Mortality outcomes in hospitalized oncology patients after rapid response team activation
Background The prognosis of hospitalized oncology patients varies widely, and physicians are poor at predicting outcomes in cancer patients. Discrete signifiers of prognosis in hospitalized oncology patients are widely sought.
Objective To test the hypothesis that oncology patients who have had rapid response team (RRT) activations would have high rates of in-hospital and 100-day mortality, and that these might differ based on malignancy type and other clinical factors.
Methods A retrospective study was performed at a single, 900+ bed academic center in the northeastern United States during a 2-year study period using an RRT-specific database. We included patients 18 years or older with a cancer diagnosis, including solid tumor and hematologic malignancy, as well as those who were status post-bone marrow transplantation, who required RRT activation. Surgical and intensive care unit patients were excluded. Primary outcome variables of interest were inpatient and 100-day mortality post-RRT activation as well as the clinical variables leading up to RRT activation.
Results RRT activation was associated with a high inpatient mortality in patients with solid tumor and hematologic malignancies (43% and 35%, respectively) and a 100-day mortality (solid tumors, 78%; hematologic malignancies, 55%). In multivariate analysis, female sex was associated with significantly higher inpatient and 100-day mortality.
Limitations This retrospective review of a single center's data on oncology patients may not apply to all hospitals.
Conclusions These findings demonstrate high inpatient and 100-day mortality in a selected population of oncology patients. The event of an RRT activation may be a useful predictor of prognosis in oncology patients and can be used to help patients and families improve advance care and end-of-life planning.
Funding Cancer Center Support Grant 5P30CA056036-17 and the Biostatistics Shared Resource of Thomas Jefferson University
Accepted for publication November 20, 2018
Correspondence Neil D Palmisiano MD; Neil.palmisiano@jefferson.edu
Disclosures: The authors report no disclosures/conflicts of interest.
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0439
Discussion
The results of the study highlight the very high mortality rates associated with oncology patients requiring RRT activations, with 39% of patients dying within the same hospital stay and 65% dying within 100 days of the RRT event. These results are particularly notable when contrasted with the 2.3% inpatient and 15.7% 100-day postdischarge mortality rates in the total oncology patient population over a similar time period. The inpatient mortality rate after an RRT activation in our study closely resembled the rate reported by Austin and colleagues, which was 33% (hospital mortality in oncology patients cited during the time was 48.2 deaths per 1,000 patient admissions).17 Of note in our study is that solid tumor patients had higher mortality than the hematologic malignancy patients; 43% died within the same hospital stay and 78% died within 100 days, compared with 35% and 55%, respectively, in patients with hematologic malignancies. The poor prognosis of oncology patients requiring an RRT evaluation must be conveyed to the patients and families and taken into consideration by health care team to determine the most appropriate course of care subsequent to RRT activation.
Our finding that female sex is significantly and strongly associated with increased inpatient and 100-day mortality in patients with solid tumors was unexpected. The cause for this disparity remains elusive. We noted that, in our study, the following types of malignancies were more common in women than men (comparison of women vs men shown in parentheses): lung (53% vs 47%), colon (60% vs 40%), acute lymphoblastic leukemia (83% vs 17%), diffuse large B-cell lymphoma (64% vs 36%), and multiple myeloma (58% vs 42%). Whether these types of cancers are more clinically aggressive and associated with earlier mortality post-RRT could not be ascertained from our data. Gender bias in clinicians’ bedside determination of severity of illness may also play some role in this substantial mortality gap.
Among all the causes for RRT activation, increased work of breathing was the only variable associated with increased inpatient mortality in solid tumor patients. In a study by Austin and colleagues, decreased oxygen saturation was the most common reason for the RRT evaluation, though it did not reach statistical significance as a predictor of inpatient mortality.17 SIRS and qSOFA scores in the 24 hours preceding the RRT event along with peri-RRT blood product administration were all significant predictors of inpatient mortality among patients with solid tumors but were not so for those with hematologic malignancies. It is interesting to note that low hemoglobin was found to be associated with inpatient mortality in a study on 456 hospitalized patients with solid tumors (there was no data on RRT evaluation in their dataset).13 The fact that these well-validated measurements of illness severity correlate positively with RRT activation and increased mortality is intuitive and lends external credibility to other findings in this study.
,In patients with hematologic malignancies, ICU transfers within 24 hours of the RRT activation were associated with 4-fold increased odds of inpatient death. This was not shown to be the case in patients with solid tumors. This should be explored in future studies because it could be crucial in conducting goals-of-care discussions in terminally ill cancer patients. The study also showed that patients with hematologic malignancies who were DNR or DNI were associated with almost 8-fold increased odds of 100-day mortality. This argues for a fair predictive ability of the care teams in this particular subgroup. Conversely, hospice referral is underused; of the patients that died at 100 days after the RRT event, only 16.2% were referred to hospice at the time of discharge.
