Disparities in cancer care: Is there a benefit for increased use of inpatient chemotherapy (IPC) in safety-net hospitals?

person PAWINA SUBEDI Jacobi Medical Center, Bronx, NY info_outline PAWINA SUBEDI, Richard J. Gralla, Anusha Bapatla, Jessica Richy

Authors person PAWINA SUBEDI Jacobi Medical Center, Bronx, NY info_outline PAWINA SUBEDI, Richard J. Gralla, Anusha Bapatla, Jessica Richy Organizations Jacobi Medical Center, Bronx, NY, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY Abstract Disclosures Research Funding No funding sources reported Background: Safety net hospitals provide care to a large number of vulnerable patients (pts) regardless of their ability to pay (1). These pts often have barriers to acceptance at many hospitals, including lack of or poor insurance, social and economic challenges. Additionally, pts frequently present with more advanced disease (2). Systemic treatment is preferentially administered on an ambulatory basis given several factors: clear financial incentives; effective supportive care; the association of good performance status (PS) with better outcomes; and patient preference (3). Only a few malignancies require inpatient systemic treatment. Strong social support is required for safe and effective ambulatory care, thus especially challenging pts at safety net hospitals in which social constraints are common. Methods: We reviewed patterns of IPC to determine efficacy and outcomes over a 3-year period at a safety net hospital, examining: malignancy type, reason for IPC treatment, treatment regimen (typically outpatient or inpatient), length of stay, and survival. Results: 82 pts met criteria. 56% had hematologic or HIV-associated malignancies. Solid tumor types included GI, breast, GYN, GU and small cell malignancies. Reasons for IPC were progression, worsening symptoms, declining PS in 55% and social constraints in 11%. Patient death within 3 months of IPC, or direct discharge to hospice/nursing home occurred in 42%. Further outpatient chemotherapy was never given in 50%. Death occurred in 15% of pts on the same hospitalization as the IPC; several additional pts were readmitted and died within one month. Individuals receiving IPC due to poor social support frequently required rapid rehospitalization, had poor outpatient follow-up, or died shortly thereafter. Three month survival was more favorable in pts with multiple myeloma or those admitted for drug-desensitization. Conclusions: Outcomes, including survival and rapid rehospitalization, were poor for pts receiving typical outpatient regimens on an inpatient basis whether due to social constraints, declining PS or worsening symptoms. A large percentage of pts never received further chemotherapy. IPC is costly, undesired by pts, and is often not a good use of resources. Pts with highly responsive cancers with fair to good PS had acceptable outcomes. IPC should be reserved for such pts if alternative outpatient regimens are not available. Earlier discussion of hospice and goals should not be replaced by chemotherapy. Institutional unavailability of key oral agents and limited outpatient resources often contribute to IPC. Better access to modern agents, enhanced social support, enlarged and better supported outpatient resources, as well as improved decision making improve cancer care. Our results do not support IPC as a frequent approach to cancer care in safety net hospitals. 1. Popescu, JAMA 2019. 2. Farkas, JCO 2012. 3. Mor, J Clin Epid 1988.