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.