Changes in Patterns of Referral for Inpatient Rehabilitation Cancer Patients due to COVID-19: A Retrospective Study

Abstract

There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April- July of 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% CI: 2.4 – 4.2), compared to 337 referrals from 7,051 admissions in 2020 (4.8%; 95% CI: 4.3 – 5.3, p= 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs 31.4%; 48.2% vs 26.5%; p = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs 21.8%; p = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized.

Introduction:

Both symptom and functional scores of cancer patients improve significantly during inpatient rehabilitation (IPR) with three hours/weekday of a combination of physical therapy, occupational therapy, speech therapy, and/or group therapy¹. Cancer patients also agree that rehabilitation helps with regaining physical independence to deal with self-care tasks². As cancer treatments improve survival rates, cancer rehabilitation may be utilized to reduce morbidity and health care costs associated with cancer and disability³.

The severe acute respiratory syndrome coronavirus 2 and the resulting illness, COVID-19, began in November 2019 and was officially declared a pandemic in March 2020⁴. The COVID-19 pandemic changed the way hospital systems operate as well as significantly impacted IPR. Several hospitals converted IPR beds into general medicine wards or isolation wards to house COVID-19 patients, with overall less access to rehabilitation^5,6.

During the pandemic, the diagnosis of cancer itself decreased, with the weekly number falling 46.4% for certain solid tumors combined⁷. There was a reflective drop in cancer screening and routine care⁸ and higher rates of cases and hospitalization in American Indians, Black and African-Americans, and Hispanic/Latino populations⁹. In addition, we expect that COVID-19 will not be the only pandemic our healthcare system will face in the future.

During the initial phases of COVID-19, our IPR did not accept patients with active COVID-19 diagnoses due to need to conserve resources. There was also a stop on elective surgeries during this time. There has been no literature reflecting how the initial phases of COVID-19 affected the referral patterns to cancer physiatry and cancer diagnoses in patients admitted to IPR. Therefore, we hypothesized that due to COVID-19, the percentage of referrals to cancer physiatry and number of IPR admissions decreased.

Methods

Study Design and Population:

After obtaining Institutional Review Board approval with waiver for consent, a retrospective chart review was performed to compare the number of admissions to the hospital and admitting service, number and type of surgical procedures, number of referrals to physiatry, and the number of admissions to IPR between April-July 2019 and April-July 2020. This study conforms to all STROBE guidelines and reports the required information accordingly (see Supplementary Checklist).

Patients are admitted to the hospital and referred by the acute care service to physiatry and therapy services as needed. Acute care service lines included: hematological including leukemia, lymphoma, and myeloma services; stem cell transplant; orthopedics, which admits primary bone tumors and metastatic tumors with pathological fractures; neurosurgery, which admits primary spine/brain tumors as well as metastatic spinal cord compression and brain metastases; neuro-oncology; and others including gynecology, breast medical oncology, sarcoma medical service, and general internal medicine, which manages endocrine neoplasms, gastrointestinal tumors and genitourinary tumors. During the pandemic, a new institutional initiative occurred which ensured advanced care planning occurred within 24 hours of admission to the hospital. This consisted of a goals of care discussion with the patient and/or medical power of attorney. It specifically focused on goals of cancer treatment, prognosis, and life expectancy and was documented in the chart by the clinic physician/advanced practice nurse (APN) if the patient was a direct admission or the admitting physician/APN in the hospital. This allowed both patients and providers to be clear on expectations regarding the patients’ cancer status and treatments they received on the acute care service. The physiatrist evaluated appropriateness for transfer to IPR and requested insurance approval. Due to the COVID-19 pandemic, initial consultations and follow ups could be conducted virtually using video, and patients were seen in person to confirm medical stability prior to transfer. There were no other changes to the process of evaluation and acceptance to IPR.

On IPR, patients are seen by a multi-disciplinary team including a physiatrist, nurse, physical, occupational, and speech therapist as needed, and case manager. The patients undergo three hours of intensive therapy a day for five days a week. To address spiritual and psychosocial issues, a social worker, and a chaplain are available on site or virtually.

Data Collection:

We collected the number of admissions and admitting service, number and type of surgical procedures, number of referrals to physiatry, and the number of admissions to IPR. For patients admitted to IPR, we also collected demographics and their primary cancer diagnosis. We obtained the discharge disposition of the IPR patients, including the reason for those transferred back to acute care.

Patients’ functional status using the Activity Measure for Post-Acute Care (AMPAC) “6-clicks” instruments were collected from therapists’ notes upon admission to IPR. One instrument assesses basic mobility and the other daily activities¹⁰. The instruments are well validated with inter-rater reliability as measured by physical and occupational therapists^10,11.

Statistical Analysis:

Demographic and clinical characteristics of the study population were summarized with standard descriptive statistics by study period and compared using t-test, rank-sum test, chi-squared test, or Fisher’s exact test depending on the underlying distribution of the data. We calculated the percentage of total admissions who were referred to physiatry along with 95% confidence intervals (CI) for each study period and compared this percentage using a chi-squared test. We calculated the percentage of those that were referred to physiatry who admitted to IPR along with 95% confidence intervals by time period and compared using a chi-squared test. All statistical analysis was performed using Stata/MP v17.0 (College Station, TX).

Results:

In 2019, there were a total of 10,274 hospital admissions and 387 referrals to physiatry (3.8%; 95% CI: 2.4 – 4.2) compared to 7,051 admissions in 2020 with 337 referrals (4.8%; 95% CI: 4.3 – 5.3, p= 0.001). There was a significant difference (p<0.001) in hospital admitting service (hematological, orthopedics, neurosurgery, neuro-oncology, other surgical, and other medical) between 2019 and 2020. 108 of 387 referrals (27.9%; 95% CI: 23.5 – 32.7) in 2019 were admitted to IPR, with 279 assessed but not admitted. 102 of 337 referrals (30.3%: 95% CI: 25.4 – 35.5, p= 0.485) in 2020 were admitted to IPR, with 235 assessed but not admitted.

Table 1 compared the characteristics of patients admitted to the IPR during 2019 and 2020, for which there was no significant difference. Functional scores as measured by AMPAC- “6-clicks” upon admission showed no difference between the two years in both basic mobility and daily activities. There was a significantly lower percentage of hematological admissions to the hospital in 2019 compared to 2020 (25.1% vs 26.9%; p = 0.01), but no statistically significant difference in neurosurgical admissions between years (3.6% vs 3.9%; p = 0.3) or the percentage of neurosurgical procedures in total procedures (9.1% vs 9.2%; p = 0.87). For patients admitted for IPR, there was an increase in percentage of patients from hematology services and a decrease from neurosurgery services in 2020 (20.4% vs 31.4%; 48.2% vs 26.5%; p = 0.01) (Table 2). There was an increased frequency of transfer back to acute care service in 2020 (10.2% vs 21.8%; p = 0.03) (Table 2). Of the 22 patients transferred back in 2020, only 1 was due to having a new diagnosis of COVID-19; 11 had hematological diagnoses. There were 11 patients that transferred off in 2019; 5 with hematological diagnoses.

Table 1:

Comparison of Demographics and Clinical Characteristics of IPR Patients

	2019 (N = 108)		2020 (N = 102)
Characteristic	N	%	N	%	p-value
Age
Median (Min-Max)	65 (25 – 91)		67 (19 – 93)		0.41
Gender					0.46
Male	57	52.78	59	57.84
Race					0.15
Asian	4	3.70	7	6.86
Black or African American	9	8.33	7	6.86
White or Caucasian	92	85.19	80	78.43
Other	3	2.78	8	7.84
Ethnicity					0.05
Hispanic or Latino	7	6.48	15	14.7
Not Hispanic or Latino	100	92.59	85	83.33
Unknown	1	0.93	2	1.96
Religion					0.19
Christian	83	76.85	81	79,41
No religion/Other	25	23.14	21	20.59
Marital status					0.27
Married	75	69.44	72	70.59
Single	10	9.26	15	14.71
Divorced	14	12.96	8	7.84
Widowed/Other	9	8.34	7	6.86
Private insurance					0.48
Yes	54	50.00	56	54.90
Medicare†					0.49
Yes	56	51.85	48	47.06
Cancer diagnosis					0.89
Orthopedics	11	10.19	12	11.76
Brain & other nervous system	25	23.15	16	15.69
Hematological	23	21.30	32	31.37
Urinary System	12	11.11	12	11.76
Other‡	37	34.27	30	29.4
Status					0.59
Newly Diagnosed	8	34.78	11	34.38
Relapsed	6	26.08	9	28.13
Remission	3	13.04	1	3.13
Post stem cell transplant	6	26.08	11	34.38
Stage					0.14
Local	8	9.64	12	17.39
Locally advanced	5	6.02	8	11.59
Advanced/metastatic	70	84.34	49	71.01

^†Patients may have more than one insurance (private insurance and Medicare)

^‡Breast, GI, Endocrine, Gynecological, Pulmonary, Skin, Soft tissue

Table 2:

Comparing Referral Sources, Functional Status, and Discharge Disposition of IPR Patients

	2019 (n = 108)		2020 (n = 102)
Characteristic	N	%	N	%	p-value
Referral Source					0.01
Leukemia/Lymphoma/Myeloma	17	15.74	21	20.59
Stem cell transplant	5	4.63	11	10.78
Orthopedics	9	8.33	14	13.73
Neurosurgery	52	48.15	27	26.47
Neuro-oncology	0	0	3	2.94
Other	25	23.15	26	25.49
Discharge destination					0.03
Home	87	80.56	73	71.57
Skilled nursing facility/Long term acute care facility	6	5.56	7	6.86
Return to Acute Care	11	10.19	22	21.57
Hospice	4	3.70	0	0
AMPAC 6 clicks: basic mobility					0.64
N	106		102
Median (Min-Max)	39 (24 – 50)		39 (24 – 50)
AMPAC 6 clicks: daily activity					0.13
N	106		102
Median (Min-Max)	34 (17 – 51)		35 (20 – 58)

Discussion and Study Limitations:

Our study showed how the initial phases of COVID-19 affected cancer physiatry as a downstream service. Due to COVID-19, cancer diagnoses were delayed during initial phases, with the weekly number falling by 46.4% (from 4310 to 2310) for several solid tumor diagnoses⁷. Patients and oncologists avoided unnecessary admissions, as initially research showed cancer is an independent risk factor for COVID-19 related mortality, with a 13–26% mortality rate^12,13. There was concern that cancer surgery was an independent predictor of 30-day mortality, though later cohort studies did not replicate these results^14,15. Our study reflected a 3,000 (30.7%) decrease in hospital admissions during the same period in 2020. We saw an overall significant increase in hematological malignancies in hospital admissions in 2020. This is consistent with the higher percentage of referrals from hematological services for patients admitted to IPR in 2020. We think the reasons are as following. First, initial shortage of personal protective equipment resulted in many procedures being cancelled or delayed. Second, the decrease in referrals from neurosurgery may also reflect elective surgeries during this period, as neurosurgical referrals decreased from 52 to 27 during the months of 2020- a 52% decrease. The number of neurosurgical procedures dropped from 419 to 311- a 26% decrease, though not a statistically significant difference between years. Third, in the same period, neurosurgery admissions decreased to 275 in 2020 compared to 370 in 2019. We speculate that due to the stop for elective surgeries during the period, patients who could have benefited with neurosurgery intervention might instead have been admitted to their primary oncology service for medical and radiation treatment.

We hypothesized that due to decreased hospital admissions, referrals to physiatry and admissions to IPR would decrease in 2020. Instead, this study showed there was a statistically significant increase in the rate of referrals to physiatry in 2020 compared to 2019, which indicated that our hypothesis was incorrect. During the pandemic, there was a decline in access to social support, volunteer services, and public transportation that IPR may help mitigate. Another reason for the growth in referrals may be the increase in earlier goals of care discussions and advanced care planning in admissions to the institution, from 11 to 49% during the pandemic¹⁶. This may have contributed to an increased awareness of providers regarding the value of physiatry in the setting of established goals of care, as concordant care focused on function and quality of life is part of cancer rehabilitation. Future research should look at longitudinal data to ensure these changes continued during the pandemic.

Furthermore, there was no significant change in patient demographics, including race, ethnicity, age or gender between 2020 and 2019. In addition, patients had a similar functional status upon admission to IPR as measured by the AMPAC “6-clicks”. This further supports that the process of patient selection during the initial phases in 2020 did not change significantly compared to 2019. Future research should look at patients’ functional gains during IPR as well as any potential differences in length of stays between the years.

Approximately 15–35% of cancer rehabilitation patients are transferred back to acute services based off prior IPR unit studies^17,18. More research is necessary to evaluate the significance of higher returns to the acute care service in 2020 compared to 2019, though not inconsistent with prior studies. In 2020, 15 patients were transferred back due to clinical instability compared to 10 patients in 2019. This may reflect more instability in patients admitted in 2020 due to access of care compared to 2019, as this may also have affected the need for monitored chemotherapy in hematological patients in 2020. 6 out of 11 hematological patients were transferred back for chemotherapy or cancer related treatment in 2020 compared to 1 out of 5 patients in 2019. This higher rate of return emphasizes the value of having an IPR integrated into the cancer facility to allow for transfers more seamlessly, though this can affect generalizability as only a few cancer institutions have an integrated IPR.

This information is useful as this is unlikely to be the last pandemic that will require major changes in hospital organization. This study highlights the role that physiatry services play in a hospital system, as IPR helps cancer patients improve function to safely discharge home. The COVID-19 pandemic presented an unprecedented challenge for hospital systems, which in-turn had downstream effects on inpatient cancer rehabilitation.

Conclusion:

This study shows that during the COVID-19 pandemic, there was an increase in referrals to physiatry despite a decrease in hospital admissions. There was also an increase in the percentage of referrals by hematology accompanied by a decrease by neurosurgery, likely due to the percentage of populations hospitalized and importance of safe discharge dispositions during the pandemic. In the future, it will be important to advocate for ongoing inpatient cancer rehabilitation services during a pandemic.

List of abbreviations:

AMPAC

Activity Measure for Post-Acute Care

CI

Confidence Interval

COVID-19

Coronavirus Disease 2019

IPR

Inpatient Rehabilitation

Data Availability:

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.