Diagnosis of Cancer in the Emergency Room - Explaining Persistent Disparities

项目摘要/摘要 癌症是急诊科的常见诊断，当病人到达急诊室时，他们的 癌症通常会进展到后期。EDS不是用来诊断癌症的。癌症方面的培训 急诊科医生的管理是有限的，患者在去急诊室就诊后经常可以获得后续护理 很难。来自其他西方国家的研究告诉我们，与非紧急情况相比，癌症 通过ED的诊断是更糟糕的结果的独立预测因素，包括更差的总体存活率。 在美国，人们对癌症的紧急诊断知之甚少。从几项研究中 在几种癌症类型中进行的研究，我们知道高达30%的癌症患者被诊断为紧急情况， 低收入和种族/少数民族患者受到影响的可能性要大得多。然而，横跨 不同的癌症类型、癌症诊断的负担和危险因素作为紧急情况一直没有得到 学习。此外，美国没有一项基于人群的研究比较了患者的存活率差异 与其他非急诊机构相比，急诊室被诊断为癌症。在那些被诊断为 紧急情况下，不清楚他们为什么去急诊室，而不是去初级保健机构寻求他们的 诊断。我们的长期目标是在美国建立紧急癌症诊断的流行病学。 将描述急诊科癌症诊断的负担，包括患者的特征 在那些受影响最严重的人群中，并量化根据社会经济地位定义的弱势群体的差距， 种族/族裔和地理隔离(目标1)。我们会评估教育署的相对重要性(与 非ED)对患者生存的诊断，在控制了已知的危险因素后，如癌症分期、治疗、 患者年龄和慢性病(目标2)。最后，我们将调查差异的可修改的驱动因素 通过检查诊断前和诊断后的护理模式来确定诊断为紧急情况的患者 预防机会和改善结果(目标3)。我们高效的书房设计使用 流行病学方法分析180万人的高质量、基于人口的SEER-Medicare数据， 被诊断为食道癌、胃癌、结肠癌/直肠癌、肝癌、胰腺癌、肺癌、 乳腺、子宫、卵巢、前列腺、膀胱、肾脏、非霍奇金淋巴瘤、骨髓瘤和白血病。这个 调查小组包括癌症流行病学、医疗保健服务、癌症健康差距、 医学社会学、肿瘤学、家庭医学和急诊医学。这将是第一次大规模的研究 美国的紧急癌症诊断建立了关于这一重要问题的证据基础， 包括受影响的人、受影响的地点和原因，将阐明一个基本上未被认识到的问题，并确定可修改的 预后最差的患者的差异的驱动因素。

PROJECT SUMMARY/ABSTRACT Cancer is a common diagnosis in the emergency department (ED) and by the time patients reach the ED, their cancer has often progressed to later stages. EDs are not intended to diagnose cancer. Training in cancer management is limited for ED physicians, and patient access to follow-up care after a visit to the ED is often difficult. Research from other western countries tells us that, compared to non-emergency settings, cancer diagnosis through the ED is an independent predictor for worse outcomes, including poorer overall survival. Very little is known about emergency diagnosis of cancer in the United States (U.S.). From a handful of studies conducted in a few cancer types, we know that up to 30% of cancer patients are diagnosed as emergencies, and low income and racial/ethnic minority patients are substantially more likely to be affected. However, across different cancer types, the burden and risk factors of cancer diagnosis as an emergency have not been studied. Furthermore, no population-based studies in the U.S. have compared survival differences in patients with cancers diagnosed in EDs vs other non-emergent settings. And among those who are diagnosed as emergencies, it is unclear why they visited the ED, rather than going to a primary care provider for their diagnosis. Our long term goal is to establish the epidemiology of emergency cancer diagnosis in the U.S. We will describe the burden of cancer diagnosis in the emergency department including the patient characteristics of those most affected and quantify disparities across vulnerable populations defined by socioeconomic status, race/ethnicity, and geographic isolation (Aim 1). We will estimate the relative importance of ED (compared to non-ED) diagnosis on patient survival, after controlling for known risk factors like cancer stage, treatment, patient age and chronic conditions (Aim 2). Finally, we will investigate modifiable drivers of disparities among patients diagnosed as emergencies by examining their pre- and post-diagnostic patterns of care to identify opportunities for prevention and improved outcomes (Aim 3). Our highly efficient study design uses epidemiologic methods to analyze high-quality, population-based SEER-Medicare data for 1.8 million, Americans who were diagnosed cancers of the esophagus, stomach, colon/rectum, liver, pancreas, lung, breast, uterus, ovary, prostate, bladder, kidney, non-Hodgkin’s lymphoma, myeloma, and leukemia. The investigative team includes experts in cancer epidemiology, healthcare delivery, cancer health disparities, medical sociology, and oncology, family, and emergency medicine. This will be the first large-scale study of emergency cancer diagnosis in the U.S. Establishing a base of evidence about this important problem, including who is affected, where, and why, will illuminate a largely unrecognized issue, and identify modifiable drivers of disparities in patients with the poorest prognoses.