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November 29, 2023
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Unaware of alternatives, patients with cancer often self-refer for emergency care

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Individuals recently diagnosed with cancer frequently decide on their own to visit hospital emergency departments for symptoms that do not require immediate care, according to a study conducted at UT Southwestern Medical Center.

“We’ve been doing work aimed at understanding how patients with cancer decide to go to the emergency department, and one of the things we’ve run into is that patients don’t really know where to go,” study lead author Arthur Hong, MD, MPH, assistant professor of internal medicine and population and data sciences at UT Southwestern, told Healio. “They know what an emergency department is, but they don’t know what warrants a visit to an ED. It’s a bit unrealistic that we ask people who are not clinically trained to make this rather important decision about their own symptoms.”

Emergency room sign
Study results showed 81% of patietns with cancer always self-referred for care at the ED. Source: Adobe Stock.

The study, published in American Journal of Managed Care, found that of the patients who visited EDs in the 6 months after their cancer diagnosis, about 81% always self-referred. Hong discussed the study findings, the value of nurse triage lines, and the role oncologists can play in educating their patients about ED visits.

Healio: What motivated you to conduct this study?

Arthur Hong, MD, MPH
Arthur Hong

Hong: I think we as medical professionals sometimes forget that people don’t always understand the difference between an urgent care and an emergency department, in terms of the hours, what they can and can’t do, and what situations are appropriate for which facility. This is heightened for folks who have been diagnosed with cancer, who might be feeling terrible due to their treatment or might feel that a symptom is more serious than it is. It’s frustrating that whenever a patient calls a medical office, the recording says, “If this is an emergency, please call 9-1-1.” Well, if the patient knew whether their situation was an emergency or not, they wouldn’t be calling the doctor’s office.”

Healio: How did you conduct the study?

Hong: Here in Dallas, we have our big university academic cancer center, and we have our academically affiliated county hospital, Parkland Health. I was able to take data on folks in the tumor registries at both hospitals. There is a health information exchange in the region where all the hospitals contribute their visits, and we can find people as they go to different hospitals. We found all these folks and the different hospitals they visited, plus we could access information on what they were diagnosed with, then grade of severity of the condition. We could also look back into their history to see if there was any record of them calling us in the 24 hours before the ED visit. We looked at this because both hospitals have 24/7 nurse lines that provide triage help. It wasn’t clear to us how often people used them.

Healio: What did you find?

Hong: We found that people don’t use the nurse triage lines very much. Unfortunately, they used them even less often at the safety net hospital than at the university hospital. Overall, they are only calling the nurse triage lines 15% of the time before they go to the emergency department.

More than half of these visits resulted in hospitalizations and one-quarter were categorized as emergencies, but another quarter of these visits did not necessitate a trip to the ED. These visits were more likely among patients who did not call a nurse triage line, went to the ED on weekends or holidays, or went to an ED closer to their home.

Healio: Your study found that 81% of these patients self-referred. Why do you think this is?

Hong: This might be an issue of people not knowing they can call the nurse triage line or not knowing it existed. We’ll have to do additional research to figure out what is happening there.

Based on the interviews we have done so far, many people have never heard of these triage lines, even though both hospitals have very robust patient education efforts. It seems that in the tidal wave of other information, it’s not getting through, or we’re not delivering this message at the right time. It’s one of those situations where they built the ball field but not many people came.

Another thing we looked at was urgent care clinics for patients with cancer. Individuals being treated for cancer have acute issues so often that urgent care clinics for these patients have been created so they can avoid going to the emergency department. You can’t just show up to these clinics. You have to call, and the nurse schedules you. I have been trying to understand how these urgent care clinics work. I investigated these innovative clinics to see why they are underused. It turns out the issue is people are not calling — so we have to get them to call more.

Healio: Your study also found that patients who visited EDs didn’t necessarily go to the ones closest to their homes. Can you discuss this finding?

Hong: People are probably going to the emergency department that they are familiar with for convenience reasons. There are also issues around not knowing who is in network for a patient’s insurance. There are also good and bad experiences that might influence a patient’s choice of ED. People might also default to their cancer treatment hospital, even if it’s far and the patient might have been better off going to a closer ED. Patients may be comforted by knowing this is where clinical staff know them and know their case. There’s a lot to untangle there.

Healio: What can our oncologist readers do to make patients more aware of their options during a potential emergency?

Hong: It’s worth thinking a bit more about how you’re targeting your patient education. If there’s a way for you to figure out who is making these ED visits, you could use that opportunity to say, “Next time, you can give us a call and we can help you figure out where to go.” You don’t want to scold the patient or make them feel like they made a mistake. You can just say something like, “This looks like it was pretty scary. I don’t know when your symptoms started, but next time, call us, and we’ll help you figure out where to go. If possible, we can help you avoid going to the emergency department.”

Healio: What are your plans for further research in this area?

Hong: Studying this urgent care clinic at Parkland was part of a grant that I received from the American Cancer Society. We did a lot of quantitative analyses and some interviews with patients, oncologists and emergency physicians. I have been presenting all of these findings to the Parkland Oncology Clinic to help them understand, so we can figure out how to reach these folks. We have been meeting for 8 months or so, and we’ve been going through these findings and coming up with a dashboard to help them figure out how to do data-driven quality improvement. I’ve been able to create a research partnership with them where I help with the data-driven insight part, and they run with it. That’s where it’s currently moving, but it can go in a lot of different directions. One of the main things this study showed is that people aren’t using services available to help them, and we’re doing them a disservice if they don’t know what to do.

Reference:

For more information:

Arthur Hong, MD, MPH, can be reached at UT Southwestern, 5939 Harry Hines Blvd., 8th Floor, Suite 124, Dallas, TX, 75390; email: arthur.hong@utsouthwestern.edu.