Disparities in outcomes among patients diagnosed with cancer associated with emergency department visits

Abstract

Importance: Diagnosis of cancer in the emergency department (ED) may be associated with poor outcomes, related to socioeconomic (SES) disparities, however data are limited. Objective: To examine the morality and associated disparities for cancer diagnoses made less than six months after an ED visit. Design: This study is case-control analysis of the Indiana State Department of Health Cancer Registry, and the Indiana Network for Patient Care. First time diagnoses of ICD-cancer appearing in the registry between January 2013 and December 2017 were included. Cases were patients who had an ED visit in the 6 months before their cancer diagnosis; controls had no recent ED visits. Main Outcome(s) and Measure(s): Primary outcome was mortality, comparing ED-associated mortality to non-ED-associated. Secondary outcomes include SES and demographic disparities. Results: 134,761 first-time cancer patients were identified, including 15,432 (11.5%) cases. In cases and controls, the mean age was same at 65 and the Charlson Comorbidity Index (CCI) was the same at 2.0 in both groups. More of the ED cohort were Black than the non-ED cohort (12.4% vs 7.4%, P<.0001, Chi Square) and more were low income (36.4%. vs 29.3%). The top 3 ED-associated cancer diagnoses were lung (18.4%), breast (8.9%), and colorectal cancer (8.9%), vs. the non-ED cohort were breast (17%), lung (14.9%), and prostate cancer (10.1%). Regardless of type, all ED-associated cancers had an over three-fold higher mortality, with cumulative death rate of 32.9% for cases vs 9.0% for controls (P<.0001) over the entire study period. Regression analysis predicting mortality, clustering by city, controlling for age, gender, race, SES, drug/alcohol/tobacco use, and CCI score, produced an odds ratio of 4.12 (95% CI 3.72-4.56 for ED associated cancers). Conclusion and Relevance: This study found that an ED visit within 6 months prior to the first time of ICD-coded cancer is associated with Black race, low income and an overall three-fold increased risk of death. The mortality rates for ED-associated cancers are uniformly worse for all cancer types. These data suggest that additional work is needed in order to reduce disparities among ED-associated cancer diagnoses, including increased surveillance and improved transitions of care.

Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system

“…Thus, it is not surprising that the most common cancers seen in our cases cohort are those that are heavily mediated by tobacco use, namely lung, HENT, pancreatic, colorectal, liver, and kidney. These results are similar compared with a statewide epidemiologic assessment we previously performed, again demonstrating that tobacco‐related cancers appear to be associated with ED visits 10,24 . Randomized clinical trials have demonstrated success at improving tobacco abstinence in low‐income ED smokers, and our work demonstrates further need for wide spread tobacco cessation programs and cancer prevention education programs which could possibly be facilitated out of the ED 19,27 .…”

“…These results are similar compared with a statewide epidemiologic assessment we previously performed, again demonstrating that tobacco-related cancers appear to be associated with ED visits. 10,24 Randomized clinical trials have demonstrated success at improving tobacco abstinence in low-income ED smokers, and our work demonstrates further need for wide spread tobacco cessation programs and cancer prevention education programs which could possibly be facilitated out of the ED. 19,27 Additionally, this work provides for the data needed to selectively target those cancers that are more likely to be suspected in an ED visit, namely lung, breast, prostate, colorectal, and cervical cancers due to their prevalence of being seen in the ED prior to their diagnosis.…”

“…While increasing evidence and factors associated with emergency presentations of cancer are available 5 , 10 , 11 , 12 , 13 (and primarily based out of the United Kingdom [UK]), to our knowledge, there are no administrative‐database studies conducted in the United States (USA) that have examined the characteristics, eventual cancer types, and outcomes of ED utilization during the pre‐diagnosis phase. This context is important, as studies from the UK cannot necessarily be generalized to the USA.…”

Novel referral pathway for patients with new solid tumors discharged from the emergency department: A pilot study

“…A diagnosis of cancer following an ED visit is associated with inferior patient‐reported and clinical outcomes compared to patients that are diagnosed through routine screening 1 . Little prospective data exists describing the care for patients diagnosed with cancer from an ED visit 1,2 . Delays in time to treatment for new cancer diagnoses continue to increase, with absolute increased risk of mortality ranging from 1.2 to 3.2% per week in curative settings with various early‐staged cancers 3 …”

“…1 Little prospective data exists describing the care for patients diagnosed with cancer from an ED visit. 1,2 Delays in time to treatment for new cancer diagnoses continue to increase, with absolute increased risk of mortality ranging from 1.2 to 3.2% per week in curative settings with various early-staged cancers. 3 Patients whose care was coordinated through their primary care physician experienced longer delays than patients who saw specialists directly, and in one analysis 29% of patients with lung cancer experienced a wait of 90 days or more.…”