Use of Unscheduled Care in both GP Out-of-Hours and Accident & Emergency departments by Patients with Terminal Cancer.

Problem

Patients with cancer often experience complex pain and symptom control issues that can cause them to presentation to unscheduled care services, notably GP-Out-Of-Hours (GPOOH) and Accident & Emergency (A&E). We aim to understand the patterns, nature and magnitude of unscheduled care attendance by patients with cancer in their last 12 months of life.

Approach

This analysis is a retrospective cohort study of NHS Tayside residents who died from cancer between 01/01/2012-30/06/2015. Patients were identified posthumously using General Register Office ‘Cause of Death’ Data. Routinely collected clinical data from all unscheduled care contacts, with both GPOOH and A&E, during their last year of life was collected using patient-specific Community Health Index (CHI) number searches. Clinical data was linked to demographic and prescribing datasets using patient CHIs.

Findings

There were 5738 patients identified as meeting the inclusion criteria; in their last year of life, 32% had presented to GPOOH and 38% had presented to A&E. Patients who presented to GPOOH were significantly more likely to present multiple times; 82.5% presented more than once, accounting for a total of 5922 unique presentations to GPOOH. Only 18% of A&E patients presented on more than one occasion. Attendances at both A&E and GPOOH increased in the weeks immediately before death. In GPOOH 61.4% of patient presentations were within 4 weeks death. In A&E presentations there were 197 different presenting complaints recorded; 4 of the 10 most common presentations were pain-related. In a case-notes analysis of GPOOH data, forty common presenting complaints were identified; of those, 13.3% were for pain-related presentations and 31% were for administration of palliative care. Preliminary discharge results indicate 1 in 3 patients had follow-up with their own GP, 1 in 4 had no follow-up, and 1 in 10 died. Only 1% were admitted to hospital. By contrast, the majority (71.1%) of patients were admitted to hospital following presentation to A&E. In GPOOH, 54.8% of contacts resulted in a home visit, 5.6% were seen in base, 8.4% were triaged to District Nurses, 8.9% triaged to NHS24, 4.8% managed with the ‘Sea and Treat’ system and 15.7% received telephone advice.

Consequences

Over a third of patients with cancer present to GPOOH and A&E in their last year of life. The reasons for presenting, frequency and multiplicity of presentations, outcomes from contacts with unscheduled care and prescribing factors associated with unscheduled care contact are vairied in GPOOH and A&E. Such presentations become more common in the weeks before death. Presentations are commonly due to uncontrolled pain and palliative care needs. This research can potentially identify factors associated with unscheduled care use and suggest clinical and service provision changes that could be made to improve the patient journey in patients with terminal cancer.