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Emergency room visits by cancer patients can often be avoided

(Photo Credit: Getty Images)

Most don’t seek advice from nurse triage lines before heading to the hospital, UTSW study shows

Provider and Patient

(Photo Credit: Getty Images)

Recently diagnosed cancer patients often decide on their own to visit hospital emergency departments (EDs) for symptoms that don’t warrant that type of care, UT Southwestern Medical Center researchers report. Their study's results, published in the American Journal of Managed Care, could help patients safely avoid going to the ED.

“Many health system telephone answering messages advise callers that ‘if this is a medical emergency, please hang up and dial 911.’ Our findings point out that patients with cancer are often referring themselves to the ED for nonemergency issues, so they may need more directed clinical advice,” said study leader Arthur Hong, M.D., M.P.H., Assistant Professor of Internal Medicine and in the Peter O’Donnell Jr. School of Public Health at UT Southwestern. Dr. Hong, a member of the Division of General Internal Medicine and the Harold C. Simmons Comprehensive Cancer Center, is a Texas Health Resources Clinical Scholar.

Kimberly Kho, M.D., M.P.H.

Arthur Hong, M.D., M.P.H., Assistant Professor of Internal Medicine and in the Peter O'Donnell Jr. School of Public Health at UT Southwestern, is a member of the Harold C. Simmons Comprehensive Cancer Center and a Texas Health Resources Clinical Scholar.

Cancer patients frequently experience a range of disease- and treatment-related symptoms, and those who are fearful or confused may make a default decision to go to the emergency room. However, Dr. Hong said, some of these visits can be avoided; patients may be better served visiting a cancer-specific urgent care center. Although most cancer care providers offer nurse triage phone lines 24 hours a day, seven days a week to dispense advice, it has been unclear how often patients use them to decide whether an ED visit is appropriate.

To answer this question, Dr. Hong and his colleagues evaluated data from the tumor registries of UT Southwestern and Parkland Health, a public safety-net health system for the uninsured that serves as the primary teaching hospital for UTSW. The researchers identified 39,498 adults with a new cancer diagnosis between 2012 and 2018, then compared records from these patients to those in a database of ED visits within six months of diagnosis. That database is maintained by the Dallas-Fort Worth Hospital Council Foundation, which keeps records of 12 million patients within a 100-mile radius of Dallas including details of their hospital visits.

Just over 40% of the patients made no ED visits in the six months after their diagnoses, but about 50% made one to three, and nearly 10% had four or more. Of patients who made ED visits, about 81% always self-referred, about 7% relied on medical advice at least once, and about 12% always called for triage help before an ED visit.

Although more than half of these visits ended in hospitalizations and a quarter were classified as emergencies but didn’t require hospitalization, another quarter did not require emergency care. These nonemergency visits were more likely for patients who did not consult a nurse triage line, went to the ED on weekends or holidays, or went to EDs closer to their home.

Patients who visited EDs bypassed an average of 13 that were closer to their homes. Those who visited closer EDs were no more likely to be experiencing a true medical emergency than those who traveled farther.

About half of ED visits were to centers not associated with the patient’s cancer care. That decision could lead to less personalized care recommendations and providers who may be less familiar with managing cancer- and treatment-related complications, which could affect outcomes, Dr. Hong said.

Future research should focus on why so many patients don't reach out for assistance from their clinicians to help them decide when emergency care is appropriate, he added. “Providers should take this as a signal to better address unmet patient needs,” Dr. Hong said.

UT Southwestern’s Simmons Cancer Center and Parkland Health have Acute Care clinics (Simmons Acute Care in the Cancer Care Outpatient Building and Parkland Oncology Acute Care), which provide urgent care services for patients with cancer and could help many patients avoid the ED while providing expert cancer support. The main way to access these clinics is to call a triage nurse, who can direct patients to the clinics. The research by Dr. Hong and his team should help spur additional efforts to ensure patients know about these available services.

Other UTSW researchers who contributed to this study include Amy Hughes, Ph.D., Assistant Professor in the O’Donnell School of Public Health, member of the Simmons Cancer Center, and a Texas Health Resources Clinical Scholar; D. Mark Courtney, M.D., M.S.C.I., Professor of Emergency Medicine; Hannah Fullington, M.P.H., Senior Quality Improvement Analyst; John Sweetenham, M.D., Adjunct Professor in the Simmons Cancer Center; Navid Sadeghi, M.D., Associate Professor of Internal Medicine and member of the Simmons Cancer Center; Song Zhang, Ph.D., Professor in the O’Donnell School of Public Health and member of the Simmons Cancer Center; and Angela Bazzell, D.N.P., APRN, FNP-BC, AOCNP, and Assistant Director of Advanced Practice Providers in the Simmons Cancer Center.

This study was funded by the Texas Health Resources Clinical Scholars Program, a National Cancer Institute Cancer Center Support Grant (1P30CA142543), and a Clinician Scientist Development Grant (CSDG-20-023-01-CPHPS) from the American Cancer Society.