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Emergency medicine
Original research
Retrospective study of cancer patients’ predictive factors of care in a large, Hungarian tertiary care centre
  1. Márton Koch1,
  2. Éva Szabó2,
  3. Csaba Varga1,3,
  4. Viktor Soós1,
  5. Lilla Prenek1,
  6. Lili Porcsa1,
  7. Szabolcs Bellyei4,
  8. Kyra Girán5,
  9. János Girán6,
  10. István Kiss6,
  11. Éva Pozsgai6,7
  1. 1Department of Emergency Medicine, Somogy County Kaposi Mór General Hospital, Kaposvár, Hungary
  2. 2Department of Otorhinolaryngology, University of Pécs Clinical Center, Pecs, Hungary
  3. 3Department of Emergency Medicine, Semmelweis University, Budapest, Hungary
  4. 4Department of Oncotherapy, University of Pécs Clinical Center, Pecs, Hungary
  5. 5Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
  6. 6Department of Public Health, Pécsi Tudományegyetem Általános Orvostudományi Kar, Pecs, Hungary
  7. 7Department of Primary Health Care, Pécsi Tudományegyetem Általános Orvostudományi Kar, Pecs, Hungary
  1. Correspondence to Dr Éva Pozsgai; pozsgay83{at}gmail.com

Abstract

Objectives To identify predictive factors of multiple emergency department (ED) visits, hospitalisation and potentially preventable ED visits made by patients with cancer in a Hungarian tertiary care centre.

Design Observational, retrospective study.

Setting A large, public tertiary hospital, in Somogy County, Hungary, with a level 3 emergency and trauma centre and a dedicated cancer centre.

Participants Patients above 18 years with a cancer diagnosis (International Classification of Diseases, 10th Revision codes of C0000–C9670) who visited the ED in 2018, who had received their diagnosis of cancer within 5 years of their first ED visit in 2018 or received their diagnosis of cancer latest within the study year. Cases diagnosed with cancer at the ED (new cancer diagnosis-related ED visits) were also included, constituting 7.9% of visits.

Primary outcome measures Demographic and clinical characteristics were collected and the predictors of multiple (≥2) ED visits within the study year, admission to inpatient care following the ED visit (hospitalisation), potentially preventable ED visits and death within 36 months were determined.

Results 2383 ED visits made by 1512 patients with cancer were registered. Predictive factors of multiple (≥2) ED visits were residing in a nursing home (OR 3.09, 95% CI 1.88 to 5.07) and prior hospice care (OR 1.87, 95% CI 1.05 to 3.31). Predictive factors for hospitalisation following an ED visit included a new cancer diagnosis-related visit (OR 1.86, 95% CI 1.30 to 2.66) and complaint of dyspnoea (OR 1.61, 95% CI 1.22 to 2.12).

Conclusions Being a resident of a nursing home and receiving prior hospice care significantly increased the odds of multiple ED visits, while new cancer-related ED visits independently increased the odds of hospitalisation of patients with cancer. This is the first study to report these associations from a Central-Eastern European country. Our study may shed light on the specific challenges of EDs in general and particularly faced by countries in the region.

  • adult oncology
  • accident & emergency medicine
  • organisation of health services

Data availability statement

Data are available on reasonable request. The datasets generated and/or analysed during the current study are not publicly available due to data privacy of human patients but are available from the corresponding author on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-070320

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This is a comparatively large, comprehensive study on patients with cancer visiting the emergency department (ED), where data regarding a wide range of parameters were collected.

    • The analysis of multiple aspects of ED visits made by patients with cancer is unique.

    • This is a retrospective study from a single centre; therefore, further studies are needed to confirm our results.

    Background

    Cancer is the second-leading cause of mortality in developed countries, and the number of cancer cases and death is projected to increase in the future,1 thus placing a huge strain on the healthcare system. A large percentage of patients with cancer present to emergency departments (ED) due to a variety of medical conditions ranging from life-threatening conditions such as sepsis and unspecific symptoms such as pain or nausea.2

    Since patients with cancer have been shown to use the ED more frequently than patients without cancer, it has been proposed that many cases related to symptom management could possibly be prevented with proactive measures or managed in an outpatient setting. Breast, prostate and lung cancer were associated with more frequent ED visits according to a study in the USA, while in an Australian investigation, patients with genitourinary cancers were found to use the ED most often.3 A recent report found that the presence of metastatic disease and/or comorbidities, such as chronic pulmonary disease, poorly controlled diabetes or renal disease were the risk factors mostly affecting the number of multiple ED visits.4 EDs providing care to a wide spectrum of patients are often overcrowded, with 10%–40% of ED visits thought to be potentially preventable.5

    Recent estimations have suggested that two-thirds of the ED visits made by patients with cancer result in hospitalisation, which is a fourfold higher ED hospitalisation rate than in the general population.6 Older patients with cancer are also significantly more likely to be admitted to an inpatient unit, than be discharged following an ED visit.3

    Identifying the characteristics, reasons and factors leading to ED use and multiple ED visits of patients with cancer are crucial for developing and ultimately implementing cost-effective preventive measures to optimise patient care and decrease the increasing cancer burden on the healthcare system. Although several large analyses have been carried out investigating the frequency and causes of patients with cancer visiting the ED in Western countries, to our knowledge, data from Eastern and Central Europe are lacking. In a previous report, as part of a large research project, we analysed the main reasons of ED visits made by patients with cancer.7

    Objectives

    The aim of our present study was to identify predictive factors of multiple ED visits, hospitalisation, death and potentially preventable ED visits made by patients with cancer at an ED in a tertiary care centre. We also analysed the relationship between frequency of ED visits and the 3-year survival of patients with cancer.

    Methods

    Setting

    The study was carried out at a large, public tertiary hospital, the Somogy County Kaposi Mór Teaching Hospital, in Kaposvár, Hungary, with a level 3 emergency and trauma Centre (ED) and a dedicated cancer centre (including an inpatient unit, a day oncology unit and a radiotherapy unit), which is responsible for the treatment of patients with cancer in Somogy county but also accepts some patients from neighbouring counties. All patients, including patients with cancer and non-cancer, with acute symptoms, are required to present themselves at the ED first as part of the single-gate system. Patients with injuries are also required to visit the emergency and trauma centre. The patients are then triaged according to the Hungarian Emergency Triage System (MSTR)8—the required triage system used in Hungary, and which was adapted from the Canadian Triage and Acuity Scale9—admitted and subsequently examined and treated. Then, based on their medical status, patients may either be discharged, or admitted to the ED’s Short Stay Unit—for a period of maximum 24 hours—or hospitalised (admitted to one of the hospital’s inpatient units.) The annual patient turnover of the ED is approximately 35 000 patients and 80% of the patients are over 18 years of age.

    Study design

    This was an observational, retrospective, study of patients with a cancer diagnosis—that is with an International Classification of Diseases, 10th Revision (ICD-10) code of C0000–C9670—who visited the ED in 2018. All patients with a cancer diagnosis above 18 years who visited the ED between 1 January 2018 and 31 December 2018 were included and who had received their diagnosis of cancer within 5 years of their first ED visit in 2018 or received their diagnosis of cancer latest within the study year.

    If a patient presented to the ED without a cancer diagnosis, but with symptoms indicative of cancer and which cancer was subsequently histologically confirmed (but within the study year), the patient was categorised as a ‘new cancer diagnosis-related ED visit’. This subgroup of patients constituted 7.9% of all ED visits made by patients with cancer, thus resulting in altogether 189 ED visits (online supplemental file 2).7

    We screened the hospital’s electronic database for all patients who met the inclusion criteria. In the study year of 2018, there were altogether 27 010 visits made by patients 18 years and older at the ED, from which 2383 cases were made by patients who had received an ICD-10 cancer diagnosis latest in the year 2018, thus constituting 8.8% of all adult ED visits.

    We carried out automated data collection with a special software, specifically developed for the purposes of the study, which included the collection of demographic data (patient’s age at first ED visit, place of residence), date and time of the ED visit, number of ED visits per patient, visit day and visit hour category, type of cancer, type and number of comorbidities, time and date of prior oncological care, triage categorisation, chief complaints, diagnosis given following ED admission, disposition (admitted to inpatient care, discharged), place of inpatient care following ED presentation and, where relevant, time of death of the patient. Types of cancer, diagnoses of comorbidities, chief complaints and diagnoses given following ED admission were classified according to ICD-10. Patients were followed up for 36 months following their last ED visit and—where applicable—the death of the patients was recorded.

    The definitions and criteria for the categorisation of data used in the study are attached as online supplemental file 1, as described previously.7

    The primary outcome measures for this study were the predictors of multiple (≥2) ED visits within the study year, admission to inpatient care following the ED visit (hospitalisation), potentially preventable ED visits (defined as cases with a non-urgent triage category (triage level 5) plus not hospitalised plus who did not die within 30 days of the ED visit) and death within 36 months after ED presentation.

    Online supplemental file 2 shows the demographic and clinical characteristics of patients with cancer (n=1512) visiting the ED in 2018.7 Since a patient could present more than once at the ED within the study year, online supplemental file 3 shows the demographic and clinical characteristics of cancer cases (n=2383) visiting the ED in 2018, as described previously.7

    The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines were used when designing and describing this study.10 The checklist is attached as online supplemental file 4. The original research protocol is attached as online supplemental file 5.

    Patients and public involvement statement

    Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    Data analysis

    The data analysis framework was developed to address the research questions set for the study. Both descriptive and exploratory approaches were used. Two data sets were created: one contained the data of the 1512 patients with cancer who had attended the ED during the study period. The other data set included the total number of ED visits (2383 cases) made by the patients with cancer in the study period. The use of two data sets was necessary because a patient may have visited the ED more than once during the study period. Moreover, some of the characteristics were related to the patient (number of visits, data related to death), while others were related to the ED visit. Frequency tables were used to describe the number of ED visits made by patients with cancer, the demographic and clinical characteristics of ED cases and the number and time of death. A Kaplan-Meier survival analysis, using a log-rank test (p≤0.05), was conducted to examine the overall survival time of the patients. The mixed effects logistic regression was chosen (due to the possibility of the same patient’s repeated visit) and used to determine the predictive factors for hospitalisation, potentially preventable ED visits and multiple (≥2) ED visits made by patients with cancer. The binary logistic regression was used to determine predictive factors for death within 36 months of patients with cancer visiting the ED. The dependent variables were the variables listed in tables 1–2 (the demographic and clinical characteristics of patients/cases). The models were checked for multicollinearity problems (tolerance <0.10 and VIF <3.0), and no multicollinearity issues were found. Statistical analyses were performed using the statistical software Jamovi V.2.2.5.

    View this table:
    Table 1

    Predictive factors for multiple (≥2) ED visits by patients with cancer

    View this table:
    Table 2

    Predictive factors for hospitalisation of patients with cancer

    Results

    Predictive factors for multiple (≥2) ED visits made by patients with cancer

    When we investigated which factors influenced multiple (2 or more) ED visits made by patients with cancer, we found that residence in a nursing home more than tripled the odds (OR: 3.09) of multiple ED visits. Prior hospice care and a chief complaint of dyspnoea increased the odds by 87% and 75%, respectively, while 2 or more comorbidities increased the odds somewhat less, but still significantly (OR: 1.40) for multiple ED visits. Prior surgical or hormone treatment, prior chemotherapy, a diagnosis of injury, having breast cancer were factors which significantly decreased the odds of multiple ED visits (OR: 0.59, 0.52, 0.71, 0.59 and 0.69, respectively) (table 1).

    We also investigated the association between multiple visits and the 3-year survival of patients with cancer visiting the ED. There was no significant difference between the survival of patients with cancer visiting the ED once or multiple times (data not shown).

    Predictive factors for hospitalisation of patients with cancer

    Predictive factors for inpatient admission following an ED visit included a diagnosis of gastrointestinal illness (OR: 1.35), prior BSC/palliative treatment (OR: 1.53) and chief complaint of dyspnoea (OR: 1.61), which all significantly increased the odds of subsequent hospitalisation. Patients with a new cancer-related visit also had 86% higher odds of being hospitalised following their ED visit (table 2).

    Factors which predicted that there would be no hospital admission following the ED visit, were prior hormone treatment, diagnoses of injury or pain and chief complaints of pain in the extremities or elsewhere, except for abdominal pain (table 2).

    Predictive factors for death within 36 months of patients with cancer visiting the ED

    Prior hospice care (OR: 2.68), residence in a nursing home (OR: 2.45), prior BSC/palliative care (OR: 2.28), being hospitalised (OR: 2.23) and cancer of the respiratory tract (OR: 2.13) significantly increased the odds of death within 36 months after an ED visit. A new cancer-related ED visit more than tripled (OR: 3.28) the odds of death within 36 months (table 3).

    View this table:
    Table 3

    Predictive factors for death of patients with cancer visiting the ED

    Younger age (being less than 65), having a potentially preventable ED visit, as well as prior hormone or surgical therapy significantly decreased the odds of death within 36 months (table 3).

    Predictive factors for potentially preventable ED visits of patients with cancer

    We investigated whether predictive factors for potentially preventable ED visits could be identified, by analysing the association between demographic and clinical characteristics of patients meeting the criteria for being potentially preventable ED visits. A total of 445 ED visits out of 2383 met the criteria for potentially preventable ED visits, which constituted 18.67% of all ED visits (table 4).

    View this table:
    Table 4

    Predictive factors for potentially preventable ED visits of patients with cancer

    A complaint of dyspnoea, prior BSC/palliative care and a subsequent diagnosis of a cardiovascular illness or gastrointestinal disease significantly decreased the odds of the ED visit being potentially preventable, with ORs of 0.38, 0.43 0.61 and 0.55, respectively (table 4).

    Pain in the extremities (OR: 1.73) and elsewhere, excepting abdominal pain (OR 1.67) as chief complaints, or diagnosis codes of pain (OR: 1.47) and injury (OR: 1.46) significantly increased the odds of the ED visit being potentially preventable (table 4).

    Discussion

    To our knowledge, this is the first study to describe predictive factors of multiple ED visits, hospitalisation, potentially preventable visits and death of patients with cancer visiting a large tertiary care emergency centre, in one comprehensive investigation. Many of the independent predictive factors identified in our study have previously been reported in other studies—which support the validity of our findings—however, we were able to identify new independent factors of multiple ED visits, such as residency in a nursing home and risk factors of hospitalisation and poor overall survival, such as a ‘new cancer-related ED visit’, as well. The additional value of our study is that our data were collected from a Central-Eastern European site, where similar studies have not previously been reported.

    Investigations from the USA and Australia have reported that a significant proportion of patients (between 44% and 63%) with cancer had multiple ED visits11 12 In line with these results, we found that 57% of patients with cancer visiting the ED had 2 or more visits within the study year. We also identified that at least two or more comorbidities, some form of prior hospice care, symptom of dyspnoea and living in a nursing home were significant risk factors for multiple ED visits. Our findings correspond with previous studies that have also described that a greater number of comorbidities,6 12 13 more severe symptoms (such as dyspnoea)14 and less than 1 year of survival after diagnosis13 15 were all associated with higher rates of ED utilisation. The higher ED utilisation frequency and potentially preventable ED transfers by nursing home residents has only recently been investigated,16 but data on the frequency of ED utilisation by patients with cancer living in nursing homes is scarce. Our analysis showed that living in a nursing home more than tripled the odds and thus was a strong risk factor for repeated ED utilisation. It has been suggested that the ED use of patients with cancer is most probably the result of the complex interaction of a number of factors, including both disease-related and health system-related factors.6 Thus, although it is possible that frequent ED use among nursing home residents is a result of their overall poorer state of health, it also appears probable that the scarcity of nursing homes and lack of human resources to adequately provide care for the elderly may also be important contributing factors to the heightened burden of the EDs in Hungary. Although to a lesser extent, residency in a nursing home also increased the odds of death (OR: 2.45) within 3 years of ED presentation among patients with cancer in our study. This may naturally be the result of a higher number of comorbidities among these patients, however, it may also be due to the previously mentioned reasons of lack of optimal care. A large epidemiological Australian analysis indicated that a significant proportion of deaths were both premature and preventable in nursing homes and that no reduction in the prevalence of deaths due to external causes had been observed in the decade preceding the study.17 Thus, our findings appear to emphasise the importance of improved care for nursing home residents and the integration of preventive methods—against falls, contraction of infections, malnutrition, dehydration, etc—among nursing home residents. The predictive factors of pain and injury as diagnosis and chief complaint of pain in the extremities for potentially preventable ED visits in our study may be explained partially by falls and injuries, which could also be potentially prevented. Furthermore, patients with minor injuries also present to the ED, which often do not even require imaging techniques (eg, X-ray, CT scan, etc) to treat, indicating that—possibly with the introduction of an outpatients phone triage system—these patients could potentially be treated at the primary healthcare level without having to burden the ED. Although studies vary regarding the proportion of ED visits being preventable, two previous reports have estimated it between 19% and 23%18 19 which is similar to our findings of 18.67%.

    The hypothesis regarding lack of specialised care may be extended to the interpretation of our subsequent findings; patients with cancer who were already receiving hospice care had almost twice the odds of having multiple ED visits than patients not in hospice care, indicating that these patients’ needs (such as symptom management) were not being adequately met. Although most other studies have focused on ED visits made by patients with advanced cancer—and not hospice care per se—it has been reported that the use of palliative care services was still comparatively low among patients with cancer, and patients with advanced stage cancer regularly visited the ED due to worsening symptoms, since it was perceived to be the quickest way to obtain hospital admission.20 A Dutch study reported that 65% of lung and patients with colon cancer with metastases used in-hospital medical care—including ED visits and inpatient care—yet specialised palliative care was initiated too late.21 Furthermore, hospitalisation rates of patients with advanced cancer were found to be 76%22 vs 58% among all oncology patients,23 indicating that the highest inpatient admission rates were among patients with advanced stage cancer. These reports correspond with our findings that receiving ‘only’ BSC was a significant predictor of hospitalisation following the ED visit. A presenting main symptom of dyspnoea and a diagnosis of gastrointestinal illness were also important risk factors for hospital admission according to our study. In line with our results, it has previously been reported that dyspnoea and gastrointestinal symptoms, such as nausea, were frequent presenting symptoms of patients with cancer when visiting the ED.24 Dyspnoea was an independent risk factor for hospitalisation and multiple ED visits, and the cancer types often associated with dyspnoea, that is, respiratory cancer, was an independent risk factor for death, in our study. Managing dyspnoea is often challenging, as it is highly distressing for both patient and caregivers, it can rarely be managed at home by the patient, and it may also indicate life-threatening pathological conditions, which may lead to or be part of disease progression and ultimately cause death as well.25 Thus, the predictive factors of hospitalisation in our study (dyspnoea, ongoing BSC, diagnosis of a gastrointestinal illness and new cancer-related ED visit) indicated the more severe status of disease in these patients.

    A recent scoping review identified three main themes which emerged across studies regarding the relationship of cancer diagnosis at the ED, including incidental findings giving rise to the suspicion of cancer, acute conditions caused by the cancer leading to the ED visit and ED use as a pathway to facilitate cancer diagnosis and care.26 Independent of the main reason, all patients diagnosed with cancer through the ED, had more advanced cancers and subsequently poorer outcomes.26 These findings of significantly poorer clinical and patient-reported outcomes and worse survival rates were reported in earlier27 and recent publications as well, including the International Cancer Benchmarking Partnership population-based study.28 In line with previous reports, our results showed that new cancer-related ED visits more than tripled the odds of death within 3 years, furthermore we also found, that new cancer-related ED visits almost doubled the odds of hospitalisation.

    Previous studies have reported that elderly patients with cancer with multiple ED visits had higher hospital admission rates and an increased mortality during admission.29 30 In accordance with these studies, ongoing BSC or hospice care, cancer of the respiratory tract, hospitalisation and multiple ED visits also increased the odds of death within 3 years among patients with cancer in our analysis.

    Limitations

    Our study has certain limitations. It was a retrospective study and carried out at a single site, therefore, further analyses need to be made in multiple sites for the confirmation of our findings. Also, due to the classification of certain data (diagnoses, symptoms, types of cancer, etc) into main categories, classification bias cannot be ruled out Finally, although patients with cancer treated at our hospital need to present with their symptoms to our ED centre, some patients with cancer may have been presented elsewhere (eg, when out of the county or country), and so these patients may not have been included. Despite being a single site, our study was a comparatively large, comprehensive study, where data regarding a wide range of parameters were collected and extensive analysis performed.

    Conclusions

    In our study, we identified predictive factors of multiple ED visits, hospitalisation, preventable visits and death within 3 years of ED presentation of patients with cancer visiting a tertiary-level ED centre. As far as we know, this is the first study to investigate these factors in one analysis and from a Central-Eastern European country. Since most studies have been published from highly developed countries, our investigation may shed some light on the specific challenges faced by countries in the region. Our novel findings include that new cancer-related ED visits and being a resident of a nursing home, both independently increased the odds of hospitalisation and death of patients with cancer visiting the ED; and nursing home residency and hospice care (indicating advanced cancer) increased the odds of multiple ED visits. These results imply the importance of strengthening care and implementing preventive measures related to these risk factors—not just from a regional but—from an international perspective, as well.

    Data availability statement

    Data are available on reasonable request. The datasets generated and/or analysed during the current study are not publicly available due to data privacy of human patients but are available from the corresponding author on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Ethical permission from the Regional Ethical Committee of the University of Pécs Medical School was gained before the research procedure under the reference number 8280-PTE2020. All methods were carried out in accordance with the Declaration of Helsinki and the relevant guidelines and regulations. All experimental protocols were approved by the Regional Ethical Committee of the University of Pécs Medical School. Consent from participants was not required according to the regulations of the Regional Ethical Committee of the University of Pécs Medical School since no individual identifiable patient data/images were used and/or presented in the current study, thus the need for informed consent for the present study was waived by the Regional Ethical Committee of the University of Pécs Medical School.

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    Supplementary materials

    Footnotes

    • MK and ÉS contributed equally.

    • Contributors MK collected, reviewed and analysed the data and prepared the manuscript. ES reviewed the literature, analysed the data and prepared the manuscript. CV, IK and EP reviewed the literature and designed the study. VS developed the software for the automated data collection. LPr and LPo collected and reviewed the data. SB analysed the data and reviewed data collection. JG and KG performed the statistical analysis, analysed the data and prepared the manuscript. EP, IK and CV analysed the data and reviewed the manuscript. All authors read and approved the final manuscript. ÉP is the guarantor of the study.

    • Funding The study was supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences 2022 (no award/grant number) and the University of Pécs ‘Dr. Pintér András Medical School Collaboration Foundation (University of Pécs Medical School-TANDEM, 2021)’ Grant (no award/grant number).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.