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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We tabulated ED visits by cancer type and time from diagnosis and then collapsed visit-level data by RLN to determine the number of ED visits for each person in the sample. The number of days from diagnosis to first ED visit was also tabulated. The cohort was stratified by cancer type and cumulative rates of ED visits were tabulated for individuals with ED visits within 0-180 and 0-365 days from diagnosis. To test the robustness of the findings adjusting for confounding factors known to impact ED use, we used logistic regression to model any ED use (Yes/No) as a function of age, gender, race/ethnicity, cancer stage, insurance status, marital status, urban residence, and Yang SES. After model estimation, we used the method of recycled predictions controlling for the confounding variables to compute the marginal probabilities of ED use by cancer type.22 To adjust for the possible impact of survival on ED use, we performed sensitivity analyses and estimated predicted probabilities adjusting for survival. Separate analyses were performed first adjusting for whether the patient died during the course of each month after diagnosis and then adjusting for whether or not the patient died within 180 days of diagnosis. All analyses were conducted using Stata 13.1.23
Results
The CCR identified 222,087 adults with a new primary cancer diagnosis in 2009-2010. After excluding those with Stage 0 cancer (n = 21,154) and nonmelanoma skin cancer (n = 1,031), for whom data are inconsistently collected by CCR, a total of 199,872 individuals were included in the analytic sample. Of those patients (Table 1), most were white non-Hispanic (62%), women (51%), holders of private insurance (53%), married (56%), and urban residents (86%). Most were older than 50 years and had either Stage I or Stage II cancer. The most common cancer types were breast (17%), prostate (16%), lung (11%), and colon (9%; results not shown). In unadjusted comparisons, the incidence of ED use was significantly higher among those who were older, of non-Hispanic black race/ethnicity, uninsured, in the lowest SES group, widowed, or diagnosed with Stage IV cancer (Table 1).
ED visits
Within 365 days after initial cancer diagnosis, 87,025 cancer patients made a total of 197,886 ED visits (not shown in tables). Of those visits, 68% (n = 134,556) occurred within 180 days of diagnosis, with 22% (n = 43,535) occurring within the first 30 days and 46% (n = 91,027) occurring within 31-180 days after diagnosis (Figure). Given that most of the visits occurred within 180 days of diagnosis, we used that time frame in subsequent analyses. Among all ED visits within 180 days of diagnosis (Table 2), the largest proportions of visits were made by those with lung cancer (16%), breast cancer (11%), and colon cancer (10%).
About 51% of visits resulted in admission to the hospital and 45% in discharge (Table 2). For some cancers (lung, colon, non-Hodgkin lymphoma, pancreatic, digestive, liver, stomach, leukemia, and myeloma) most of the visits resulted in admission to the hospital (Table 2). Among visits resulting in admission, the top three principal diagnoses were: septicemia (8%), cardiovascular problems (7%), and complications from surgery (5%) (not shown in tables). Among visits resulting in a discharge home, the three top principal diagnoses were abdominal pain (7%), cardiovascular problems (6%), and urinary, kidney, and bladder complaints other than a urinary tract infection (5%) (results not shown).
Individuals
The cumulative incidence of at least one ED visit was 35% (n = 70,813) within 180 days after diagnosis (Table 3). Visit rates varied by cancer type: individuals with pancreatic (62%), brain (60%), and lung (55%) cancers had the highest cumulative incidences of ED use within 180 days of diagnosis (Table 3). Those with melanoma (14%), prostate (17%), and eye (18%) cancers had the lowest cumulative incidences of ED visits (Table 3).
Recycled predictions from logistic regression models, accounting for potential confounding factors, yielded substantively similar results for the cumulative incidence of ED use across cancer types (Table 4). Results did not differ substantially after accounting for survival. Differences in the predicted probability of an ED visits adjusting for death within 180 days of diagnosis were noted to be 2% or greater from estimates reported in Table 4 for only four cancers. Estimates of having any ED visits for those with lung cancer decreased from 46% to 44% (95% CI: 43.0-44.4%), pancreatic cancer from 53% to 49% (95% CI: 48-51%), liver cancer from 51% to 47% (95% CI: 49-53%), and those with eye cancers increased from 20% to 22% (95% CI: 18-26%) (not shown in tables).
