Linkage to care outcomes for patients in the emergency department referred to a cancer diagnostic program.
Authors: Nimgaonkar Vivek , Rhinehart Dena , Reeb Kristen , Balasubramaniyan Kumar , Murphy Jacob , Parma Mitchell , Feliciano Josephine Louella 
Published: September 2024

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Background:
An estimated 20-50% of patients receive a cancer diagnosis in the emergency department (ED), and a disproportionate share come from minority or lower socioeconomic backgrounds. A new suspected diagnosis of cancer is a critical time for patients and our institution implemented a novel cancer diagnostics program (CDP) to help with diagnosis and linkage to care. The CDP includes a multidisciplinary team and performs outreach after receipt of a referral, coordinating expedited diagnostic work-up and establishment of oncologic care. Here, we explore linkage to care outcomes, including implications for racial equity in access to care.
Methods:
A retrospective review was conducted for all patients referred from any ED to the Johns Hopkins CDP for suspected cancer from Aug 2021 to Dec 2023. Electronic health record data were manually extracted including demographics and linkage to care outcomes. National area deprivation index (ADI) score was collected using the University of Wisconsin Neighborhood Atlas. A comparison of time to oncologic visit between White and Black patients was performed with the Mann-Whitney test.
Results:
From Aug 2021 to Dec 2023, 52 patients were referred from the ED to the CDP. Median age was 58 (IQR: 48-68.25); 23 (44.2%) patients were female. 23 (44.2%) were Black. Of the 52 patients referred, 88.5% were successfully contacted by the CDP with median time to contact of 4 days (IQR 2-8). 76.9% of patients were confirmed to have malignancy (47.5% of whom had stage IV disease at diagnosis), while 23.1% had benign findings. Of those with malignancy, 87.5% were successfully contacted by the CDP; all of those contacted were successfully referred to an oncologic provider, with an attendance rate of 91.5% and median time to appointment of 22 days (IQR: 13-29.75). Of the patients referred to the CDP, 25.0% had an ED visit and 17.3% had a hospitalization within 30 days related to the suspected malignancy. Time to oncologic appointments were similar between Black and White patients with malignancy referred to the CDP (median for White patients: 20.5 vs. Black: 24.0; Mann-Whitney p= 0.35).
Conclusions:
Despite high proportions of minority patients and disadvantaged socioeconomic factors, the CDP had high rates of success in linking patients seen in the ED to outpatient oncologic care. In particular, Black and White patients had similar times to first oncologic appointment. This hypothesis-generating work demonstrates both the need and one potential intervention to improve access to outpatient care for this vulnerable population.

Select demographics and clinical data for patients referred from the ED to the CDP.

Selected Demographics (N =52)

Race, N (%)
White Black Other
18 (34.6) 23 (44.2) 11 (21.1)

Primary insurance coverage, N (%)
Medicare Medicaid Private Self-pay
22 (42.3) 1 (1.9); 11 (21.2) with secondary Medicaid coverage 24 (46.2) 4 (7.7)

ADI, median (IQR)

53.5 (27.0, 76)

Employed, N (%)

23 (45.1)