TIMELY COORDINATION AND TREATMENT FOR COLORECTAL CANCERS DIAGNOSED IN THE EMERGENCY DEPARTMENT
Vanessa Arientyl*, Patricia Friedmann, DAVID WEITHORN, Haejin In
Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
BACKGROUND
Patients diagnosed with cancer in the Emergency Department (ED) have worst outcomes compared to cancers diagnosed elsewhere. Time between diagnosis and treatment (DTI) is an important quality indicator. We aimed to compare the DTI for colorectal cancer (CRC) between patients diagnosed in the Emergency Department (EDdx) and elsewhere (non-EDdx), to see if delays to treatment are a driver of the poor outcomes, and to understand the mechanisms of delays.
MATERIALS AND METHODS
CRC patients diagnosed at a single urban academic institution from 2012-2014 were identified. Chart review was conducted to abstract presenting location, symptoms, diagnostic work-up, multidisciplinary oncologic consultation and treatment. DTI was compared for patients diagnosed with CRC as a result of an emergency department visit (EDdx) with those diagnosed following presentation elsewhere (non-EDdx). As a second part of the analysis we randomly selected 20 patients from each group and conducted an in-depth chart review to understand reasons for delays in treatment. Delay was defined as greater than 4 weeks.
RESULTS
Of 626 patients meeting inclusion criteria, 42% were EDdx. DTI was shorter for EDdx overall [EDdx vs non-EDdx: 12 days (IQR 4-30) vs 37 days (IQR 21-58)]. EDdx had shorter DTI even when emergency surgeries were excluded [15 vs 38 days], when examined by symptom acuity [Acute: 11.5 vs 35 days , Non-acute: 13.5 vs 40] and by stage of cancer [Stage 1: 14.5 vs 43 days, Stage 2: 8 vs 37, Stage 3: 16 vs 35, Stage 4: 15 vs 29].
Detailed subset analysis of 20 patients in each group showed that timely consultations occurred for 17 of the EDdx patients, compared to 13 of the non-ED patients. Of the 17 EDdx patients with timely consultations, 16 consultations occurred during their index admission.
The majority of patients (65%) had surgery as their initial treatment. Of the 12 EDdx patients that underwent surgery as their initial treatment, 10 had timely surgery of which 7 were performed on the same admission as their diagnosis. In contrast, of the 14 non-EDdx patients that had surgery as their initial course of therapy, 5 had surgery in a timely manner. A third of these delays were due to surgical scheduling. For patients who got chemotherapy as their initial therapy, timely initiation occurred in 5 of 7 EDdx patients while only for 1 of 6 non-EDdx patients.
CONCLUSION
Cancers identified in the ED had less delays to treatment compared to cancers diagnosed elsewhere. Delays were largely driven by time to consultation and getting surgery. While cancer diagnoses in the ED encompass many negative predictors such as the increased severity of disease, lack of routine medical care or poor socioeconomic status, our findings suggest that care coordination is improved for cancer discovered in the ED. Coordination of care could not explain worst outcomes observed by EDdx patients.
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