Cancer patients as frequent attenders in emergency departments: A national cohort study

Abstract

BackgroundCancer patients contribute significantly to emergency department (ED) utilization. The objective of this study was to identify factors associated with patients becoming ED frequent attenders (FA) after a cancer‐related hospitalization.MethodsA retrospective cohort study was conducted using national administrative, billing, and death records of Singapore residents discharged alive from Singapore public hospitals from January 2012 to December 2015, with a primary discharge diagnosis of cancer. Patients with four or more ED visits within any 12‐month period after discharge from their index hospitalization were classified as FA. Time to FA distribution was estimated using the Kaplan‐Meier method, and factors associated with risk of FA were identified using multivariate Cox regression analyses.ResultsRecords for 47 235 patients were analyzed, of whom 2980 patients were FA within the study period. Age (<17 years, hazard ratio [HR] 2.92, 95% CI 2.28‐3.74; 75‐84 years, HR 1.29, 95% CI 1.16‐1.45; and ≥85 years, HR 1.71, 95% CI 1.45‐2.02, relative to age 55‐64), male gender (HR 1.26, 95% CI 1.16‐1.37), Charlson comorbidity index (HR 1.21, 95% CI 1.19‐1.23), and socioeconomic factors (Medifund use, HR 1.40, 95% CI 1.23‐1.59; housing subsidy type, HR 2.12, 95% CI 1.77‐2.54) were associated with increased risk of FA. Primary malignancies associated with FA included brain and spine (HR 2.51, 95% CI 1.67‐3.75), head and neck cancers (tongue, HR 2.05, 95% CI 1.27‐3.31; hypopharynx, HR 2.72, 95% CI 1.56‐4.74), lung (trachea and lung, HR 1.57, 95% CI 1.13‐2.18; pleural, HR 3.69, 95% CI 2.12‐6.34), upper gastrointestinal (stomach, HR 1.93, 95% CI 1.26‐2.74; esophagus, HR 4.13, 95% CI 2.78‐6.13), hepato‐pancreato‐biliary (liver, HR 1.42, 95% CI 1.01‐2.00, pancreas, HR 2.48, 95% CI 1.72‐3.59), and certain hematological malignancies (diffuse non‐Hodgkin's lymphoma, HR1.59, 95% CI 1.08‐2.33, lymphoid leukemia, HR 1.86, 95% CI 1.21‐2.86). Brain (HR 1.69, 95% CI 1.27‐2.26), lung (HR 1.31, 95% CI 1.01‐1.71), liver (HR 1.46, 95% CI 1.14‐1.89), and bone (HR 1.35, 95% CI 1.04‐1.76) metastases were also associated with FA.ConclusionThere are cancer‐specific factors contributing to ED frequent attendance. Additional resources should be allocated to support high‐risk groups and prevent unnecessary ED use.

Factors driving frequent attendance at emergency departments for patients with head and neck cancer

“…Patients receiving less housing subsidies (3‐3.9 [OR, 0.34; 0.16‐0.71] and ≥4 [OR, 0.37; 0.19‐0.73]) were less likely to be an FA (Table ). These findings were similar to our previous study …”

“…In this study, we found that these factors associated with an increased risk of FA status: lower SES (housing subsidy type) and greater comorbidity. This was similar to the findings from other studies …”

“…Studies have shown FAs to have a higher chronic disease burden, lower SES, and higher utilization of nonemergency health care services . In a previous national cohort study, we found that certain cancer profiles increased the risk of ED FA: head and neck cancers were up to twice as likely to be an FA …”

“…A single‐center retrospective cohort study was conducted using National Cancer Centre head and neck cancer registry data (matched with Singapore death registry data), linked with administrative data of ED visits and inpatient admissions. Our data are from a single‐institution prospectively collected head and neck cancer registry, covering more than 50% representation of the patients nationally, linked to the national death registry, which has 100% coverage of the entire country …”

“…Previous studies have evaluated the risk factors for increased health care utilization . The commonest ED complaints of patients with cancer appear to be similar to that of the general population but may also present with unique cancer‐related issues, either from the cancer itself or from complications of treatment or side effects .…”