Review Article

Addressing the disparities and the factors related to prolonged inpatient length of stay for solid tumor oncology patients during the COVID-19 pandemic: A narrative review

Kamaraju S*, Mohan M, Wright T, Charlson J, Wiger W, Kwarteng J, Rezazadeh A, Hammons L and Power S

Published: 17 September, 2021 | Volume 5 - Issue 3 | Pages: 046-053

Solid tumor oncology treatments are primarily performed in the outpatient setting. However, hospitalizations are inevitable due to complications of cancer and treatment-related toxicities. With rising health care spending, the length of hospital stay (LOS) is increasingly considered a proxy for healthcare costs. There are several ongoing efforts to abbreviate the inpatient LOS and ensure a safe and timely discharge to the outpatient setting. In addition to the acute illness and the associated comorbidities, various factors affect the LOS: social determinants of health (SDOH), nutritional status in cancer patients, and end-of-life issues. Furthermore, it is unclear how the institutional policies on social distancing and visitation during the current coronavirus disease (COVID-19) pandemic may impact the LOS. The purpose of this article is to review various factors and barriers that lead to longer LOS for solid tumor patients during the COVID-19 pandemic, and identify the critical areas of quality improvement.

Read Full Article HTML DOI: 10.29328/journal.jro.1001038 Cite this Article Read Full Article PDF


Hospital length of stay; COVID 19; Social determinants of health; Oncology; Cancer disparities


  1. Martos-Benítez FD, Soler-Morejón CdD, Lara-Ponce KX, Orama-Requejo V, Burgos-Aragüez D, et al. Critically ill patients with cancer: A clinical perspective. World J Clin Oncol. 2020; 11: 809-835. PubMed: https://pubmed.ncbi.nlm.nih.gov/33200075/
  2. Tsamakis K, Gavriatopoulou M, Schizas D, Stravodimou A, Mougkou A, et al. Oncology during the COVID-19 pandemic: challenges, dilemmas and the psychosocial impact on cancer patients. Oncol Lett. 2020; 20: 441-447. PubMed: https://pubmed.ncbi.nlm.nih.gov/32565968/
  3. Bains AS, Wang E, Duran D, Lee-Riley L, Volpicelli F. Maintaining Throughput and Reducing Discharge Delays After Increasing Capacity During The Covid-19 Pandemic: A New York City Hospital’s Experience. NEJM Catal Innov Care Deliv. 2020.
  4. Prevention CfDCa. Interim guidance for implementing home care of people not requiring hospitalization for COVID-19. 2020.
  5. Rickman HM, Rampling T, Shaw K, Martinez-Garcia G, Hail L, et al. Nosocomial transmission of COVID-19: a retrospective study of 66 hospital-acquired cases in a London teaching hospital. Clin Infect Dis. 2021; 72: 690-693. PubMed: https://pubmed.ncbi.nlm.nih.gov/32562422/
  6. Tsamakis K, Rizos E, Manolis AJ, Chaidou S, Kympouropoulos S, Spartalis E, et al. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med. 2020; 19: 3451-3453. PubMed: https://pubmed.ncbi.nlm.nih.gov/32346406/
  7. Lenght of Hospital Stay [Internet]. OECD.ORG. 2019. OECD (2021), Length of hospital stay (indicator). 2021.
  8. D'Agostino F, Vellone E, Cocchieri A, Welton J, Maurici M, et al. Nursing Diagnoses as Predictors of Hospital Length of Stay: A Prospective Observational Study. J Nurs Scholarsh. 2019; 51: 96-105. PubMed: https://pubmed.ncbi.nlm.nih.gov/30411479/
  9. University Hospital N, NJ. University Hospital, Newark, NJ. 2008.
  10. Freeman WJ WA, Heslin KC, et al. Overview of U.S. Hospital Stays in 2016: Variation by Geographic Region. 2021.  PubMed: https: //hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-Hospital-Stays.jsp.
  11. Kwok CS, Zieroth S, Van Spall HGC, Helliwell T, Clarson L, et al. The Hospital Frailty Risk Score and its association with in-hospital mortality, cost, length of stay and discharge location in patients with heart failure short running title: Frailty and outcomes in heart failure. Int J Cardiol. 2020; 300: 184-190. PubMed: https://pubmed.ncbi.nlm.nih.gov/31699454/
  12. M ST. Differences Between Public And Private Hospital Payment Rates Narrowed, 2012–16. Health Affairs. 2020; 39: 94-99. PubMed: https://pubmed.ncbi.nlm.nih.gov/31905058/
  13. Michas F. Inpatient average length of stay in U.S. hospitals by cancer type 2008-2017. USA: Statista; 2020. PubMed: https: //www.statista.com/statistics/325181/average-hospital-stay-in-the-us-per-inpatient-case-by-cancer-type/.
  14. Schneider N, Dreier M, Amelung VE, Buser K. Hospital stay frequency and duration of patients with advanced cancer diseases – differences between the most frequent tumour diagnoses: a secondary data analysis. Eur J Cancer Care. 2007; 16: 172-177. PubMed: https://pubmed.ncbi.nlm.nih.gov/17371427/
  15. Aravani A, Samy EF, Thomas JD, Quirke P, Morris EJA, Finan PJ. A retrospective observational study of length of stay in hospital after colorectal cancer surgery in England (1998–2010). Medicine. 2016; 95: e5064. PubMed: https://pubmed.ncbi.nlm.nih.gov/27893655/
  16. Suda KJ, Motl SE, Kuth JC. Inpatient Oncology Length of Stay and Hospital Costs: Implications for Rising Inpatient Expenditures. The J Appl Res. 2006; 6: 126-131.
  17. Whittle SB, Lopez MA, Russell HV. Payer and race/ethnicity influence length and cost of childhood cancer hospitalizations. Pediatr Blood Cancer. 2019; 66: e27739. PubMed: https://pubmed.ncbi.nlm.nih.gov/30989762/
  18. Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health. Health Affairs. 2016; 35: 1416-1423. PubMed: https://pubmed.ncbi.nlm.nih.gov/27503966/
  19. Martin S, Smith P. Explaining variations in inpatient length of stay in the National Health Service. J Health Econom. 1996; 15: 279-304. PubMed: https://pubmed.ncbi.nlm.nih.gov/10159443/
  20. Kurani SS, McCoy RG, Lampman MA, Doubeni CA, Finney Rutten LJ, et al. Association of Neighborhood Measures of Social Determinants of Health With Breast, Cervical, and Colorectal Cancer Screening Rates in the US Midwest. JAMA Network Open. 2020; 3: e200618. PubMed: https://pubmed.ncbi.nlm.nih.gov/32150271/
  21. Bostic RW, Thornton RLJ, Rudd EC, Sternthal MJ. Health In All Policies: The Role Of The US Department Of Housing And Urban Development And Present And Future Challenges. Health Aff. 2012; 31: 2130-2137. PubMed: https://pubmed.ncbi.nlm.nih.gov/22914341/
  22. Krieger J, Higgins DL. Housing and Health: Time Again for Public Health Action. Am J Public Health. 2002; 92: 758-768. PubMed: https://pubmed.ncbi.nlm.nih.gov/11988443/
  23. Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, et al. Neighborhoods, Obesity, and Diabetes — A Randomized Social Experiment. New Eng J Med. 2011; 365: 1509-1519. PubMed: https://pubmed.ncbi.nlm.nih.gov/22010917/
  24. Kirby JB, Kaneda T. Neighborhood socioeconomic disadvantage and access to health care. J Health Soc Behav. 2005; 46: 15-31. PubMed: https://pubmed.ncbi.nlm.nih.gov/15869118/
  25. Ye H, Lee S, Kim H. Effects of Neighborhood Characteristics on Length of Inpatient Stay: Findings from the U.S. National Data. Soc Work Res. 2016; 40: 117-126. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886271/
  26. Bein T, Hackner K, Zou T, Schultes S, Bösch T, et al. Socioeconomic status, severity of disease and level of family members' care in adult surgical intensive care patients: the prospective ECSSTASI study. Intensive Care Med. 2012; 38: 612-619. PubMed: https://pubmed.ncbi.nlm.nih.gov/22273749/
  27. Sari AA, Rezaei S, Arab M, Majdzadeh R, Matin BK, et al. Effects of Smoking on Cost of Hospitalization and Length of Stay among Patients with Lung Cancer in Iran: a Hospital-Based Study. Asian Pac J Cancer Prev. 2016; 17: 4421-4426. PubMed: https://pubmed.ncbi.nlm.nih.gov/27797255/
  28. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020; 395: 912-920. PubMed: https://pubmed.ncbi.nlm.nih.gov/32112714/
  29. Fenton M. Community Design and Policies for Free-Range Children: Creating Environments That Support Routine Physical Activity. Child Obes. 2012; 8: 44-51. PubMed: https://pubmed.ncbi.nlm.nih.gov/22799480/
  30. Cummins S, Flint E, Matthews SA. New Neighborhood Grocery Store Increased Awareness Of Food Access But Did Not Alter Dietary Habits Or Obesity. Health Aff. 2014; 33: 283-291. PubMed: https://pubmed.ncbi.nlm.nih.gov/24493772/
  31. LaVeist TA, Wallace JM, Jr. Health risk and inequitable distribution of liquor stores in African American neighborhood. Soc Sci Med. 2000; 51: 613-617. PubMed: https://pubmed.ncbi.nlm.nih.gov/10868674/
  32. Ahn KY, Hur H, Kim DH, Min J, Jeong DH, et al. The effects of inpatient exercise therapy on the length of hospital stay in stages I-III colon cancer patients: randomized controlled trial. Int J Colorectal Dis. 2013; 28: 643-651. PubMed: https://pubmed.ncbi.nlm.nih.gov/23417645/
  33. Shoemaker MJ, Gutowski A, Mallgren M, Oliver L, Van Dam A, et al. Physical Therapist Determination of Discharge Disposition in the Acute Care Setting. J Acute Care Physical Ther. 2019; 10: 93-106.
  34. Shayne M, Culakova E, Poniewierski MS, Dale DC, Crawford J, et al. Risk factors for in-hospital mortality and prolonged length of stay in older patients with solid tumor malignancies. J Geriatr Oncol. 2013; 4: 310-318. PubMed: https://pubmed.ncbi.nlm.nih.gov/24472473/
  35. Faller H, Bülzebruck H, Drings P, Lang H. Coping, distress, and survival among patients with lung cancer. Arch Gen Psychiatry. 1999; 56: 756-762. PubMed: https://pubmed.ncbi.nlm.nih.gov/10435611/
  36. Prieto JM, Blanch J, Atala J, Carreras E, Rovira M, et al. Psychiatric Morbidity and Impact on Hospital Length of Stay Among Hematologic Cancer Patients Receiving Stem-Cell Transplantation. J Clin Oncol. 2002; 20: 1907-1917. PubMed: https://pubmed.ncbi.nlm.nih.gov/11919251/
  37. Kotkamp-Mothes N, Slawinsky D, Hindermann S, Strauss B. Coping and psychological well being in families of elderly cancer patients. Criti Rev Oncol Hemato. 2005; 55: 213-229. PubMed: https://pubmed.ncbi.nlm.nih.gov/15886008/
  38. Baldwin C, Spiro A, Ahern R, Emery PW. Oral Nutritional Interventions in Malnourished Patients With Cancer: A Systematic Review and Meta-Analysis. J Nat Cancer Instit. 2012; 104: 371-385. PubMed: https://pubmed.ncbi.nlm.nih.gov/22345712/
  39. Aoyagi T, Terracina KP, Raza A, Matsubara H, Takabe K. Cancer cachexia, mechanism and treatment. World J Gastrointest Oncol. 2015; 7: 17-29. PubMed: https://pubmed.ncbi.nlm.nih.gov/25897346/
  40. Aishadwi A, Nadershah M, Carlson ER, Young LS, Burher PA, et al. Nutritional Considerations for Head and Neck Cancer Patients: A Rev Literat. 2013; 71: 1853-1860. PubMed: https://pubmed.ncbi.nlm.nih.gov/23845698/
  41. Shen LJ, Chen C, Li BF, Gao J, Xia YF. High weight loss during radiation treatment changes the prognosis in under-/normal weight nasopharyngeal carcinoma patients for the worse: a retrospective analysis of 2433 cases. PloS One. 2013; 8: e68660. PubMed: https://pubmed.ncbi.nlm.nih.gov/23869226/
  42. Walsh D, Szafranski M, Aktas A, Kadakia KC. Malnutrition in Cancer Care: Time to Address the Elephant in the Room. J Oncol Pract. 2019; 15: 357-359. PubMed: https://pubmed.ncbi.nlm.nih.gov/31188710/
  43. D’Almeida CA, Peres WAF, de Pinho NB, Martucci RB, Rodrigues VD, Ramalho A. Prevalence of Malnutrition in Older Hospitalized Cancer Patients: A Multicenter and Multiregional Study. J Nutri Health Aging. 2020; 24: 166-171. PubMed: https://pubmed.ncbi.nlm.nih.gov/32003406/
  44. Vellas B, Villars H, Abellan G, Soto ME, Rolland Y, Guigoz Y, et al. Overview of the MNA--Its history and challenges. J Nutr Health Aging. 2006; 10: 456-463. PubMed: https://pubmed.ncbi.nlm.nih.gov/17183418/
  45. McSharry D, Malhotra A. Potential influences of obstructive sleep apnea and obesity on COVID-19 severity. J Clin Sleep Med. 2020; 16: 1645. PubMed: https://pubmed.ncbi.nlm.nih.gov/32356516/
  46. Memtsoudis SG, Ivascu NS, Pryor KO, Goldstein PA. Obesity as a risk factor for poor outcome in COVID-19-induced lung injury: the potential role of undiagnosed obstructive sleep apnoea. Br J Anaesth. 2020; 125: e262-e263. PubMed: https://pubmed.ncbi.nlm.nih.gov/32439072/
  47. Bellini B, Cresci B, Cosentino C, Profili F, Bartolacci S, et al. Obesity as a risk factor for hospitalization in COronaVirus Disease-19 (COVID-19) patients: Analysis of the Tuscany regional database. Nutr Metab Cardiovasc Dis. 2021; 31: 769-773. PubMed: https://pubmed.ncbi.nlm.nih.gov/33549434/
  48. Calder PC, Carr AC, Gombart AF, Eggersdorfer M. Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections. Nutrients. 2020; 12: 1181. PubMed: https://pubmed.ncbi.nlm.nih.gov/32340216/
  49. Gröber U, Holzhauer P, Kisters K, Holick MF, Adamietz IA. Micronutrients in Oncological Intervention. Nutrients. 2016; 8: 163. PubMed: https://pubmed.ncbi.nlm.nih.gov/26985904/
  50. Rosenfeld EB, Chan JK, Gardner AB, Curry N, Delic L, et al. Disparities Associated With Inpatient Palliative Care Utilization by Patients With Metastatic Gynecologic Cancers: A Study of 3337 Women. Am J Hospice Palliat Med. 2017; 35: 697-703. PubMed: https://pubmed.ncbi.nlm.nih.gov/29141457/
  51. Islam JY, Deveaux A, Previs RA, Akinyemiju T. Racial and ethnic disparities in palliative care utilization among gynecological cancer patients. Gynecologic Oncol. 2020; 34: 106705. PubMed: https://pubmed.ncbi.nlm.nih.gov/33473361/
  52. Mrad C, Abougergi MS, Daly B. One Step Forward, Two Steps Back: Trends in Aggressive Inpatient Care at the End of Life for Patients With Stage IV Lung Cancer. J Oncol Pract. 2018; 14: e746-e757. PubMed: https://pubmed.ncbi.nlm.nih.gov/30265173/
  53. Kinoshita H, Maeda I, Morita T, Miyashita M, Yamagishi A, et al. Place of Death and the Differences in Patient Quality of Death and Dying and Caregiver Burden. J Clini Oncol. 2015; 33: 357-363. PubMed: https://pubmed.ncbi.nlm.nih.gov/25534381/
  54. Teno JM, Mor V, Ward N, Roy J, Clarridge B, et al. Bereaved Family Member Perceptions of Quality of End-of-Life Care in U.S. Regions with High and Low Usage of Intensive Care Unit Care. J Am Geriatr Soc. 2005; 53: 1905-1911. PubMed: https://pubmed.ncbi.nlm.nih.gov/16274371/
  55. Mason MC, Chang GJ, Petersen LA, Sada YH, Tran Cao HS, et al. National Quality Forum Colon Cancer Quality Metric Performance: How Are Hospitals Measuring Up? Ann Surg. 2017; 266: 1013-1020. PubMed: https://pubmed.ncbi.nlm.nih.gov/27617852/ 
  56. Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). J Telemed Telecare. 2020; 26: 309-133. PubMed: https://pubmed.ncbi.nlm.nih.gov/32196391/
  57. Kuderer NM, Choueiri TK, Shah DP, Shyr Y, Rubinstein SM, et al. Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study. Lancet. 2020; 395: 1907-1918. PubMed: https://pubmed.ncbi.nlm.nih.gov/32473681/
  58. Çelebi G, Pişkin N, Çelik Bekleviç A, Altunay Y, Salcı Keleş A, et al. Specific risk factors for SARS-CoV-2 transmission among health care workers in a university hospital. Am J Infect Control. 2020; 48: 1225-1230. PubMed: https://pubmed.ncbi.nlm.nih.gov/32771498/
  59. Tabah A, Ramanan M, Laupland KB, Buetti N, Cortegiani A, et al. Personal protective equipment and intensive care unit healthcare worker safety in the COVID-19 era (PPE-SAFE): An International survey. J Crit Care. 2020; 59: 70-75. PubMed: https://pubmed.ncbi.nlm.nih.gov/32570052/ 
  60. Onesti CE, Tagliamento M, Curigliano G, Harbeck N, Bartsch R, et al. Expected Medium- and Long-Term Impact of the COVID-19 Outbreak in Oncology. JCO Glob Oncol. 2021; 7: 162-172. PubMed: https://pubmed.ncbi.nlm.nih.gov/33529077/
  61. Rhee C, Baker M, Vaidya V, Tucker R, Resnick A, et al. Incidence of Nosocomial COVID-19 in Patients Hospitalized at a Large US Academic Medical Center. JAMA Netw Open. 2020; 3: e2020498. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489854/
  62. Reeves JJ, Hollandsworth HM, Torriani FJ, Taplitz R, Abeles S, et al. Rapid response to COVID-19: health informatics support for outbreak management in an academic health system. J Am Med Inform Assoc. 2020; 27: 853-859. PubMed: https://pubmed.ncbi.nlm.nih.gov/32208481/
  63. Ahmed H, Patel K, Greenwood DC, Halpin S, Lewthwaite P, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalisation or ICU admission: A systematic review and meta-analysis. J Rehabi Med. 2020; 52: jrm00063. PubMed: https://pubmed.ncbi.nlm.nih.gov/32449782/
  64. Fung M, Babik JM. COVID-19 in Immunocompromised Hosts: What We Know So Far. Clin Infect Dis. 2020; 72: 340-350. PubMed: https://pubmed.ncbi.nlm.nih.gov/33501974/
  65. Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, et al. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021; 372: n693. PubMed: https://pubmed.ncbi.nlm.nih.gov/33789877/
  66. Arnold DT, Hamilton FW, Milne A, Morley AJ, Viner J, et al. Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort. Thorax. 2020; 76: 399-401. PubMed: https://pubmed.ncbi.nlm.nih.gov/33273026/
  67. Carfì A, Bernabei R, Landi F, Group ftGAC-P-ACS. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020; 324: 603-605. PubMed: https://pubmed.ncbi.nlm.nih.gov/32644129/
  68. Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, et al. Post-acute COVID-19 syndrome. Nat Med. 2021; 27: 601-615. PubMed: https://pubmed.ncbi.nlm.nih.gov/33753937/
  69. Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. J Med Virol. 2021; 93: 1013-1022. PubMed: https://pubmed.ncbi.nlm.nih.gov/32729939/
  70. Carvalho-Schneider C, Laurent E, Lemaignen A, Beaufils E, Bourbao-Tournois C, et al. Follow-up of adults with noncritical COVID-19 two months after symptom onset. Clinical microbiology and infection: the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2021; 27: 258-263. PubMed: https://pubmed.ncbi.nlm.nih.gov/33031948/
  71. Moreno-Pérez O, Merino E, Leon-Ramirez JM, Andres M, Ramos JM, et al. Post-acute COVID-19 syndrome. Incidence and risk factors: A Mediterranean cohort study. J Infect. 2021; 82: 378-383. PubMed: https://pubmed.ncbi.nlm.nih.gov/33450302/
  72. Garrigues E, Janvier P, Kherabi Y, Le Bot A, Hamon A, et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020; 81: e4-e6. PubMed: https://pubmed.ncbi.nlm.nih.gov/32853602/
  73. Chopra V, Flanders SA, O'Malley M, Malani AN, Prescott HC. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19. Ann Intern Med. 2021; 174: 576-578. PubMed: https://pubmed.ncbi.nlm.nih.gov/33175566/
  74. Donnelly JP, Wang XQ, Iwashyna TJ, Prescott HC. Readmission and Death After Initial Hospital Discharge Among Patients With COVID-19 in a Large Multihospital System. JAMA. 2021; 325: 304-306. PubMed: https://pubmed.ncbi.nlm.nih.gov/33315057/

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