Clinical characterisation of patients diagnosed with cancer following emergency self-referral.

BACKGROUND: Despite their frequency and potential impact on prognosis, cancers diagnosed via self-referral to the emergency department are poorly documented. We conducted a detailed analysis of cancer patients diagnosed following emergency self-referral and compared them with those diagnosed following emergency referral from primary care. Given the challenges associated with measuring intervals in the emergency self-referral pathway, we also aimed to provide a definition of the diagnostic interval for these cancers. METHODS: A retrospective observational analysis was performed on patients diagnosed with 13 cancers, either following emergency self-referral or emergency referral from primary care. We analysed demographics, tumour stage, clinical data (including 28 presenting symptoms categorised by body systems), and diagnostic intervals by cancer site, then testing for differences between pathways. RESULTS: Out of 3624 patients, 37 % were diagnosed following emergency self-referral and 63 % via emergency referral from primary care. Emergency self-referrals were associated with a higher likelihood of being diagnosed with cancers manifesting with localising symptoms (e.g., breast and endometrial cancer), whereas the likelihood of being diagnosed with cancers featuring nonspecific symptoms and abdominal pain (e.g., pancreatic and ovarian cancer) was higher among patients referred from primary care. Diagnostic intervals in self-referred patients were half as long as those in patients referred from primary care, with most significant differences for pancreatic cancer (28 [95 % CI -34 to -23] days shorter, respectively). CONCLUSION: These findings enrich the best available evidence on cancer diagnosis through emergency self-referral and showed that, compared with the emergency referral pathway from primary care, these patients had a significantly increased likelihood of presenting with symptoms that are strongly predictive of cancer. Since the starting point for the diagnostic interval in these patients is their emergency presentation, comparing it with that of those referred from primary care as an emergency is likely to result in biased data.

Time to Diagnosis and Presenting Symptoms of Patients Diagnosed With Cancer Through Emergency and Nonemergency Routes: A Large Retrospective Study From a High-Volume Center.

PURPOSE: The symptoms with which a patient with cancer presents and the route taken to diagnosis (emergency v nonemergency) may affect the speed with which the diagnosis of cancer is made, thereby affecting outcomes. We examined time to diagnosis by symptom for cancers diagnosed through emergency and nonemergency routes (NERs). METHODS: We performed a retrospective review of patients diagnosed with 10 solid cancers at Hospital Clínic of Barcelona between March 2013 and June 2023. Cancers were diagnosed through emergency presentation and admission (inpatient emergency route [IER]), emergency presentation and outpatient referral (outpatient emergency route [OER]), and primary care presentation and outpatient referral (NER). We assessed the effect of diagnostic routes on intervals to diagnosis for 19 cancer symptoms. RESULTS: A total of 5,174 and 1,607 patients were diagnosed with cancer through emergency routes and NERs, respectively. Over 85% of patients presenting with alarm (localizing) symptoms such as hematuria through emergency routes were diagnosed with the expected cancer, whereas those with nonlocalizing symptoms such as abdominal pain had a more heterogeneous cancer-site composition. Median intervals were shorter for alarm than nonlocalizing symptoms and tended to be shorter in IERs than OERs. However, for most symptoms, intervals in both routes were invariably shorter than in the NER. For example, diagnostic intervals for hematuria and abdominal pain were 3 and 5 days shorter in IERs than OERs, but they were 5-8 and 17-22 days shorter than in the NER, respectively. CONCLUSION: For patients with alarm symptoms, intervals were shorter than for those with nonlocalizing symptoms and, for most symptoms, intervals were shorter when patients were evaluated by emergency routes rather than NERs.

Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis.

BACKGROUND: Time intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital. METHODS: Patients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined. RESULTS: There were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1-2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage. CONCLUSION: System level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.

Time intervals in the pathway to emergency cancer diagnosis.

Aim: Evidence on time-based metrics for cancers diagnosed through emergency presentation is lacking. We examined the duration of intervals from first symptoms to cancer diagnosis in the emergency versus primary care (PC) presentation route. Methods: Retrospective study of outpatients diagnosed with 15 solid cancers over 5 years. The outcome was the length of prediagnostic intervals by diagnostic route. Results: Median intervals in emergency presenters (n = 3167) were shorter than in PC presenters (n = 2215). However, intervals in emergency presenters with three or more prior PC consultations were similar to PC but remarkably longer than in those with one or two and no consultations. Conclusion: As we provide new interval measures for the emergency diagnostic pathway, results highlight the contribution of prior consultations to interval lengths.

Time intervals in the care pathway to cancer diagnosis during the COVID-19 pandemic: A large retrospective study from a high-volume center.

Despite extensive research on cancer care during the COVID-19 pandemic, evidence on the impact on prediagnostic time intervals is lacking. To better understand how COVID-19 changed the pathway to diagnosis of cancer, we examined the length of intervals from symptom onset to diagnosis for 13 common cancer types with known clinical stage over 1-year nonpandemic period (March 2019 to March 2020; N = 844) and three biannual COVID periods (March 2020 to September 2021; N = 1172). We analyzed the patient interval (from first symptoms to presentation to a physician), the primary care/emergency department interval (from presentation with relevant symptoms to a primary care or emergency department physician to referral to a hospital-based diagnosis center) and the hospital interval (from referral to diagnosis). Compared to nonpandemic data, there were significant changes across COVID periods. The pandemic mostly impacted patient intervals for cancers diagnosed over the first 6 months after onset in March 2020. Overall median patient intervals were longest in the early COVID period (39 [IQR 22-64] days) and shortest in the nonpandemic period (20 [IQR 13-30] days; Kruskal-Wallis test [χ2 ], P < .0001). Differences in clinical stage between periods were relevant, with cancers from the mid-period (September 2020 to March 2021) showing the most advanced stage. A shift to later stage was plausibly a result of delayed intervals in the early COVID period. Since intervals are eventually relevant to prognosis, our results provide a baseline against which the impact of improvement strategies to minimize the negative outcomes of COVID-19-associated cancer delays can be assessed and implemented.

Quick diagnosis units: predictors of time to diagnosis and costs.

Financial crisis has forced health systems to seek alternatives to hospitalization-based healthcare. Quick diagnosis units (QDUs) are cost-effective compared to hospitalization, but the determinants of QDU costs have not been studied.We aimed at assessing the predictors of costs of a district hospital QDU (Hospital Plató, Barcelona) between 2009 and 2016.This study was a retrospective longitudinal single center study of 404 consecutive outpatients referred to the QDU of Hospital Plató. The referral reason was dichotomized into suggestive of malignancy vs other. The final diagnosis was dichotomized into organic vs nonorganic and malignancy vs nonmalignancy. All individual resource costs were obtained from the finance department to conduct a micro-costing analysis of the study period.Mean age was 62 ±â€Š20 years (women = 56%), and median time-to-diagnosis, 12 days. Total and partial costs were greater in cases with final diagnosis of organic vs nonorganic disorder, as it was in those with symptoms suggestive or a final diagnosis of cancer vs noncancer. Of all subcosts, imaging showed the stronger correlation with total cost. Time-to-diagnosis and imaging costs were significant predictors of total cost above the median in binary logistic regression, with imaging costs also being a significant predictor in multiple linear regression (with total cost as quantitative outcome).Predictors of QDU costs are partly nonmodifiable (i.e., cancer suspicion, actually one of the goals of QDUs). Yet, improved primary-care-to-hospital referral circuits reducing time to diagnosis as well as optimized imaging protocols might further increase the QDU cost-effectiveness process. Prospective studies (ideally with direct comparison to conventional hospitalization costs) are needed to explore this possibility.

Quick outpatient diagnosis in small district or general tertiary hospitals: A comparative observational study.

While quick diagnosis units (QDUs) have expanded as an innovative cost-effective alternative to admission for workup, studies investigating how QDUs compare are lacking. This study aimed to comparatively describe the diagnostic performance of the QDU of an urban district hospital and the QDU of its reference general hospital.This was an observational descriptive study of 336 consecutive outpatients aged ≥18 years referred to the QDU of a urban district hospital in Barcelona (QDU1) during 2009 to 2016 for evaluation of suspected severe conditions whose physical performance allowed them to travel from home to hospital and back for visits and examinations. For comparison purposes, 530 randomly selected outpatients aged ≥18 years referred to the QDU of the reference tertiary hospital (QDU2), also in Barcelona, were included. Clinical and QDU variables were analyzed and compared.Mean age and sex were similar (61.97 (19.93) years and 55% of females in QDU1 vs 60.0 (18.81) years and 52% of females in QDU2; P values = .14 and .10, respectively). Primary care was the main referral source in QDU1 (69%) and the emergency department in QDU2 (59%). Predominant referral reasons in QDU1 and 2 were unintentional weight loss (UWL) (21 and 16%), anemia (14 and 21%), adenopathies and/or palpable masses (10 and 11%), and gastrointestinal symptoms (10 and 19%). Time-to-diagnosis was longer in QDU1 than 2 (12 [1-28] vs 8 [4-14] days; P < .001). Malignancy was more common in QDU2 than 1 (19 vs 13%; P = .001). Patients from both groups with malignancy, aged ≥65 years and requiring >2 visits to be diagnosed were in general more likely to be males, to have UWL and adenopathies and/or palpable masses but less likely anemia, to undergo more examinations except endoscopy, and to be referred onward to specialist outpatient clinics.Despite some differences, results showed that, for diagnostic purposes, the overall performance and effectiveness of QDUs of urban district and reference general hospitals in evaluating patients with potentially serious conditions were similar. This study, the first to compare the performance of 2 hospital-based QDUs, adds evidence to the opportunity of producing standardized guidelines to optimize QDUs infrastructure, functioning, and efficiency.