of post-acute care settings on discharge have been found to be associated with lower readmission rate and lower mortality in non-cancer patients. In our study, we found no difference in 90-day readmission or mortality rate by discharge setting. The similar readmission and death rate seen in our study across discharge settings despite differences in comorbidities and age suggest that these individuals can benefit from the therapy and medical services available at these settings.
We found that most reasons for acute hospitalization were due to respiratory issues followed by secondary malignancies. This finding is consistent with what has been previously reported in a study of emergency room presentation of lung cancer patients that reviewed both cancer-related and cancer-unrelated conditions 27. Cancer providers should be aware that lung cancer patients are most likely to seek acute care for respiratory symptoms and develop treatment plans to prevent unnecessary hospitalization.
There are several limitations to our study. First, we were unable to identify the patient’s stage of lung cancer nor where the patient was in the treatment continuum. Given that lung cancer patients have such a poor survival rate with only 19% living at 5 years after diagnosis, we felt that it would be reasonable to compare these patients at different stages 12. Second, this study was performed at a single metropolitan institution which limits the generalizability of this study to lung cancer patients at other healthcare institutions and in other regions. Additionally, we limited our study to lung cancer patients that discharged to IRF, SNF, home health care or home, which is not inclusive of all discharge settings. We focused on these discharge locations as these are settings most commonly utilized and referenced in post-acute care service literature. By focusing on these discharge settings, our study does not address other settings such as long-term acute care facilities where patients may receive skilled therapy services. Finally, our study was a retrospective review of electronic medical records and is thereby limited to the accuracy of the documentation.