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Malignant Pleural Effusion

FINAL REPORT

Introduction

Pleural effusions in patients with malignancies are frequent complication of a variety of advanced cancers. These are often difficult to treat and result in recurrent dyspnea as well as frequent hospital visits for multiple treatments.

The usual approach to patients with symptomatic malignant pleural effusion (MPE) is to perform repeated pleural taps (thoracentesis), or to place an intercostal catheter and attempt pleurodesis with a sclerosing agent such as talc or a tetracycline. The first approach is resource intensive (requires multiple visits to physician or ultrasound department), painful and only partially and temporarily effective in relieving symptoms. The second requires a 10-14 day hospitalization, can only be performed in a portion of patient who undergo chest tube placement, can be significantly painful and has been associated with severe pulmonary complications.

A new procedure has been developed; using a long-term tunneled catheter inserted into the pleural space. This catheter can permit self-drainage by the patient or home care nurses on a regular basis at home. It is thought that the use of this catheter will assist in avoiding emergency visits, acute care hospitalizations and repeated procedures for these patients, enhancing quality of life for patients and reducing health care costs. The

catheter can be safely inserted as an outpatient procedure under local anesthesia.

In order to better understand the current management of malignant pleural effusions in the Calgary Health Region, and to evaluate the potential impact of a new treatment approach for this disease, the Malignant Pleural Effusion project was initiated and completed as part of the Calgary Health Region (CHR) Quality Improvement and Health Information (QIHI) program via the Medicine Quality Council.

Participants

Team leader:

• Dr. Alain Tremblay, Department of Medicine, Division of Respiratory Medicine

Team Members:

• Lori Forand, QI measurement and evaluation specialist in QIHI

• Linda Perkins, Concurrent Review Coordinator QIHI

• Sheila Cloutier, Home care, CHR

• Lee Johnson, TBCC outpatient clinic manager

• Patricia Barclay, TBCC Dyspnea clinic nurse

• Trish Clark, Palliative Clinical Nurse Specialist TBCC

• Dr. Neil Hagen, Senior Leader Medical Services & Palliative care medicine TBCC

• Brent Wylie, FMC Respiratory Services

Sponsors:

• Marlene Mysack, Senior Leader Patient Care Services TBCC

• Dr. Sid Viner, Medical Director, PLC site

• Medicine Quality Council / Quality Improvement and Health Information (QIHI) program

Data collection team

• Dianne Burnand, Janet James Whalen, Bev Campbell

Methods

In order to gain the most out of this evaluation, simultaneous sub-studies were conducted, each addressing various issues related to Malignant Pleural Effusions.

A retrospective analysis on hospitalized patients treated for malignant pleural effusion was conducted for CHR adult hospitals during a calendar year. This was followed by a prospective data collection on a cohort of inpatients treated for MPE and a comparable group of outpatients treated with the Pleurx catheter. Thirdly, a prospective database of all patients undergoing Pleurx placement was maintained and analyzed. Finally a literature review was completed to review published experience with the Pleurx approach to the treatment of MPE.

The remainder of this report details the findings of these studies.

Retrospective analysis

A retrospective analysis of the CHR health record database was performed to assess the scope of this clinical problem. The records were queried for the period of fiscal 2000/2001. Full datasets can be found in appendix 1.

A total of 561 inpatients were detected with malignancy and pleural effusion or MPE, accounting for a total of over 10,000 hospital days. A total of 160 intercostal catheters and 153 thoracentesis were performed in this inpatient population. Thirty three attempts at pleurodesis were documented, suggesting that the majority (80%) of patients undergoing chest tube placement do not qualify for this procedure. In fact, only 6 % of the total group of patients received pleurodesis.

|Table 1: Patients hospitalized with malignancy and pleural effusion or malignant pleural effusion |

|CHR Site: |

|** This represents a death during the reported hospital stay. | | | | | |

|ALOS - average length of stay (total days divided by total discharges) | | | | |

Data from patients with malignancy, pleural effusion and chest tube placement was analyzed separately in table 2 to identify patients in which the MPE clearly represented an important clinical problem for the patient. We found 160 patients accounting for over 2600 hospital days meeting these criteria.

|Table 2: Inpatients with MPE with an Insertion of Intercostal Catheter for Drainage |

|  |  |  |  |

|Site Identifier: |Total |Total Days Stay |ALOS (days) |

|FMC |108 |1,819 |16.8 |

|PLC |33 |596 |18.1 |

|RGH |19 |204 |10.7 |

|CHR Adult Sites |160 |2,619 |16.4 |

It was also found that patients treated under the care of Respirologists had the shortest LOS of all specialties who had admitted at least 10 patients across all sites (Table 3).

|Table 3: Average LOS according to admitting physician specialty | | | |

|Most Responsible Physician Service |FMC |PLC |RGH |Total |

| |Total |ALOS |Total |ALOS |Total |ALOS |Average LOS |

|10 Internist |12 |13.2 |31 |11 |17 |12.5 |11.9 |

|16 Nephrologist |10 |43.2 |- |- |- |- |43.2 |

|18 Respirologist |12 |10.0 |16 |9.1 |14 |8.9 |9.3 |

|31 Cardiovascular Surgeon/Cardioth |63 |12.3 |4 |14.3 |- |- |12.4 |

|50 Obstetrician & Gynaecologist |30 |17.4 |3 |8 |- |- |16.5 |

|55 Intensivist |10 |23.2 |3 |12.7 |2 |8.0 |19.1 |

|66 Haematologist |11 |28.5 |12 |13.7 |- |- |20.8 |

|74 Oncologist |63 |18.8 |- |- |- |- |18.8 |

The conclusion from these data is that patients with MPE are commonly seen as inpatients in the CHR, that their LOS are prolonged, and that only a small minority (6%) receive pleurodesis, the only treatment know to result in long term control of this problem, short of the new approach being evaluated currently.

Prospective analysis

A) Hospital cohort

Three data coordinators within the Region’s three adult acute care sites collected daily data over a five-week period from March 4th through April 8th 2002. Data coordinators visited all inpatient acute care units, except for peri-partum, pediatric and psychiatry units, on a daily basis to locate any suitable patients. Data was gathered using daily chart reviews and patients were followed until their discharge from acute care.

Three elements were required for a patient to be included in the study. The patient was required to be diagnosed with a malignancy, to have documentation of a pleural effusion for which they were being actively treated, either with chest tube or a therapeutic thoracentesis (draining > 200ml of fluid).

Full details of this cohort can be found in appendix 2.

B) Pleurx cohort

A convenience sample of 18 patients undergoing Pleurx catheter placement was selected from the larger Pleurx database (see below). The selection criteria for these 18 consecutive patients was residence within the Calgary City Limits and procedure before April 17th, 2002, in order to avoid inaccuracies in re-admission data from patient outside the CHR and so that a 3 month follow-up be ensured within the timeline of this project.

Data Collection

Descriptive data was collected on the Hospital cohort regarding specific interventions performed in hospital to compare with the retrospective data. Data were collected on patients in both groups regarding hospital admissions and LOS for the period 3 months pre and post procedure or admission for comparison.

Results

In the 5 week data collection period, 13 inpatients were identified with actively treated malignant pleural effusions. This is consistent with the previous finding of 160 patients receiving intercostal catheters over one year (13.3 / month) in the retrospective analysis.

11 chest tubes were placed with 3 patients enduring more than one chest tube. Repeated thoracentesis occurred in 2 patients both of whom were at PLC. It should be noted that only 2/13 hospitalized patients (15%) actually underwent pleurodesis, including only one of three patients with 2 chest tubes. This number which concurs with the retrospective data is extremely low given that pleurodesis is the only way to achieve long term symptom control short or using the Pleurx catheter.

|Table 4: LOS for Hospital MPE Cohort (*67 day |

|outlier excluded) |

Mean and median LOS for these patients are seen in table 4. The main indications for remaining in hospital other than

MPE were diagnostic workups or palliative pain management.

|Site |Mean |Median |

|FMC |20.4* |25.0 |

|PLC |27.3 |30.5 |

|RGH |20.7 |19.0 |

The Pleurx cohort consisted of 18 patients with symptomatic pleural effusions referred for treatment. 5 patients had the procedure while admitted in hospital, but none were admitted specifically for the procedure. Discharge home was facilitated by the procedure in 4 patients, while the 5th was transferred to hospice. All 13 other procedures were performed as outpatient procedures in the FMC bronchoscopy suite or TBCC Dyspnea clinic.

The CHR health record database was searched to identify all inpatient admissions in the CHR for the period of 3 months pre and post catheter placement or hospital discharge for each group. This data is summarized in tables 5 & 6.

The Pleurx patients and Hospital patients had similar numbers of hospital admissions per patient in the 3 months prior to intervention (0.59 vs. 0.4), but the Pleurx group had higher number of inpatient days than the Hospital group (6.05 vs. 2.6 days / patient) suggesting that the Pleurx group were not necessarily in better health to start off.

|Table 5: Hospital Admissions 3 months Pre and Post intervention |

|  |Hospital Cohort|Pleurx Cohort |

|Admissions Pre/patient |0.4 |0.59 |

|Admissions Post/patient |1 |0.24 |

The situation changed dramatically in the 3 months post intervention with the Pleurx patients experiencing much lower readmissions (0.24 vs. 1/patient) and hospital days (1.41 vs. 8 / patient) than the hospitalized cohort. This is strong evidence that the Pleural catheter approach avoids hospitalization.

In addition, the actual admission days

|Table 6: Hospital Days 3 months Pre and Post intervention |

| |Hospital Cohort|Pleurx Cohort |

|Hospital Days Pre/patient |2.6 |6.05 |

|Hospital Days Post/patient |8 |1.41 |

(see table 4) associated with the intervention for the Hospital group are not represented in this analysis, suggesting that an even larger number of hospital days could potentially be avoided.

This analysis demonstrates that in patients with malignant pleural effusions and similar pre-procedure hospitalizations rates, treatment with a tunneled pleural catheter (Pleurx) leads to fewer hospital readmissions and hospital days than the standard treatment. This also confirms that the minority of patients treated as inpatients for MPE receive pleurodesis, which is in fact the only other way to obtain long term symptom relief.

Pleurx Database

The placement of indwelling long term tunneled pleural catheter for home drainage of malignant pleural effusions first became available in the CHR in October 2001 at the Foothills Medical Center site, based out of the Bronchoscopy Suite and operated by the Respiratory Medicine division as well as the Respiratory Services department. Procedures are performed on outpatients and FMC inpatients by a member of the Respiratory Medicine division (Alain Tremblay), and assisted by a respiratory therapist.

The procedure was expanded to a specialized clinic at the Tom Baker Cancer Center (Dyspnea Clinic) in January of 2002. This clinic is operated by Dr. Tremblay and Pat Barclay, RN. Strong support from the palliative care team is provided Patricia Clark.

All patients in whom a Pleurx catheter insertion was attempted were entered in a database. The main purpose of the data base was to monitor patient demographic, primary tumor sites, complication rates, spontaneous pleurodesis rates, and survival. A summary of the first 53 insertions follows.

A total of 48 patients underwent 53 procedures. (3 patients received bilateral drains, 2 patients had a second successful insertion after the first failed). Mean age was 62.8 years, with a range of 35 to 87.

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Lung cancer and breast cancer comprised over 50% of cases, which was expected as these are common tumors, and both are associated with MPE as a frequent complication of disease. It should also be noted that lung cancer is the number one cancer killer for both men and women (more than breast, prostate and colon combined) and that breast cancer is the most common non skin tumour in women. This emphasizes the importance of effective palliative treatments for patients with these tumours.

Of note, 3 patients with mesothelioma were treated with 4 catheters (one patient received sequential bilateral drains) with good success in relieving dyspnea. This is a significant achievement for a disease in which no therapy has ever been shown to modify its course.

Complications have been minimal. Five attempted insertions were unsuccessful (9.4%). Two patients had loculated fluid confirmed on subsequent ultrasound, one had tumour involvement of the skin making catheter placement impossible, one had insufficient remaining pleural fluid because of recent tube drainage, and one had a clot blocking the catheter immediately after insertion. The last 3 have had successful reinsertion attempts. In all, 96% of all effusions treated had an eventually successful Pleurx tube placement.

One patient (2% of catheters) experienced a cellulitis at the insertion site and required outpatient P.O. antibiotics.

Significant improvement in dyspnea was noted in the majority of patients. Unfortunately it was not feasible to follow patients with detailed symptom scores and quality of life questionnaires as part of routine clinical care (see literature review below).

So far 11 of 48 inserted catheters have been removed following spontaneous pleurodesis (23%) at a mean 47 days post catheter placement. None of these patients have had recurrence of symptomatic effusion on the treated side.

None of the effusions treated with a Pleurx required an alternative drainage procedures such as ultrasound guided thoracentesis at any point since this technique has been introduced in Calgary.

Only one patient has visited an emergency room for catheter or effusion related problems (cellulitis). This is likely achieved by eliminating the need for recurrent emergency thoracentesis.

At least 12 patients have died, 11 with a catheter in place, although some of the mortality data is incomplete, given that several patients were lost to follow-up most likely because of death, without us knowing a specific mortality date. The mean survival after tube placement in these 12 patients was 89 days. Incomplete data makes calculations of overall median survivals unreliable.

All patients were referred to Home Care for assistance with the drainage procedure. The CHR Adult Home Care nursing team was specifically trained for this procedure. Patients living outside the CHR also had homecare referrals, associated with detailed instructions provided to the respective Home Care teams. There is no doubt that the strong support of the Home Care teams has been essential to the success of this approach. This has also frequently made the need for increased home care services apparent more rapidly (e.g. institution of palliative care support at home), likely reducing return hospital visits.

In summary, this prospective database on all patients treated with a Pleurx catheter in the CHR confirms that a large majority of referred patients with MPE can undergo successful placement of the catheter on an outpatient basis in a simple procedure room. Complications rates are minimal. Our growing experience confirms that the catheters are well tolerated and offer symptomatic improvement in a large majority of patients.

Literature Review

A review of published literature on the use of tunneled pleural catheters for the treatment of MPE was performed to answer some of the questions which were beyond the scope of the data available as part of this project, such as quality of life and cost-benefit analysis. Three papers were found which addressed the use of the Pleurx catheter in the management of MPE.

Putnam1 conducted a large multi-center randomized controlled trial comparing an indwelling pleural catheter vs. doxycycline pleurodesis. 144 patients were randomized. Hospitalization time for the procedure was 1.0 days for the catheter group and 6.5 days for the pleurodesis group. Quality of life as measured with the Guyatt CRQ and Borg scores were similar in both groups up to 90 days of follow-up. 21% of pleurodesis patients had late failures as compared to 13% of the Pleurx patients (p value non-significant). It should be noted that the pleurodesis attempt and success rates seen in this (and other research studies) greatly exceeds what is seen in day to day practice. This is likely because of patient selection for study entry by the exclusion of poor performance patients as well as those no found to be fit for pleurodesis.

In a follow-up study, Putnam2 studied the economics aspects of the Pleurx approach in a retrospective comparison of 100 consecutive Pleurx patients (60 outpatients / 40 inpatients) and 68 consecutive pleurodesis patients at The University of Texas M.D. Anderson Cancer Center. The groups were similar in terms of demographics, tumour sites and median survival (3.4 months). Median LOS was 7 days for pleurodesis patients vs. 0 days for outpatient Pleurx patients. Early (7 day charges) were lower for the outpatient Pleurx group than for both the inpatient Pleurx group and the pleurodesis group.

A third paper by Pollack3 describes a series of 28 patients with symptomatic MPE who had 31 effusions treated. Catheters were placed under ultrasound guidance with a 100% successful insertion rate. The authors describe improved dyspnea in 94% of patients at 48 hours and 91% at 30 days. Spontaneous pleurodesis was achieved in 42% of patients, and only 7% of patients required hospital time for care related to the catheter.

These 3 studies confirm that the treatment of MPE can be successfully achieved with an indwelling pleural catheter with excellent impact on quality of life, avoidance of hospitalization, minimal complications and at a lower cost than the traditional approach of pleurodesis.

1. Putnam JB, Light RW, Rodriguez RM, et. al. A Randomized Comparison of Indwelling Pleural Catheter and Doxycycline Pleurodesis in the Management of Malignant Pleural Effusions. Cancer 1999;86:1992-9

2. Putnam JB, Walsh GL, Swisher SG, et. al. Outpatient Management of Malignant Pleural Effusion by a Chronic Indwelling Pleural Catheter. Ann Thorac Surg 2000;69:369-75

3. Pollack JS, Burdge CM, Rosenblatt M, et. al. Treatment of Malignant Pleural Effusion with Tunneled Long Term Drainage Catheters. J Vasc Interv Radiol 2001;12:201-8

Impact of Implementing New Approach

It is believed that this new approach to the treatment of patients with MPE can, will, and in fact has already started to revolutionize the care of this common problem. This approach should lead to improved patient outcomes in addition to improved resource utilization for the health system as a whole.

Impact on patients

• Avoidance of hospitalization for MPE treatment

This is a very significant benefit, given the short (median 3 months) survival of these patients and the prolonged hospital stay associated with pleurodesis as well as the increased re-admission rates seen in patients not treated with the Pleurx.

• Avoidance of repeated thoracentesis

Avoidance of repeated painful procedures is an obvious improvement in the palliation of this patient population. As seen in our prospective database, no patient treated with a catheter required subsequent thoracentesis.

• Avoidance of the risk of toxicity associated with sclerosing agents used for pleurodesis

• Increased patient control over symptoms

Many patients have been able to travel outside the city, with the reassurance that their pleural effusion will be controlled during their trip by ongoing self drainage procedures. Others have golfed, gone hunting and participated in fitness classes with a catheter in place. Emergency room visits related to the treated effusion have been virtually eliminated.

• Effective, rapid and persistent symptom control in the majority of unselected patients with low complication rates

In fact, the only patients who have failed Pleurx treatment are patients who had previously undergone (failed) attempts at chest tube placement and pleurodesis, or who have had repeated thoracentesis. These procedures are well known to lead to loculation of pleural fluid, making subsequent drainage near impossible.

• Improved patient quality of life

All of these benefits add up to improve quality of life for patients with terminal illness suffering from MPE.

Impact on resource utilization

• Decrease in hospital admissions and hospital days

This was clearly demonstrated in our data and confirms the published literature. It is easily conceivable that the 160 patients identified in the retrospective analysis could all have been treated as outpatients, eliminating the associated 2619 hospital days incurred (table 2). As well, this outpatient treatment would be expected to reduce subsequent re-admissions to hospital by over 75% and reduce hospital days by over 80% (Tables 5 & 6).

It is also suspected that a significant proportion of the 561 patients identified in table 1, while not candidates for pleurodesis, would benefit prom the Pleurx, leading to similar decreases in hospital days.

• Decrease in the need for ultrasound guided thoracentesis

The elimination of the need for repeated thoracentesis would reduce the cost and workload of diagnostic ultrasound services in the region, an already overburdened service.

• Decreased emergency room visits

As noted only one patient visited the emergency room for a catheter / effusion related problem (cellulitis). This is a significant improvement achieved by avoiding the need for emergent thoracentesis commonly preceded by an emergency room visit for increasing dyspnea.

• Need for funding of outpatient catheter related drainage supplies

The main catheter related costs relate to supplies required for home drainage of the effusions. While this cost is not negligible, it appears to be more than overcome by the reduction in hospital days. The question of the specific source of funding for this remains unresolved at this time.

Conclusion

A new approach to the treatment of malignant pleural effusion has been evaluated in the CHR as part of a Quality Improvement and Health Information project.

This analysis has demonstrated that this approach is feasible, can successfully treat the majority of patients with MPE with substantial advantage and higher success rates than the current standards. Overall, an improved quality of life can be obtained for treated patients.

This report has also detailed that this approach is associated with dramatic reduction in hospital admissions and inpatient hospital days, leading to substantial savings for the health system as a whole.

Perhaps the most important indication of the success of this approach is the rapid increase in referrals received from Calgary Respirologists, Oncologists and Thoracic Surgeons to our clinic requesting that their patients be treated with this modality.

It is suggested that outpatient treatment of patients with MPE with chronic indwelling pleural catheters should be the first line of treatment for patients suffering from MPE. For this to be achieved, commitment from Regional and Provincial health care administration bodies will be required to ensure adequate funding and support of such a program. This is especially important with regards to providing adequate support for outpatient clinics specializing in the management of these patients, the funding of home supplies for patients and the ongoing support of home care nursing services.

With the appropriate reallocation of resources, it is expected that this program can continue to grow in the Calgary Health Region and eventually be expanded to benefit patients Province wide.

Appendix 1 – Retrospective data

|Table 1: Patients hospitalized with malignancy and pleural effusion or malignant pleural effusion |

|CHR Site: |

|** This represents a death during the reported hospital stay. | | | | | |

|ALOS - average length of stay (total days divided by total discharges) | | | | |

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|Table 2: Malignant Pleural Effusion - Institution To (on Discharge) | | | | |

|Site |Institution to: |Total |% of Site |LOS (days) |ALOS (days) |

|F |No Transfer |211 |74% |3,364 |16 |

|  |HOME CARE PROGRAM |44 |15% |845 |19 |

|  |UNCLASSIFIED FACILITY/HOSPICE |8 |3% |186 |23 |

|  |DR.VERNON FANNING CALGARY |3 |1% |180 |60 |

|  |BANFF MINERAL SPRINGS |2 |1% |15 |8 |

|  |GLENMORE PARK AUX HOSP CALGARY |2 |1% |150 |75 |

|  |MEDICINE HAT REGIONAL HOSPITAL |2 |1% |25 |13 |

|  |PETER LOUGHEED HOSPITAL |2 |1% |62 |31 |

|  |SUNDRE GENERAL HOSPITAL |2 |1% |29 |15 |

|  |BASSANO GENERAL HOSPITAL |1 |0% |10 |10 |

|  |BROOKS HEALTH CENTRE |1 |0% |26 |26 |

|  |CARDSTON MUNICIPAL HOSPITAL |1 |0% |9 |9 |

|  |CLARESHOLM GENERAL HOSPITAL |1 |0% |20 |20 |

|  |CROSS BOW AUX HOSPITAL CALGARY |1 |0% |115 |115 |

|  |HIGH RIVER GENERAL HOSPITAL |1 |0% |17 |17 |

|  |LETHBRIDGE REGIONAL HOSPITAL |1 |0% |7 |7 |

|  |OUT OF PROVINCE/COUNTRY HOSP |1 |0% |14 |14 |

|  |ROCKYVIEW GENERAL HOSPITAL |1 |0% |5 |5 |

|  |Foothills Total |285 |100% |5,079 |18 |

|P |No Transfer |106 |66% |1,529 |14 |

| |HOME CARE PROGRAM |29 |18% |585 |20 |

|  |UNCLASSIFIED FACILITY/HOSPICE |7 |4% |152 |22 |

|  |FOOTHILLS PROVINCIAL HOSPITAL |5 |3% |52 |10 |

|  |DIDSBURY HOSPITAL |2 |1% |21 |11 |

|  |DR.VERNON FANNING CALGARY |2 |1% |84 |42 |

|  |MEDICINE HAT REGIONAL HOSPITAL |2 |1% |16 |8 |

|  |PINCHER CREEK MUNICIPAL HOSP |2 |1% |44 |22 |

|  |BOWCREST NURSING HOME CALGARY |1 |1% |13 |13 |

|  |BROOKS HEALTH CENTRE |1 |1% |29 |29 |

|  |CHINOOK NURSING HOME CALGARY |1 |1% |63 |63 |

|  |CROSS BOW AUX HOSPITAL CALGARY |1 |1% |175 |175 |

|  |HANNA HEALTH CARE COMPLEX |1 |1% |62 |62 |

|  |OUT OF PROVINCE/COUNTRY HOSP |1 |1% |30 |30 |

|  |Peter Lougheed Total |161 |100% |2,855 |18 |

|R |No Transfer |74 |64% |1,117 |15 |

|  |HOME CARE PROGRAM |23 |20% |376 |16 |

|  |UNCLASSIFIED FACILITY/HOSPICE |9 |8% |367 |41 |

|  |FOOTHILLS PROVINCIAL HOSPITAL |4 |3% |50 |13 |

|  |BEVERLY CENTRE INC CALGARY |1 |1% |66 |66 |

|  |FATHER LACOMBE NURS HOME CALG |1 |1% |2 |2 |

|  |HIGH RIVER GENERAL HOSPITAL |1 |1% |5 |5 |

|  |MAYFAIR NURSING HOME |1 |1% |53 |53 |

|  |NURSING HOME |1 |1% |90 |90 |

|  |Rockyview General Total |115 |100% |2,126 |18 |

|Table 3: Location of admission | | | | |

|Entry Category: |Total |Deaths |ALOS |CHR Resident |

|Foothills Medical Centre |

|Clinics |6 |2 |47.8 |5 |

|Direct |161 |24 |16.2 |92 |

|Emergency Department |117 |39 |18.7 |100 |

|FMC Total |284 |65 |17.8 |197 |

|Peter Lougheed Centre |

|Clinics |4 |0 |20.8 |2 |

|Direct |58 |11 |17.7 |42 |

|Emergency Department |97 |29 |17.9 |85 |

|Day Surgery |2 |0 |5.5 |2 |

|PLC Total |161 |40 |17.7 |131 |

|Rockyview General Hospital |

|Clinics |17 |2 |9.4 |14 |

|Direct |26 |6 |21.8 |22 |

|Emergency Department |72 |22 |19.5 |66 |

|RGH Total |115 |30 |18.5 |102 |

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|CHR Total |560 |135 |17.9 |430 |

|Table 4: LOS according to specialty of | | | | | | | |

|admitting MD | | | | | | | |

|Most Responsible Physician Service |FMC |PLC |RGH |Total |

| |Total |ALOS |Total |ALOS |Total |ALOS |Average LOS |

|10 Internist |12 |13.2 |31 |11 |17 |12.5 |11.9 |

|12 Cardiologist |4 |13.0 |- |- |1 |2 |10.8 |

|15 Gastroenterologist |1 |14.0 |3 |10.3 |- |- |11.2 |

|16 Nephrologist |10 |43.2 |- |- |- |- |43.2 |

|18 Respirologist |12 |10.0 |16 |9.1 |14 |8.9 |9.3 |

|28 Pediatrician |- |- |- |- |- |- | |

|30 General Surgeon |18 |17.4 |20 |20.6 |5 |19.2 |19.1 |

|31 Cardiovascular Surgeon/Cardioth |63 |12.3 |4 |14.3 |- |- |12.4 |

|32 Neurosurgeon |1 |17.0 |- |- |- |- |17.0 |

|34 Orthopedic Surgeon |2 |18.0 |4 |22.5 |- |- |21.0 |

|39 Urologist |- |- |- |- |2 |14.0 |14.0 |

|44 Pediatric Orthopedic Surgeon |- |- |- |- |- |- | |

|50 Obstetrician & Gynaecologist |30 |17.4 |3 |8 |- |- |16.5 |

|55 Intensivist |10 |23.2 |3 |12.7 |2 |8.0 |19.1 |

|57 Anesthesiologist |- |- |3 |22.3 |- |- |22.3 |

|60 Otolaryngologist |- |- |2 |20.5 |- |- |20.5 |

|64 Psychiatrist |1 |5.0 |- |- |- |- |5.0 |

|66 Haematologist |11 |28.5 |12 |13.7 |- |- |20.8 |

|72 Geriatrician |1 |47.0 |- |- |- |- |47.0 |

|74 Oncologist |63 |18.8 |- |- |- |- |18.8 |

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|Table 5: Average LOS according to admitting physician specialty | | | |

|Most Responsible Physician Service |FMC |PLC |RGH |Total |

| |Total |ALOS |Total |ALOS |Total |ALOS |Average LOS |

|10 Internist |12 |13.2 |31 |11 |17 |12.5 |11.9 |

|16 Nephrologist |10 |43.2 |- |- |- |- |43.2 |

|18 Respirologist |12 |10.0 |16 |9.1 |14 |8.9 |9.3 |

|30 General Surgeon |18 |17.4 |20 |20.6 |5 |19.2 |19.1 |

|31 Cardiovascular Surgeon/Cardioth |63 |12.3 |4 |14.3 |- |- |12.4 |

|50 Obstetrician & Gynaecologist |30 |17.4 |3 |8 |- |- |16.5 |

|55 Intensivist |10 |23.2 |3 |12.7 |2 |8.0 |19.1 |

|66 Haematologist |11 |28.5 |12 |13.7 |- |- |20.8 |

|74 Oncologist |63 |18.8 |- |- |- |- |18.8 |

|Table 5: Cases with a Malignancy and a procedure code for Pleurodesis, by Site | |

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|Table 6: Inpatients with MPE with an Insertion of Intercostal Catheter for Drainage |

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|Site Identifier: |Total |Total Days Stay |ALOS (days) | |

|FMC |108 |1,819 |16.8 | |

|PLC |33 |596 |18.1 | |

|RGH |19 |204 |10.7 | |

|CHR Adult Sites |160 |2,619 |16.4 | |

| | | | | |

| |(Fiscal 2000-2001) | | | |

Appendix 2 – Retrospective data

MALIGNANT PLEURAL EFFUSION STUDY

Results:

Sample

In one month of data collection across 3 adult CHR acute care sites in a 4 week study period, a cohort of 13 patients was found that met the inclusion criteria. Another 57 patients admitted with pleural effusion were also followed but did not end up meeting inclusion criteria for 2 main reasons:

a. they did not receive any active treatment for their pleural effusion in terms of having a thoracentesis, a chest tube or pleuroedesis.

b. they did not have a confirmed diagnosis of cancer by way of pathology confirmation or a documented history of cancer. The profile of these observed but not included patients is found in Appendix I.

➢ Patients by Site:

FMC --6

PLC -- 4

RGH – 3

➢ 2/13 patients came from outside the Calgary Health Region

➢ 11/13 patients were found on medical units, 2/13 on surgical units

Patient Profile

Day of admission to hospital as an inpatient was examined for provisional diagnosis, admitting physician service , route of admission, and presenting complaints.

Table 1 – Diagnosis on Day of Admission

|Primary Dx on Admit Day |Secondary Dx on Admit |Tertiary Dx on Admit |Admitting MD service |

| | | | |

|NYD - Dyspnea | | |Oncology |

|Pleural Effusion |NYD-Suspected Cancer | |Hematology |

|Pneumonia |Pleural Effusion | |Hospitalist |

|Cancer - Lung |Pleural Effusion | |Pulmonary |

|Cancer - Lung |Dehydration | |Oncology |

|Cancer - Bowel |Pleural Effusion | |Palliative |

|Cancer - Breast |Pleural Effusion | |Pulmonary |

|Cancer - Lymphoma | | |Family Medicine |

|Dehydration |Pneumonia |Cancer - Breast |Family Medicine |

|Fracture - Lower Limb - Leg | | |Orthopedics |

|Gall Bladder Disease |Leukemia (remission) | |Surgery- General |

|Gall Bladder Disease |Myelodysplasia | |Surgery - General |

|GI Bleed - Lower | | |Hospitalist |

Presenting Complaints:

The number of patients with a confirmed pleural effusion on their day of admission to hospital was 6/13. The opinion of the data reviewers was that the pleural effusion was the major reason for an inpatient admission for these 6 patients. All other effusions were found part way through the inpatient stay. Details of findings are found below. .

Table 2 Chest X-Ray Results Indicating Pleural Effusion.

|Cancer on Admit Day |CXR Date |X-Ray RESULT |Readmit Last |

| | | |60 days |

|Confirmed |Admit Day |Large pleural effusion |Y |

|Suspected |Day 7 |Presumably, some of the confluent density in the (L) lung |N |

| | |represents pleural fluid | |

|Confirmed |Admit Day |RUL collapsed and R hydropneumothorax, Right Pleural |N |

| | |Effusion occupies 40% of R hemithorax | |

|Confirmed |Day 7 |pleural effusion both evident, only right sided tapped |N |

|Confirmed |Day 14 |There is a large R. pleural effusion ie secondary |N |

| | |atelectasis in the RML and RLL | |

|Confirmed |Admit Day |worsening pleural effusion |N |

|Confirmed |Admit Day |CT scan on admit; no xray; lge pleural eff; hemithorax |Y |

|Confirmed |Admit Day |Large(L) sided pleural effusion |N |

|Confirmed |Admit Day |Lung is complete white out |Y |

|Suspected |Day 12 |right sided pleural effusion has increased; left sided not |N |

| | |change | |

|No Malignancy |Day 15 |bilateral with increased in left and right sides |N |

|No Malignancy |Day 9 |small bilateral effusion |N |

|No Malignancy |Day 6 |mod bilateral pleural effusions |N |

| | | | |

Signs and Symptoms on Presentation to Hospital

➢ 12/13 patients presented with SOB, of these 2 had chest pain, 3 had a persistent cough and 2 had both cough and chest pain.

➢ 7/13 patients were documented as palliative either on day of admission or some pint in their inpatient stay.

Route of Admission

➢ 7 patients came in through Emergency

➢ 3 were direct admit requests from physicians

➢ 2 were direct admits from ambulatory clinics

➢ 1 was transferred from an out of region site

Discharge Disposition

➢ 5 patients died in hospital (1 was waitlisted for hospice)

➢ 4 went home with home care support

➢ 3 went home (1 was potentially needing long term care placement)

➢ 1 went to hospice

Final discharge was similar in every case to the predicted destination for all cases which did not die in hospital.

Code Status (Documented):

➢ Level 1 Full Code - 2 cases

➢ Not Documented – 3 cases (will default to full code )

➢ Level 2 – Partial Code – 7 cases

➢ Level 3 Care and Comfort – 1 case

All patients who were designated as palliative were either code level 2 or 3. Code status did not have any direct correlation with amount or type of treatment that was rendered.

Treatment Profile

Table 3 Combinations of Treatments Used for Pleural Effusions

|Thoracentesis 1 |Thoracentesis 2 |Chest Tube 1 |Chest Tube 2 |Pleurodesis |FMC |PLC |RGH |

|N |N |Y |N |N |  |  |1 |

|N |N |Y |N |N |1 |  |1 |

|N |N |Y |N |Y |  |1 |  |

|N |N |Y |Y |N |1 |  |  |

|Y |N |N |N |N |2 |  |  |

|Y |N |Y |N |N |1 |  |  |

|Y |N |Y |Y |N |  |  |1 |

|Y |N |Y |Y |Y |1 |1 |  |

|Y |Y |N |N |N |  |1 |  |

|Y |Y |Y |N |N |  |1 |  |

|  |  |  |  |  |6 |4 |3 |

Over this small sample of 13 patients, 10 chest tubes were placed with 3 patients enduring more than one chest tube. Repeat throacentesis occurred in 2 patients both of whom were at PLC. .

System Utilization Information

Length of Stay

With only 13 cases in this study, the median and mode are the more stable estimates. The range in LOS for all patients was 3 to 67 days as an inpatient. Data below is presented with and without the 67 day case included in the FMC analysis.

Table 4 Length of Stay for Malignant Pleural Effusion Cases

|Site |Mean |Median |Mode |Range |

|FMC |28.2 (with outlier) |25,0 (with outlier) |25.0 |3 to 67 (with outlier) |

| |20.4 (without outlier) |25.0 (without outlier) | |3 to 37 (without outlier) |

|PLC |27.3 |30.5 |8.0 *smallest mode |8 to 40 |

| | | |reported) | |

|RGH |20.7 |19.0 |13.0 *smallest mode |13 to 30 |

| | | |reported | |

Appropriateness s of Inpatient Bed Usage

Table 5 Care Level Found on Each Day of Stay for Study Patients

|Care Level on Day of Stay |FMC |PLC |RGH |

|Intensive Care |12 |  |3 |

|Acute Care |61 |58 |19 |

|  |  |  |  |

|Palliative |50 |4 |31 |

|Skilled Nursing(Stable pt/Stable Tx plan) |42 |36 |7 |

|Community Management Possible |4 |11 |2 |

|Total Days of Stay Reviewed |169 |109 |62 |

| | | | |

In the malignant pleural effusion patient population, most of the higher level care need days (acute level), occurred intermittently when procedures were being done with skilled nursing or palliative care days in between procedures. If less procedures were happening in sequence, then the overall use of inpatient bed days would likely decrease. Under current practices, the care required following chest tube insertions, thoracentesis and pleuroedesis is heavily dependent on 24 hour nursing care and observation. This study population showed few potential community management days that could be diverted from inpatient care given the current treatment practices. Provision of high levels of home care (2 to 3 visits per day) might offset some of the skilled nursing days in which the treatment plan is being supervised to completion in a patient with ADL deficits. Palliative care days can also include dealing with negotiation of next staps and destinations with patients and families. Other than decreasing the wait time for accessing hospice and palliative home care, there may not be much room to reduce these level of care days especially when palliative treatments of symptoms is still being frequently adjusted.

Patients in this study were also complex in terms of the number of reasons for lingering in hospital other than to treat the pleural effusions. These reasons were combinations of social and family issues as well as medical conditions other than pleural effusions. The following table outlines the factors contributing to the hospital stays.

|Other Reasons Why Patient Stayed in Hospital | | | |

|Reason |# of Patients |Site | |

|No other reason other than the pulmonary Embolism to be in hospital |1 |PLC | |

|  |1 |RGH | |

|Undergoing diagnostic workup |1 |FMC | |

|  |1 |PLC | |

|Undergoing diagnostic workup and |1 |PLC | |

|Undergoing treatment for palliation not related to the PE and |  |  | |

|Post-Op complication |1 |FMC | |

|Surgery needed |1 |PLC | |

|Post-Op complication |  |  | |

|Undergoing diagnostic workup |  |  | |

|Undergoing treatment by rehab therapists |  |  | |

|Undergoing treatment for palliation not related to the PE |  |  | |

|Palliative pain management |1 |FMC | |

|Undergoing diagnostic workup |  |  | |

|Family/Social Issues |  |  | |

|Undergoing treatment by rehab therapists |  |  | |

|Undergoing treatment for palliation not related to the PE |  |  | |

|Palliative pain management |1 |RGH | |

|Undergoing diagnostic workup |  |  | |

|Organizing Care Centre Transfer |  |  | |

|Family/Social Issues |  |  | |

|Termination of life in acute care environment preferred |  |  | |

|Palliative pain management |1 |RGH | |

|Organizing palliative care in the community |  |  | |

|Palliative pain management |1 |FMC | |

|Organizing palliative care in the community |  |  | |

|Palliative pain management |1 |FMC | |

|Organizing palliative care in the community |  |  | |

|Undergoing diagnostic workup |  |  | |

|Family/Social Issues |  |  | |

|Undergoing treatment by rehab therapists |  |  | |

|Undergoing treatment for palliation not related to the PE |  |  | |

|Palliative pain management |1 |FMC | |

|Surgery needed |  |  | |

|Organizing palliative care in the community |  |  | |

|Undergoing diagnostic workup |  |  | |

|Organizing Care Centre Transfer |  |  | |

|Undergoing treatment by rehab therapists |  |  | |

|Undergoing treatment for palliation not related to the PE |  |  | |

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