One-third of people with cancer visit ED within 90 days of diagnosis
Key takeaways:
- One in three patients diagnosed with cancer in Ontario presented to the ED in the 90 days prior to diagnosis.
- The findings represent a potential route to diagnosis.
Approximately one in three patients diagnosed with cancer in Ontario presented to an ED in the 90 days preceding their diagnosis, according to findings published in Canadian Medical Association Journal.
In the retrospective, population-based study, researchers reviewed linked administrative databases to identify 651,071 patients in Ontario aged 18 years or older with a confirmed cancer diagnosis between 2014 and 2021.
Investigators used multivariable logistic regression to assess factors correlated with ED use.
Approximately one-third of patients (35.3%) visited an ED within 90 days prior to their diagnosis, and half (51.4%) of these visits resulted in admission to the hospital.
Several factors appeared associated with increased odds of an ED visit before cancer diagnosis. These included rural residence (OR = 1.15; 95% CI, 1.13-1.17); residence in northern Ontario (northeast region OR = 1.14; 95% CI, 1.1-1.17; northwest region OR = 1.27; 95% CI, 1.21-1.32) and living in the most marginalized areas vs. the least marginalized quintile (material resources OR = 1.37; 95% CI, 1.35-1.4; housing OR = 1.09; 95% CI, 1.06-1.11).
Researchers observed significant variation in ED use by cancer type, with high odds among patients with intracranial, liver/gallbladder, thoracic or pancreatic cancers.
Among the patients who sought care at an ED prior to diagnosis, 64% visited once, 23% visited twice, and 13% visited three or more times.
“There is a large proportion of patients who are using the ED prior to their diagnosis, and this could represent a route to diagnosis,” Keerat Grewal, MD, MSc, an emergency physician and clinician scientist at Schwartz/Reisman Emergency Medicine Institute at Mount Sinai Hospital in Toronto, and ICES — formerly known as Institute for Clinical Evaluative Services — told Healio. “We need to make sure that EDs have timely access to the kinds of services needed to work up these patients if they don’t require admission. This highlights a tremendous opportunity to improve care for this large group of patients.”
Healio spoke with Grewal about the limitations EDs face in providing optimal diagnostic services in an outpatient setting, as well as how her team’s findings could be used to improve this aspect of care.
Healio: Prior to your study, what had been known about ED utilization patterns among individuals with cancer?
Grewal: There has been research in this area in Europe and also some studies out of the United States looking at patients who are diagnosed through the ED. It has been identified as a route to cancer diagnosis in those studies. However, there has not been much research into this in Canada. My colleagues and I had been seeing a lot of patients in our EDs with suspected cancer, and we realized that we don’t always have the best next steps for them. Not all of these patients need to be admitted to the hospital for further cancer work-up and confirmation of diagnosis. However, for patients who can be discharged from the ED, the follow-up patients may receive for further cancer work-up can be quite variable, depending on where the patient was seen, what type of cancer they have, etc. We realized that we needed to quantify this issue. This study was part of a larger Canadian Institutes of Health Research-funded study looking at the ED as a route to cancer diagnosis.
Healio: How did you conduct the study?
Grewal: We used administrative health databases from ICES — population-based data that looks at insured patients in Ontario. We have universal health care for medically necessary care, so we are able to track health care use in the province and link it to outcomes.
We were able to determine who used the ED before the date of their diagnosis. We then evaluated which patient populations were more likely to use the ED. Because we were using administrative data, we don’t know for certain that cancer was suspected during these ED visits, but we chose that 90-day window because those visits would seem likely to be related to cancer.
Healio: What did you find?
Grewal: Older patients, patients from rural areas, patients from Northern Ontario and those with certain types of cancer — such as brain cancer and pancreatic cancer — had a very high risk for ED use prior to cancer diagnosis. These findings are similar to many studies out of the U.S. and U.K., but we additionally found that nearly a third of patients with a cancer diagnosis use the ED before they are diagnosed. That is higher than some of the studies in the U.S. and U.K.
Healio: Why is the ED not the most suitable environment for cancer diagnosis?
Grewal: EDs are overcrowded, and lots of patients are being seen and cared for in waiting rooms. Additionally, ED physicians don’t have a one-on-one physician-patient relationship. In the ED, we often only see patients once for a limited amount of time. It’s just not the best environment for having this potentially life-altering discussion.
Healio: Will you conduct further research on this topic?
Grewal: We plan to do more research into why certain patient populations are more likely to use the ED before their diagnosis. We want to know if there is an issue of inequity or lack of access to care for these patients, such that they have to go through the ED to obtain a suspected cancer diagnosis. Also, because so many patients are using the ED prior to their cancer diagnosis, we need to be sure that all EDs have equal access to further care for these patients. Regardless of where these patients are presenting, we want to know that they will have reliable access to cancer care and follow-up.
Reference:
For more information:
Keerat Grewal, MD, MSc, can be reached at keerat.grewal@sinaihealth.ca.
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