David Weithorn1, Vanessa Arientyl1, Ian Solsky1, Goyal Umadat2, Rebecca Levine1, Bruce Rapkin2, Jason Leider3, Haejin In4. 1. Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. 2. Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York. 3. Department of Medicine, Albert Einstein College of Medicine, Bronx, New York. 4. Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York. Electronic address: hin@montefiore.org.
Abstract
BACKGROUND: The rate of diagnosis of colorectal cancer (CRC) in the emergency department (ED), its characteristics, and its effect on outcomes have been poorly described. MATERIALS AND METHODS: Chart review was conducted to identify presenting clinical setting leading to diagnosis, symptoms, and history of colonoscopy for patients diagnosed with CRC at a single institution from 2012-2014. Patients diagnosed with CRC as a result of an ED visit (EDDx) were compared with those diagnosed after presentation to other settings (non-EDDx). RESULTS: Of 638 patients meeting inclusion criteria, 271 (42.4%) were EDDx patients. These patients were more likely to be older than 80 y (29.89% versus 19.35%), have Medicare (59.78% versus 42.78%) or Medicaid (23.62% versus 12.81%) insurance, have stage IV cancer (45.02% versus 18.26%), and were symptomatic at the time of presentation (94.83% versus 64.03%). EDDx patients were less likely to ever have had a colonoscopy (21.77% versus 41.69%). In a model adjusted for patient demographics, cancer stage, presence of symptoms, and history of prior colonoscopy, EDDx was associated with increased mortality (hazard ratio, 1.89; 95% confidence interval, 1.3-2.8). On stratifying survival by stage, it was found that for all stages, EDDx was associated with decreased survival. CONCLUSIONS: More than 40% of patients with CRC received their diagnosis through the ED. EDDx was associated with a nearly twofold mortality risk increase. EDDx should be considered a marker of poor outcomes for CRC and may be related to unaccounted patient-level or systems-level factors. Efforts should be made to identify modifiable risks of cancer diagnosis in the ED to improve cancer outcomes.
BACKGROUND: The rate of diagnosis of colorectal cancer (CRC) in the emergency department (ED), its characteristics, and its effect on outcomes have been poorly described. MATERIALS AND METHODS: Chart review was conducted to identify presenting clinical setting leading to diagnosis, symptoms, and history of colonoscopy for patients diagnosed with CRC at a single institution from 2012-2014. Patients diagnosed with CRC as a result of an ED visit (EDDx) were compared with those diagnosed after presentation to other settings (non-EDDx). RESULTS: Of 638 patients meeting inclusion criteria, 271 (42.4%) were EDDx patients. These patients were more likely to be older than 80 y (29.89% versus 19.35%), have Medicare (59.78% versus 42.78%) or Medicaid (23.62% versus 12.81%) insurance, have stage IV cancer (45.02% versus 18.26%), and were symptomatic at the time of presentation (94.83% versus 64.03%). EDDx patients were less likely to ever have had a colonoscopy (21.77% versus 41.69%). In a model adjusted for patient demographics, cancer stage, presence of symptoms, and history of prior colonoscopy, EDDx was associated with increased mortality (hazard ratio, 1.89; 95% confidence interval, 1.3-2.8). On stratifying survival by stage, it was found that for all stages, EDDx was associated with decreased survival. CONCLUSIONS: More than 40% of patients with CRC received their diagnosis through the ED. EDDx was associated with a nearly twofold mortality risk increase. EDDx should be considered a marker of poor outcomes for CRC and may be related to unaccounted patient-level or systems-level factors. Efforts should be made to identify modifiable risks of cancer diagnosis in the ED to improve cancer outcomes.
Authors: Christopher T Aquina; Adan Z Becerra; Zhaomin Xu; Francis P Boscoe; Maria J Schymura; Katia Noyes; John R T Monson; Fergal J Fleming Journal: Surgery Date: 2017-02-23 Impact factor: 3.982
Authors: J Wattacheril; J R Kramer; P Richardson; B D Havemann; L K Green; A Le; H B El-Serag Journal: Aliment Pharmacol Ther Date: 2008-08-08 Impact factor: 8.171
Authors: Reiko Nishihara; Kana Wu; Paul Lochhead; Teppei Morikawa; Xiaoyun Liao; Zhi Rong Qian; Kentaro Inamura; Sun A Kim; Aya Kuchiba; Mai Yamauchi; Yu Imamura; Walter C Willett; Bernard A Rosner; Charles S Fuchs; Edward Giovannucci; Shuji Ogino; Andrew T Chan Journal: N Engl J Med Date: 2013-09-19 Impact factor: 91.245