Emergency department use by recently diagnosed cancer patients in California
Background Improving the quality of cancer care and reducing preventable health system use are goals of increasing importance to health practitioners and policy makers. Emergency department (ED) visits are often cited as a source of preventable health system use, however, few studies have described the incidence of ED use by recently diagnosed cancer patients in population-based samples, and no study has addressed the full spectrum of cancer types.
Objective To describe ED use by recently diagnosed cancer patients.
Methods California Office of Statewide Health Planning and Development data and the California Cancer Registry were used to describe ED use in the year after a cancer diagnosis (2009-2010). The incidence of ED use was tabulated by cancer type. Logistic regression and recycled predictions were used to examine ED use adjusting for confounding factors.
Results Most ED visits (68%) occurred within 180 days of diagnosis. The incidence of ED use for all cancer types examined was 17% within 30 days, 35% within 180 days and 44% within 365 days of diagnosis. ED use varied by cancer type (5%-39% within 30 days of diagnosis; 14%-62% within 180 days; and 22%-69% within 365 days). Patterns of ED use by cancer type remained similar after accounting for demographic and socioeconomic factors.
Limitations Those common to administrative and registry datasets. Specifically, we were unable to account for ED visits in relation to cancer treatment dates and comorbid conditions.
Conclusions Cancer patients use EDs at higher rates than previously reported, with considerable variability by cancer type. Future research should examine reasons for ED visits by cancer type and identify predictors of ED use, including treatment and comorbid conditions.
Funding/sponsorship The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries, under cooperative agreement 5NU58DP003862-04/DP003862; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their contractors and subcontractors.
Accepted for publication January 20, 2017
Correspondence Rebecca S Lash, PhD; rebeccaslash@gmail.com
Disclosures The authors report no disclosures/conflicts of interest.
Citation JCSO 2017;15(2):95-102
©2017 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0334
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In 2017 there will be nearly 1.7 million new cancer cases diagnosed, and over 600,000 cancer deaths in the Unites States.1 A 2013 Institute of Medicine report highlighted problems with the current quality of cancer care, including high costs and fragmentation of care.2 Other national reports have called for improvements in the overall quality of care and for reducing costly and possibly avoidable use of health services such as emergency department (ED) visits.3-6 Reduction of avoidable ED visits is often cited as a pathway to reduce costs by avoiding unnecessary tests and treatments that occur in the ED and subsequent hospital admissions.7,8
ED crowding, long waits, and unpredictable treatment environments can also make an ED visit an unpleasant experience for the patient. ED visits during cancer treatment can be particularly troubling and present health concerns for patients who are immunocompromised. In particular, cancer patients in the ED have been found to experience delays in the administration of analgesics, antiemetics, or antibiotics.9
Few studies have examined ED use or its associated predictors among cancer patients. Reports to date that have described ED use have focused on different cancers, which makes comparisons across studies difficult.10 Moreover, the time frames of interest and the type of event after which ED use is evaluated (ie, diagnosis or treatment) are inconsistent in the existing literature.10 Some studies quantifying ED use excluded patients admitted to the hospital after an ED visit.11,12 Taken together, these studies do not provide a clear overview of the extent of ED use by cancer patients or the amount of cancer-related care provided by EDs.
,Patterns of ED use among cancer patients derived from large and generalizable samples may help inform providers about true risk factors for ED use. In addition, prioritizing new interventions and focusing future research on groups of patients who are at higher risk for preventable ED use could also improve overall care. To address these issues, accurate estimates of ED use among cancer patients are required.
To our knowledge, this is the first study to describe ED use across a range of cancers in a large population-based sample and to consider the timing of ED visits in relation to initial diagnosis. The findings could provide benchmark comparison data to inform future efforts to identify the subset of possibly preventable ED visits and to design interventions to address preventable ED use.
Material and methods
Data source
California’s Office of Statewide Health Planning and Development (OSHPD) manages the patient discharge dataset (PDD) and the emergency department use (EDU) dataset, providing a high-quality source of information on inpatient and ED use in the state.13 A principal diagnosis and up to 24 secondary diagnoses are recorded in OSHPD datasets. The EDU dataset was used to identify treat-and-release ED visits, and the PDD was used to identify hospitalizations initiated in the ED. The California Cancer Registry (CCR) obtains demographic and diagnosis information for every new invasive cancer diagnosed in California, and data collected by the registry are considered to be complete.14 CCR-OSPHD-linked data provide high-quality health care use information for cancer patients in California.15,16 Using an encrypted version of the social security number called the record linkage number (RLN), we linked the CCR records to the corresponding OSHPD files from 2009-2010.
Institutional review board approval for this study was obtained from the University of California, Davis, Human Subjects Committee and the State of California Committee for the Protection of Human Subjects.
Analysis
ED visits. Visits were included if they occurred on or up to 365 days after the date of cancer diagnosis recorded in the CCR. The visits were coded in mutually exclusive groups as occurring within 30, 31-180, and 181-365 days of diagnosis. Subsequently, we flagged each person as having any ED visit (Yes/No) within 180 days and within 365 days of diagnosis, and we tallied the total number of visits occurring within these time frames for each person.
Cancer type. We used relevant site and histology codes to classify cancer type into 24 mutually exclusive categories using the Surveillance Epidemiology and End Result‘s International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3) Recode Definitions17-19 (Suppl Figure 1).
Individual-level variables. Sociodemographic information for each person was collected from the CCR including gender, age, race/ethnicity, marital status, health insurance status, rural residence, survival time in months, neighborhood socio-economic (SES) status based on the Yang index, and the American Joint Committee on Cancer (AJCC) stage.20,21
Data analysis
Demographic information was analyzed for the cohort using descriptive statistics (frequencies, proportions, means, standard deviations, and ranges) and evaluated for correlations. Fewer than 20 observations had missing data and we removed those observations from our analyses on an item-specific basis.
