A retrospective analysis showed that in the first 3 months after diagnosis of cancer in older patients, the healthcare utilisation peaked, typically related to active cancer treatment, and then decreased in the time thereafter. Only general practitioner contacts and home care remained high throughout the whole 3-year period, highlighting primary care as a key element of the healthcare system for older patients.
Healthcare utilisation in terms of hospital admissions, hospital days, emergency department visits, intensive care days, general practitioner contacts, home care days, and nursing home admissions following cancer diagnosis was significantly higher among patients with potential frailty based on Geriatric 8 (G8) screening than in patients with a normal G8 score, and this difference persisted over time and after adjustment for confounding variables. Patients with an abnormal G8 score had fewer contacts with a specialist than patients with a normal score. The findings are published by Prof. Hans Wildiers of the Department of General Medical Oncology, University Hospitals Leuven in Leuven, Belgium, and colleagues on 13 June 2023 in The Lancet Healthy Longevity.
To optimise cancer treatment for older patients, it is important to identify frailty and underlying geriatric conditions at cancer diagnosis. Geriatric screening and geriatric assessment are key elements in achieving this goal, the authors wrote in the background. Geriatric screening with tools such as the G8 is the first step to quickly assess general health status and aids in selecting patients who need geriatric assessment; G8 has high sensitivity, acceptable specificity, and is one of the more robust geriatric screening tools.
In a busy oncology clinic or setting with scarce resources, geriatric screening with G8 followed by geriatric assessment in the case of an abnormal screening compared with geriatric assessment for all patients, has the potential for broader implementation. However, research on the association of the G8 with clinical outcomes beyond survival is scarce and more evidence is needed for long-term outcomes. Understanding poorly explored outcomes such as long-term healthcare utilisation and its patterns are especially important for older patients since treatment goals are more likely to focus on quality of life and the desire to maintain functional independence for as long as possible rather than length of life compared with younger patients.
In this study, by linking clinical and population-based data, the authors aimed to assess long-term healthcare utilisation after a new cancer diagnosis in older patients and investigate the association between healthcare utilisation and baseline G8 screening results.
For this retrospective analysis, the study team included data from 3 cohort studies for patients aged ≥70 years with newly diagnosed cancer who underwent G8 screening between 19 October 2009 and 27 February 2015, and who survived more than 3 months after G8 screening. The clinical data were linked to cancer registry and reimbursement data for long-term follow-up. The occurrence of outcomes such as inpatient hospital admissions, emergency department visits, use of intensive care, contacts with general practitioner, contacts with a specialist, use of home care, and nursing home admissions was assessed in the 3 years after G8 screening.
The study team assessed the association between outcomes and baseline G8 score with normal score defined as >14 or abnormal as ≤14 of 17 points, using adjusted rate ratios (aRRs) calculated from Poisson regression and using cumulative incidence calculated as a time-to-event analysis with the Kaplan-Meier method.
In total, 7556 patients had a new cancer diagnosis, of whom 6391 patients with a median age of 77 years met inclusion criteria. An abnormal baseline G8 score was reported in 4110 of 6391 patients (64.3%). In the first 3 months after G8 screening, healthcare utilisation peaked and then decreased over time, except for general practitioner contacts and home care days, which remained high throughout the 3-year follow-up period.
Compared with patients with a normal baseline G8 score, patients with an abnormal baseline G8 score had more hospital admissions (aRR 1.20, 95% confidence interval [CI] 1.15–1.25; p < 0.0001), hospital days (aRR 1.66, 95% CI 1.64–1.68; p < 0.0001), emergency department visits (aRR 1.42, 95% CI 1.34–1.52; p < 0.0001), intensive care days (aRR 1.49, 95% CI 1.39–1.60; p < 0.0001), general practitioner contacts (aRR 1.19, 95% CI 1.17–1.20; p < 0.0001), home care days (aRR 1.59, 95% CI 1.58–1.60; p < 0.0001), and nursing home admissions (16.7% versus 3.1%; p < 0.0001) in the 3-year follow-up period.
At 3 years, among 2281 patients with a normal baseline G8 score, 1421 (62.3%) continued to live at home independently and 503 (22.0%) had died. Of the 4110 patients with an abnormal baseline G8 score, 1057 (25.7%) continued to live at home independently and 2191 (53.3%) had died.
The authors commented that all these findings add to the literature supporting the use of G8 in oncology practice. It is not only a useful geriatric screening tool but also a means to identify older patients with a short-term and long-term risk of increased healthcare utilisation. This is valuable information to consider in the treatment decision process when selecting therapies with potential toxicity or risk of functional decline. For example, insights from such study can contribute to the development of targeted interventions such as dietician or physiotherapist referral to reduce long-term healthcare use associated with adverse outcomes.
Future studies with a prospective design are needed to confirm these findings and to identify the cause of increased healthcare utilisation in patients with an abnormal G8 scores. Furthermore, comparative analyses between G8 and other geriatric screening tools, such as ECOG performance status, for predicting long-term outcomes would be valuable. Additionally, the impact of geriatric interventions on long-term healthcare utilisation should be studied.
The study was funded by a grant from Kom op tegen Kanker (Stand up to Cancer, the Flemish Cancer Society).
Depoorter V, Vanschoenbeek K, Decoster L, et al. Long-term health-care utilisation in older patients with cancer and the association with the Geriatric 8 screening tool: a retrospective analysis using linked clinical and population-based data in Belgium. The Lancet Healthy Longevity; Published online 13 June 2023. DOI: https://doi.org/10.1016/S2666-7568(23)00081-8