Effects of Multidisciplinary Team Care on Utilization of Emergency Care for Patients With Lung Cancer

Objectives

To improve the quality of care, multidisciplinary team (MDT) care was implemented in Taiwan. This study examined the relationship between MDT care and emergency department (ED) visits for lung cancer patients.

Study Design

A retrospective cohort study with MDT care participants and matched a double number of control group of non-participants was followed.

Methods

In this study, 22,817 patients with newly diagnosed lung cancer were recruited from 2005 to 2007 in Taiwan. Matching based on the propensity of receiving MDT care was used. A total of 8172 patients were observed in this study. A c2, ANOVA, logistic regression, and Poisson regression were used to elucidate the effects of MDT care.

Results

The lung cancer patients participating in MDT had lower risk to visit an ED (OR = 0.89; 95% CI, 0.80-0.98), and the incidence rate ratio decreased by 11% (95% CI, —0.15 to –0.07). Gender, monthly salary, urbanization of the residence area, comorbid conditions, catastrophic illness/injury, treatment method, number of outpatient visits, length of stay,

hospital ownership, level of hospital, and the age of the patient’s physician were all significantly related to the frequency of ED visits (P <.05).

Conclusions

The frequency of ED visits of patients with MDT care was lower than that of those without it. The patients with MDT received enhanced care.

Am J Manag Care. 2014;20(8):e353-e364

• Multidisciplinary team care can improve the effectiveness of care for lung cancer patients.
• The incidence rate ratio of emergency department (ED) visits decreased 11% for lung cancer patients participating in MDT care.
• The primary cause of ED visits was fever for both the MDT participants (25.46%) and non-MDT participants (23.97%).

Worldwide, lung cancer is the most common cancer

in terms of both incidence and mortality. In

2012, there were 1.8 million new cases and 1.59

million deaths caused by lung cancer.¹ Since 1998, lung cancer

has been the leading cause of cancer death in Taiwan

and worldwide.² Although progress has been made in the

diagnosis and treatment of lung cancer, both the incidence

and mortality rate of lung cancer have increased in recent

years. Formal multidisciplinary team (MDT) care has been

widely promoted worldwide to improve coordination, communication,

and decision making in cancer management.^3,4

The Taiwan bureau of National Health Insurance has implemented

“multidisciplinary team care for cancer patients”

since April 2003 to enhance the quality of cancer diagnosis

and treatment. The bureau emphasizes an MDT approach

that provides a complete cancer treatment plan for patients.

MDT care goes beyond such conventional treatments for

lung cancer as surgical excision, radiation therapy, and chemotherapy.

The MDT members can include related clinical

physicians, nursing staff, a psychological consultant, a social

worker, and a case manager to discuss a dedicated treatment

plan and to integrate all treatments and care. Therefore,

the patient with MDT care should benefit from stable and

continuous care that includes regular outpatient visits and

inpatient treatment, all arranged and coordinated through

the case manager. The Bureau of National Health Insurance

(NHI) paid additional fees to physicians to make MDT care

financially appealing.

The MDT approach has been used for years in numerous

countries. Studies from the United States, Germany, the

United Kingdom, and Australia have demonstrated that an

MDT that integrates surgeons, tumor physicians, radiology

physicians, psychologists, physiatrists, and dietitians can improve

the quality of life for cancer patients,5 lower the cost

of healthcare,⁶ and increase the satisfaction of treatment for

patients,⁶ efficiency of treatment,^4,5,7,8 and survival rate.^9,10 In

Taiwan, Wang et al found the relative risk of death was lower

for oral cavity cancer in MDT care participants.⁴ Chen et

al found that chronic kidney disease patients who participated

in MDT had a better survival rate than nonparticipants

have initiate renal replacement therapy instead of

after MDT intervention.¹¹

Hospital emergency departments (EDs) are typically designed

to manage emergent or unexpected situations and

are generally crowded and busy.¹² As detailed in 1 study,

in North Carolina in 2008, 0.9% of ED visits were cancer

related; 7.7% of the state’s cancer survivors visited the ED;

and each ED visitor received 1.4 ED services per year on

average.¹³ In Taiwan, in 2012, 1.9% of ED visits were cancer

related.¹⁴ The reasons cancer patients seek ED services

include pain, dyspnea, nausea, and vomiting, among others.

13,15 Among cancer patients, lung cancer patients are,

as a group, the likeliest of all to seek ED services.13 The

main reasons that prompt the visits of lung cancer patient

to EDs include respiratory symptoms, fever, neurological/

psychiatric issues, and digestive complaints.¹⁶

The high percentage of ED visits for cancer patients

has been recognized as an indicator that end-of-life cancer

care is of less-than-ideal quality. Better care, it is believed,

could help cancer patients avoid at least some of the urgent

medical problems that necessitate ED visits.

Most studies on lung cancer in MDT care have been

limited, sometimes because the sample size was small and

sometimes because the focus was narrowly on survival.

Few studies have examined the changes in the utilization

of ED services after patients have become involved in

MDT care. Therefore, this study investigates the influence

of the participation and nonparticipation of patients

in MDT care on the utilization of ED visits.

METHODS

Data Source

This retrospective and longitudinal cohort study analyzed

the Cancer Dataset in the National Health Insurance

Research Database (from 1997 to 2008) published

by the Taiwan National Health Research Institutes and

provided by the Bureau of National Health Insurance

of Taiwan. The database included

the medical records of all individuals

insured by National Health Insurance

in Taiwan. At the end of 2009,

a total of 23,026,000 people were insured,

constituting 99.59% of Taiwan’s

population. From these data we could

extrapolate the utilization of health

services by the lung cancer patients in

Taiwan. The Bureau of National Health Insurance implemented

MDT care in April 2003, and this study used the

years of suffering from lung cancer diagnosis for cancer

treatments (the major

International Classification of Diseases,

Ninth Revision, Clinical Modification

[

ICD-9-CM

] code

140.x-293.x).

1. Participants. According to the database, 8172 lung

cancer patients in Taiwan were newly diagnosed between

2005 and 2007. New patients defines a first-time lung cancer

diagnosis based on

ICD-9-CM

code 162.x, and diagnosis

following a year of chemotherapy, radiation treatment,

surgery, or other cancer treatment. We followed up with

each patient within 1 year after lung cancer diagnosis. We

excluded those patients who had not received any treatment

since their diagnosis, and we also excluded the patients

who died within 1 month after diagnosis (N = 2050

patients). Since the physicians could decide whether the

patients participated in the MDT care or not, the MDT

participants might exhibitbias selection. Therefore, to reduce

the bias selection from this population-based data,

this study used a propensity score matching to evaluate

the likelihood of participating in MDT care for each patient

and so selected double patients as the control group.

In beginning, the study selected 22,817 lung cancer patients

which were 2736 patients who joined an MDT care

and 20,081 patients who did not. After propensity score

matching, there were 2724 MDT patients and double patients

in non-MDT groups.

2. Variable Description and Defintion. Independent

variables included patients’ gender, age, monthly salary,

urbanization of their area of residence, Charlson Comorbidity

Index (CCI) score, catastrophic illness number of

cancer outpatient visits, number of hospitalizations, and

participation status in MDT care, as well as certain characteristics

of their hospital and physician. Dependent

variables included whether the patients used ED service

or not, and the frequency of ED use in the 12 months following

diagnosis, excluding the utilization of the ED due

to trauma.

Study participants were categorized by gender (male,

female); age (divided into 7 groups from less than 24 years

to 75 years and older); monthly salary (divided into 8

groups); urbanization of residence area (noted on a scale

of 1 to 7,¹⁷ with 1 being the most urban and 7 the least);

CCI score (the extent of comorbidity was adapted by

Deyo);¹⁸ catastrophic illness (yes or no); number of cancer

outpatient visits (divided into 7 groups, from 0 visits to 26

and above); length of stay of hospitalization due to lung

cancer within 1 year after cancer diagnosis (LOS; divided

into 5 groups); ownership of the hospital visited most frequently

(public or non-public); level of that hospital (first

level, second level, third level, and clinic); and characteristics

(gender, age) of the patient’s physician.

t

3. The study used descriptive statistics, x² test, test,

and ANOVA to analyze the characteristics of demography,

health status, disease treatment method, utilization

of healthcare within 1 year, hospital and physicians’

characteristics, and the differences in ED visits between

those who did and did not participate in MDT care. Logistic

regression and Poisson regression were used to analyze

the inference factors of probability and frequency of

ED visits between the patients who did and did not participate

in MDT care. All analyses were performed using

the sets statistical package version 9.2.

RESULTS

Table 1

Table 2

and show the characteristic distribution

before and following PSM of the sample. Following PSM,

8172 subjects were selected for this study. The characteristics

included the gender, age, monthly salary, urbanization

of residence area, CCI score, catastrophic illness, and

treatment methods of MDT and non-MDT participants.

The differences between the 2 groups on all these variable

measures were not statistically significant (

P

>.05).

Table 3

shows the top 20 causes of lung cancer patients’

ED visits. The primary cause was fever for both

the MDT participants (25.46%) and non-MDT partici

pants (23.97%), followed by dyspnea and respiratory abnormalities;

chest pain; abdominal pain; and dizziness

and fainting. These 5 causes account for 64% of the

reasons lung cancer patients visited the ED, and there

were no significant differences in this regard between the

MDT and non-MDT patients. Fewer MDT participants

(7.94%) visited EDs because of lung cancer-related chest

pains than non-MDT participants (10.2%). Furthermore,

fewer MDT participants (1.06%) visited EDs because

of coughing than did non-MDT participants (2.24%).

Among the top 20 causes for the MDT participants’

ED care visits were general symptoms (2.88%), convulsions

(1.7%), and other nervous and musculoskeletal

system symptoms (0.59%). For non-MDT participants,

ED visit reasons included alteration of consciousness

(1.75%), shock without mention of trauma (1.02%), and

general symptoms (0.56%).

Table 4

shows comparisons

of the ED care uses of MDT participants and non-MDT

participants who had different demographic variables

and treatment characteristics. Before controlling for

other factors, the results of the c2 test showed that MDT

participants had less chance to use ED services than

non-MDT paticipants, but not significantly. However,

the number of ED care visits in MDT participants was

significantly less than non-MDT participants. Patients

who had higher percentages of ED service uses tended

to be male; have monthly salaries lower than NT$57,800

(New Taiwan dollars); live in less urbanized areas; have

CCI scores greater than 7; have a greater likelihood to

have suffered a catastrophic illness; have made more

cancer outpatient visits; have had a longer LOS. Patients

who made more ED visits also tended to be receiving the

treatments of radiology therapy; or radiology therapy +

chemotherapy; or surgery + radiology therapy + chemotherapy.

In addition, patients who are treated by physicians

aged 44 years or less have significantly higher

percentages of ED service use (

P

<.05).

Patients in our study with the following characteristics

had greater mean numbers of ED service uses: non-MDT

participants (mean = 1.53 ± standard deviation [SD] 2.63);

those between 25 and 34 years of age (mean = 2.37 ± SD

4.25); those with a, CCI score of 12 or greater (mean =

2.67 ± SD 3.01); residing at levels 4 and 5 in urbanization

of residence area (mean = 1.66 ± SD 3.21); those with

catastrophic injury or illness beyond lung cancer (mean =

1.51 ± SD 2.54); greater number of cancer outpatient visits

(mean = 1.66 ± SD 2.93), longer LO; and receiving surgery

+ radiology therapy + chemotherapy (mean = 1.72 ± SD

2.98). Patients who are treated at public hospitals have

greater mean numbers of ED service uses (mean = 1.57

± SD 2.39), and patients who are treated by physicians

55 years or older have the smallest mean number of ED

service uses (mean = 1.14 ± 1.88), a statistically significant

difference in comparison to patients treated by younger

physicians (

P

<.05).

Table 5

shows the results of the logistic regression and

Poisson regression that were performed on the variables.

The results of the logistic regression show that MDT participants

have a lower likelihood of seeking ED services

(OR = 0.89; 95% CI, 0.80-0.98), which differs significantly

from non-MDT participants (

P

= .022). Female patients are

less likely to visit EDs compared with male patients (OR

= 0.73; 95% CI, 0.66-0.81); patients with monthly salaries

either between NT$57,801 and NT$72,800, or NT$72,800

or more, are less likely to visit EDs compared with patients

with premium-based monthly salaries of NT$17,280

or less (OR = 0.34; 95% CI, 0.21-0.54; OR = 0.52; 95% CI,

0.30-0.91); patients with CCI scores between 4 and 6, between

7 and 9, between 10 and 12, and 12 or greater are

more likely to visit EDs compared with patients with CCI

scores of 3 or less (OR = 1.60; 95% CI, 1.28-2.00; OR =

2.62; 95% CI, 2.13-3.22; OR = 3.70; 95% CI, 3.02-4.52; OR

= 7.82; 95% CI, 5.31-11.54); and patients with catastrophic

illness are more likely to visit EDs compared with patients

without catastrophic illness (OR = 2.94; 95% CI, 2.01-4.31).

Patients receiving surgery + radiology therapy, surgery +

chemotherapy, radiology therapy + chemotherapy, and

surgery + radiology therapy + chemotherapy are more

likely to visit EDs compared with patients receiving only

surgeries (OR = 1.89; 95% CI, 1.54-2.32; OR = 1.90; 95% CI,

1.57-2.30, OR = 1.61; 95% CI, 1.17-2.22; OR = 2.71; 95%

CI, 2.25-3.28). Patients with more than 1 outpatient visit

and treated in a district hospital, rather than a first-level

hospital, are more likely to visit the ED. Patients with longer

LOS and who are treated by physicians over 35 years

of age are less likely to visit the ED. These differences are

all statistically significant (

P

<.05).

The results of the Poisson regression showed that after

controlling for the other variables, the MDT participants

visited EDs fewer times compared with non-MDT participants

(β = -0.09; 95% CI, —0.13 to 0.05). Female patients

visited EDs fewer times compared with male patients

(β = -0.18; 95% CI, —0.22 to 0.14). Patients who were insured

dependents or who had monthly salaries between

NT$17,281 and NT$22,800 visited EDs more times compared

with patients with monthly salaries of NT$17,280

or less (β = 0.10; 95% CI, 0.04-0.16; and β = 0.06; 95% CI,

0.00-0.11), whereas patients with premium-based monthly

salaries between NT$36,301 and NT$45,800, between

NT$57,801 and NT$72,800, and NT$72,801 or greater,

visited EDs fewer times compared with patients having

monthly salaries of NT$17,280 or less (β = —0.17; 95% CI,

—0.28 to 0.06; β = -0.43; 95% CI, –0.64 to 0.22; β = –0.42;

95% CI, —0.68 to 0.17). Patients at levels 2 and 3 and 4 and

5 of urbanization of residence area visited EDs more times

compared with patients at level 1 (the most urban) of urbanization

of residence area (β = 0.06; 95% CI, 0.01-0.11;

β = 0.16; 95% CI, 0.13-0.22). Patients with CCI scores between

4 and 6, between 7 and 9, between 10 and 12, and of

12 or more visited EDs more times compared with patients

with CCI scores of 3 or less (β = 0.39; 95% CI, 0.27-0.50; β

= 0.65; 95% CI, 0.54-0.76; β = 0.95; 95% CI, 0.85-1.06; and

β = 1.32; 95% CI, 1.19-1.45). Patients with catastrophic illness

visited EDs more times compared with patients without

them (β = 0.63; 95% CI, 0.41-0.85). Patients receiving

radiology therapy, surgery + radiology therapy, surgery +

chemotherapy, radiology therapy + chemotherapy, and

surgery + radiology therapy + chemotherapy visited EDs

more times compared with patients receiving only surgeries

(β = 0.32; 95% CI, 0.18-0.47; β = 0.34; 95% CI, 0.24-0.43;

β = 0.52; 95% CI, 0.43-0.61; β = 0.26; 95% CI, 0.13-0.40; β

= 0.66; 95% CI, 0.57—0.74). Patients receiving treatment at

private hospitals visited EDs fewer times compared with

patients receiving treatments at public hospitals (β = —0.11;

95% CI, -0.15 to 0.06). Patients with more than 1 outpatient

visit and treated in a second-level hospital or thirdlevel

hospital, rather than a medical center, visited the ED

more times. Patients with longer LOS and treated by physicians

aged 45 years or more visited the ED fewer times.

These differences were all statistically significant (

P

<.05).

DISCUSSION

Our results showed that MDT participants visited EDs

fewer times compared with non-MDT participants. Although

EDs can provide immediate care to relieve acute

symptoms, cancer patients cannot receive proper and

holistic care because EDs, which are frequently crowded

and busy, are not satisfactory environments for such

care.¹³ In learning that MDT participants use ED care less

frequently, indicating that MDT care reduces lung cancer

patients’ needs to use ED services, we can infer that MDT

care improves the quality of cancer patient care.

The most common cause of cancer patients’ ED visits

is fever (approximately 25%), which differs from the most

common cause—pain&mdash;identified in previous studies.^13,15,19

This is possibly because various countries adopt different

standards in the timing and methods of prescribing anti-infectives

and antipyretic and analgesic medication. Further

analysis must be conducted to examine cancer patients’

medication dosage and uses. In the 2008 study by Mayer

et al,¹³ approximately 7.7% of North Carolina’s cancer patients

(having all kinds of cancer, and ranging from recently

diagnosed to diagnosed years earlier) sought ED care, whereas

57% of the lung cancer patients in this study sought ED

care. This is possibly because (a) this study examined the

selected cancer patients’ ED service uses for the first year after

they were diagnosed by physicians, whereas Mayer et al

investigated all cancer patients’ ED service uses during that

year, which resulted in the substantial difference; or (b) the

charge of ED service in Taiwan was inexpensive ($5 to $15

US) compared with that in the United States.

Male patients use ED services more frequently than

female patients, which is consistent with the results of

previous studies.^13,20 Cancer patients with catastrophic illness

use ED services more frequently, which is consistent

with the findings in the study conducted by Liu et al16 in

2006. Patients with higher CCI scores have more severe

comorbidities and thus use medical services, such as the

ED, more frequently. Patients earning higher salaries are

less likely to use ED services and use their services less

frequently compared with patients earning lower salaries,

possibly because the former are more capable of maintaining

and enhancing the quality of the daily care they receive

and are, therefore, less likely to require ED care. Patients

residing in less urbanized areas are more likely to use ED

services and to use them more frequently compared with

patients residing in more urbanized areas, indicating differing

access to medical services based on the residential

area’s level of urbanization. Patients whose cancer is being

treated by surgery alone use ED services less frequently

compared with patients receiving other treatments, possibly

because they had relatively simple procedures that

caused few complications or because they might have been

diagnosed relatively early, with less of a chance to develop

issues needing ED attention. In addition, lung cancer patients

receiving only chemotherapy use ED services less

frequently, although the difference is not statistically significant.

Patients receiving treatments at private hospitals

and public hospitals do not significantly differ regarding

whether they seek ED care. However, patients receiving

ongoing treatments at private hospitals visited EDs fewer

times compared with patients receiving treatments at

public hospitals, possibly reflecting a gap between private

and public care quality. As for physicians’ characteristics,

gender has no effect on patients’ ED service uses. In contrast,

patients who are treated by senior physicians are

less likely to use ED services and use these services less

frequently. This could indicate that physicians with more

medical experience can reduce their patients’ urgent and

unpredictable needs regarding receiving medical services.

PSM was employed to reduce the selection bias resulting

from varied patients’ characteristics in MDT participation.

The matching was based on variables including

gender, age, monthly salary, urbanization of residence

area, CCI scores, catastrophic illness/injury, treatment

methods, whether the patient’s hospital was public or private,

and characteristics of the patient’s physician. However,

we did not include certain factors that may have

affected patients’ ED service uses, such as smoking and

drinking habits, cancer staging, and type of lung cancer.

These data types are difficult to obtain and constitute

a limitation of this study. The results only showed the

strong potential causation but not the direct evidence.

CONCLUSION

This study found that lung cancer patients who participate

in MDT care use ED services less frequently.

EDs cannot provide cancer patients with holistic care.

Therefore, cancer patients should be provided with

MDT care to reduce their need for ED services. In addition,

patients participating in MDT care are less likely

to have urgent and unpredictable needs for medical care,

indicating that MDT care enhances the management of

lung cancer patients.

This study found that the primary cause of lung cancer

patients’ ED visits is fever, which differs from the findings

of studies conducted in other countries. Future studies can

be conducted to analyze the dosages of anti-infection and

antipyretic and analgesic medications that physicians prescribe

to lung cancer patients to elucidate the causes of the

high frequency of fever in Taiwanese lung cancer patients.

Acknowledgments

The authors are grateful for financial support from China Medical

University and Asia University (grant numbers: CMU100-ASIA-10,

DOH102-TD-B-111-004) as well as the National Science Council (grant

number: NSC98-2410-H-468-015-MY2) in Taiwan. They also deeply appreciate

the provision of the dataset of cancer patients by the National

Health Research Institutes.

Author Affiliations: Department of Public Health and Department of

Health Services Administration, China Medical University, Taichong,

Taiwan, ROC (SMW); Department of Health Services Administration,

China Medical University, Taichung, Taiwan, ROC (YHW, KHH,

WCT); Department of Health Care Administration, Oriental Institute of

Technology, Taipei, Taiwan, ROC (SMW); and Department of Healthcare

Administration, Asia University, Taichung, Taiwan, ROC (PTK).

Funding Source: This study was funded by China Medical University

and Asia University (grant numbers: CMU100-ASIA-10, DOH102-

TD-B-111-004) and the National Science Council (grant number:

NSC98-2410-H-039-004).

Author Disclosures: The authors report no relationship or financial

interest with any entity that would pose a conflict of interest with the

subject matter of this article.

Authorship Information: Concept and design (SMW, WCT); analysis

and interpretation of data (PTK, SMW, KHH, WCT, YHW); drafting of

the manuscript (SMW); critical revision of the manuscript for important

intellectual content (KHH, WCT); statistical analysis (PTK, YHW); funding

(KHH, WCT); administrative, technical, or logistic support (KHH);

and supervision (PTK, WCT).

Address correspondence to: Wen-Chen Tsai, DrPH, No. 91 Hsueh-Shih

Road, Taichung, Taiwan 40402, ROC. E-mail: wtsai@mail.cmu.edu.tw.

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