Nursing - Theses
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ItemUnplanned Emergency Department Presentations by Cancer Patients Receiving Systemic Anti-Cancer Therapy( 2021)Background In Australia, emergency department presentations have been found to be common for people affected by cancer, and even more so for patients receiving systemic anti-cancer therapy. These presentations are associated with lengthy admissions, treatment dose reductions, and treatment delays. The emergency department often provides cancer patients with access to unscheduled medical care and to specialist cancer advice for symptoms they may experience. At a health system level, there has been an increasing number of people presenting to the emergency department, and subsequently, a need to reduce emergency department presentations in people who are not critically unwell. The need to deliver safe and high-quality care to mitigate unplanned emergency department presentations has received considerable attention in the international health care community. However, substantial work is needed to develop models of care to reduce emergency department presentations that may be potentially avoidable. The aim of this thesis is to understand why patients who receive systemic anti-cancer therapy make unplanned emergency department presentations. This understanding can support the development of robust evidence to inform future research and strengthen the development of models of care to support patients receiving systemic anti-cancer therapy. Methods This study used a convergent, mixed-methods research design, underpinned by Andersen’s behavioural model of health service use, to explore patterns of health service use and contextual, individual and health behaviours that influence cancer patients’ decisions to engage with health services. Study 1 was a retrospective cohort study of unplanned emergency department presentations that occurred within 28 days of receiving systemic anti-cancer therapy in the outpatient setting between December 2014 and November 2017. This study explored patterns of, and risk factors associated with, making an emergency department presentation to one large public tertiary hospital in Melbourne, Australia. Study 2 was a systematic review that explored methods reported in published literature investigating the incidence of unplanned emergency department presentations by patients receiving systemic anti-cancer therapy. Study 3 was an explanatory sequential mixed methods study that explored the contextual, individual and health behaviours that influenced the decision to engage with health services during systemic anti-cancer therapy. Thematic analysis of textual data was undertaken using template analysis. Participants in Study 3 were recruited from October 2016 to March 2017. Results Study 1 identified that 45% (n = 1,182) of cancer patients made a total of 2,310 emergency department presentations within 28 days of receiving systemic anti-cancer therapy in the outpatient setting. More than half (58%, n = 1,341) of the emergency department presentations resulted in patient admission for further care. Patients born outside of Australia and those diagnosed with head and neck, upper gastrointestinal, colorectal, lung, skin or breast cancer were identified as having a significantly increased risk of making an emergency department presentation. Study 2 comprised a total of 21 papers, and overall, the risk of bias was assessed as moderate. There was substantial clinical and methodological heterogeneity in the studies included in the systematic review, such as the population and study setting, the period for which the participants were observed, and in the reporting of participants who were lost to follow-up. In Study 3, 16 of 58 (28%) participants presented to the emergency department over the 6-month study period. Four overarching themes were generated from the 19 semi-structured interviews involving: 1) missed opportunities for preparation and support; 2) the importance of symptoms and need for care; 3) navigating the system and preference for care provider; and 4) enablers and barriers to accessing care. An additional two integrative themes were generated from the semi-structured interviews: 1) the unknown and unpredictable; and 2) individual health beliefs and behaviours. Integrated findings found that perceived need was a stronger driver of emergency department presentation than socio-demographics factors. Participants experienced a combination of enablers and barriers to accessing other sources of health care that may have influenced their need to present to the emergency department; these included that the availability of appointments with their general practitioner was a barrier, and the presence of social supports was an enabler. Based on findings from the literature review and this PhD, a new conceptual framework for emergency department use by patients receiving systemic anti-cancer therapy is offered. Conclusions The knowledge generated in this PhD contributes novel and important insight as to why patients receiving systemic anti-cancer therapy present to the emergency department. Studies have shown that some emergency department presentations are avoidable; the findings from this PhD can assist in developing new strategies to mitigate these avoidable presentations and can inform future healthcare policy, organisational planning, and clinical practice. This PhD has provided robust evidence for future research and the need for sophisticated research designs that reflect the complexity of cancer patients and the health care system.