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Emergency Presentations Predict Worse Outcomes Among Patients with Pancreatic Cancer

  • Original Article
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Abstract

Background

Emergency presentation (EP) of cancer, a new cancer diagnosis made following an emergency department (ED) visit, is associated with worse patient outcomes and greater organizational stress on healthcare systems. Pancreatic cancer has the highest rate of EPs among European studies but remains understudied in the U.S.

Aims

To evaluate the association between pancreatic cancer EPs and cancer stage, treatment, and survival.

Methods

We conducted a retrospective cohort study among patients with pancreatic adenocarcinoma diagnosed from 2007 to 2019 at a tertiary-care Veterans Affairs medical center. Electronic health records were reviewed to identify EP cases, defined as a new pancreatic cancer diagnosis made within 30 days of an ED visit where cancer was suspected. We used multivariate logistic regression models and Cox proportional hazards models to examine the associations between EPs and cancer stage, treatment, and survival.

Results

Of 243 pancreatic cancer patients, 66.7% had EPs. There was no difference in stage by EP status. However, patients diagnosed through EPs were 72% less likely to receive cancer treatment compared to non-emergency presenters (adjusted OR 0.28; 95% CI 0.13–0.57). Patients with EPs also had a 73% higher mortality risk (adjusted HR 1.73; 95% CI 1.29–2.34). This difference in mortality remained statistically significant after adjusting for cancer stage and receipt of cancer treatment (adjusted HR 1.47; 95% CI 1.09–1.99).

Conclusions

Pancreatic cancer EPs are common and independently associated with lower treatment rates and survival. Enhanced understanding of process breakdowns that lead to EPs can help identify care gaps and inform future quality improvement efforts.

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Abbreviations

AJCC:

American Joint Committee on Cancer

BMI:

Body mass index

CCR:

Cancer Care Registry

CDW:

Corporate data warehouse

CI:

Confidence interval

CMS:

Centers for Medicare and Medicaid Services

CPT:

Current Procedural Terminology

ECOG:

Eastern Cooperative Oncology Group

ED:

Emergency department

EP:

Emergency presentation

EHR:

Electronic health record

HR:

Hazards ratios

ICD:

International Classification of Disease

IQR:

Interquartile range

NASEM:

National Academies of Sciences, Engineering, and Medicine

NCIN:

National Cancer Intelligence Network

OR:

Odds ratio

U.K.:

United Kingdom

U.S.:

United States

VA:

Veterans Affairs

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Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs of the United States Government.

Funding

The study was funded in part by Texas Medical Center Digestive Diseases Center (PHS grant P30DK056338); the Gordon and Betty Moore Foundation (Diagnostic Excellence Award, grant number: GBMF11505); and a Veterans Affairs Health Services Research and Development Career Development Award (1 IK2 HX003346-01A2). Drs. Khalaf, Kramer, Singh and Kanwal are additionally supported by the Veterans Administration Health Services Research and Development Service Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413). Dr. Singh is also supported by the VA National Center for Patient Safety, the VA HSR&D Service (IIR17-127) and the Agency for Healthcare Research and Quality (R18 HS029347 and R01 HS028595).

Author information

Author notes

  1. Natalia Khalaf and Basim Ali are joint first authors.

Authors and Affiliations

  1. Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd. MS:111-D, Houston, TX, 77030, USA

    Natalia Khalaf, Yan Liu, Jennifer R. Kramer, Fasiha Kanwal & Hardeep Singh

  2. Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Natalia Khalaf, Basim Ali, Yan Liu, Hashem El-Serag & Fasiha Kanwal

  3. Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Hashem El-Serag & Hardeep Singh

  4. Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA

    Jennifer R. Kramer

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  7. Hardeep Singh
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Contributions

NK, BA and HS contributed to study concept and design, analysis and interpretation of data, drafting of the manuscript and critical revision of the manuscript for important intellectual content. NK, FK, and HS contributed to obtaining funds and providing material support. YL contributed to acquisition of data, analysis and interpretation of data. JK contributed to study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript and study supervision. HES, FK and HS contributed to study concept and design, interpretation of data, and critical revision of the manuscript. All authors gave final approval of the version to be published.

Corresponding author

Correspondence to Natalia Khalaf.

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Conflicts of interest

No relevant conflicts of interest exist.

Ethical approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Baylor College of Medicine and Research and Development at the Michael E. DeBakey Veterans Affairs Medical Center approved this study.

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Cite this article

Khalaf, N., Ali, B., Liu, Y. et al. Emergency Presentations Predict Worse Outcomes Among Patients with Pancreatic Cancer. Dig Dis Sci 69, 603–614 (2024). https://doi.org/10.1007/s10620-023-08207-6

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  • DOI: https://doi.org/10.1007/s10620-023-08207-6

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