Inpatient versus Outpatient Biopsy Following Detection of New Cancer: An Analysis of Quality Measures and Patient Outcomes

From the 2023 HVPA National Conference

Kaleb Foster BS (Temple University Hospital), Ho-Man Yeung MD

For patients with poor health literacy or significant social barriers to care, navigating the process of obtaining an outpatient biopsy can be difficult and inefficient. If transitions of care do not occur smoothly, these patients may have delayed tissue confirmation of malignancy. Here, we compare outcomes between patients who receive an inpatient biopsy versus those who receive an outpatient biopsy, following detection of suspected cancer during hospitalization.

To determine the utilization and outcomes between inpatient versus outpatient approach to biopsy for suspicious masses.

This is a retrospective review of hospitalized patients at Temple University Hospital from Jan 1st through Dec 31st, 2019. Patients are included if they have positive radiographic findings consistent with a suspected cancer, for which a diagnostic biopsy is required and ultimately confirmed malignant. Patient records were analyzed for presence of metastasis, rate of hospice/death, lost to follow up, LOS, 30-day readmission, time from detection to biopsy, time from detection to treatment, time from biopsy to outpatient oncology follow up, and number of advanced imaging studies and consultations while hospitalized. Statistical analysis was performed with two tailed t-test, Fisher’s exact test, and Pearson’s correlation coefficient.

73 unique subjects were identified with 45 receiving biopsies as inpatient and 28 as outpatient. Metastatic disease on presentation, hospice/death, treatment, and follow up rates were not statistically significant between inpatient and outpatient biopsy groups. The most common primary malignancies discovered during hospitalizations were lung (27.7%) and gastrointestinal (23.3%). Time from detection to biopsy was significantly different with a median of 2 days [95% CI 0-34] for the inpatient group and 34 days [95% CI 29-122] for the outpatient group (p <0.01). However, time to outpatient oncology appointment (22 [95% CI 4-79] vs 35 [95% CI 19-90] days, p=0.63) and time to treatment (27 [95% CI 0-160] vs 77 [95% CI 51-128] days, p=0.79) did not differ. 30-day readmission rate was higher in the inpatient group (24.4% vs 3.5%, p <0.05), and LOS was longer (10 [95% CI 9-17] vs 3 [95% CI 3-5] days, p <0.01). Length of stay moderately correlates to the more inpatient consultations and more MRI/CT studies performed (r= 0.63 and 0.48, respectively).

For hospitalized patients incidentally found to have suspicious masses, physicians may pursue either inpatient or outpatient biopsy. The inpatient group resulted in higher length of stay, more consultations, and more advanced imaging compared to outpatient group. On the other hand, there is a significant time delay for patients acquiring an outpatient biopsy.

Clinical Implications:
Interventions aimed at promoting follow up and organizing timely appointments should be implemented. Using these results, we wish to pursue a standardized care flow for arranging timely outpatient biopsies. A multidisciplinary, top-down approach involving hospital leaders, primary care providers, subspecialists, and proceduralists should be pursued towards improving navigation and communication and barriers to cancer care.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog