Early Readmission to Hospital in Patients With Cancer With Malignant Pleural Effusions: Analysis of the Nationwide Readmissions Database.

BACKGROUND: Hospital readmissions are costly to health-care systems and represent a measure of quality care. Patients with cancer with malignant pleural effusions (MPEs) are at high risk for rehospitalization; however, risk factors for readmissions in this population are not well described. Understanding the incidence and risk factors for readmission could facilitate the development of a readmission reduction strategy in this patient population. METHODS: We conducted a retrospective cohort study using the Nationwide Readmissions Database (NRD) (2014 sample) to determine the proportion of all-cause, unplanned, 30-day readmissions to hospital among patients with MPEs. Survey weighting methods that accounted for the NRD sampling design were used to generate nationally representative estimates. We used multivariable logistic regression to determine predictors of early readmission. RESULTS: There were 27,900 unplanned readmissions after 108,824 index hospitalizations for MPEs, a rate of 25.6% (95% CI, 25.0%-26.3%). The mortality rate during readmission to hospital was 17.3% (n = 4,840; 95% CI, 16.6%-18.1%). Mean cost per readmission was $15,452 ± $415, with total aggregate costs of > $400 million. Predictors of early readmission included having Medicaid insurance status, treatment with thoracentesis only, and discharge to a care facility or home health care. CONCLUSIONS: One in four patients with cancer and MPEs are readmitted to hospital within 30 days of discharge, and nearly one in five die during the readmission. Nondefinitive management with thoracentesis led to more readmissions. A further understanding of factors that drive preventable readmissions could significantly improve quality of care in this population.

Assessment of precision irradiation in early non-small cell lung cancer and interstitial lung disease (ASPIRE-ILD): study protocol for a phase II trial.

BACKGROUND: Stereotactic ablative radiotherapy (SABR) has become an established treatment option for medically-inoperable early-stage (Stage I-IIA) non-small cell lung cancer (ES-NSCLC). SABR is able to obtain high rates of local control with low rates of symptomatic toxicity in this patient population. However, in a subset of patients with fibrotic interstitial lung disease (ILD), elevated rates of SABR-related toxicity and mortality have been described. The Assessment of Precision Irradiation in Early Non-Small Cell Lung Cancer and Interstitial Lung Disease (ASPIRE-ILD) study will conduct a thorough prospective evaluation of the clinical outcomes, toxicity, changes in diagnostic test parameters and patient-related outcomes following SABR for ES-NSCLC for patients with fibrotic ILD. METHODS: ASPIRE-ILD is a single-arm Phase II prospective study. The accrual target is 39 adult patients with T1-2N0M0 non-small cell lung cancer with co-existing ILD who are not candidates for surgical excision. Pathological confirmation of diagnosis is strongly recommended but not strictly required. Enrolled patients will be stratified by ILD-related mortality risk. The starting SABR dose will be 50 Gy in 5 fractions every other day (biologically effective dose: 100 Gy10 or 217 Gy3), but the radiation dose can be de-escalated up to two times to 50 Gy in 10 fractions daily (75 Gy10 or 133 Gy3) and 45 Gy in 15 fractions daily (58 Gy10 or 90 Gy3). Dose de-escalation will occur if 2 or more of the first 7 patients in a cohort experiences grade 5 toxicity within 6 months of treatment. Similarly, dose de-escalation can also occur if 2 or more of the first 7 patients with a specific subtype of ILD experiences grade 5 toxicity within 6 months of treatment. The primary endpoint is overall survival. Secondary endpoints include toxicity (CTC-AE 4.0), progression-free survival, local control, patient-reported outcomes (cough severity and quality of life), rates of ILD exacerbation and changes in pulmonary function tests/high-resolution computed tomography findings post-SABR. DISCUSSION: ASPIRE-ILD will be the first prospective study specifically designed to comprehensively evaluate the effectiveness and safety of SABR for ES-NSCLC in patients with co-existing ILD. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03485378. Date of registration: April 2, 2018.