Transferred and Delayed Care of Patients with Colorectal Cancer in a Safety-Net Hospital System—Manifestations of a Distressed Healthcare System
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Safety-net hospital systems provide care to a large proportion of United States’ under- and uninsured population. We have witnessed delayed colorectal cancer (CRC) care in this population and sought to identify demographic and systemic differences in these patients compared to those in an insured health-care system.
Design, Patients, and Approach/Measurements
We collected demographic, socioeconomic, and clinical data from 2005–2007 on all patients with CRC seen at Parkland Health and Hospital System (PHHS), a safety-net health system and at Presbyterian Hospital Dallas System (Presbyterian), a community health system, and compared characteristics among the two health-care systems. Variables associated with advanced stage were identified with multivariate logistic regression analysis and odds ratios were calculated.
Three hundred and eighteen patients at PHHS and 397 patients at Presbyterian with CRC were identified. An overwhelming majority (75 %) of patients seen at the safety-net were diagnosed after being seen in the emergency department or at an outside facility. These patients had a higher percentage of stage 4 disease compared to the community. Patients within the safety-net with Medicare/private insurance had lower rates of advanced disease than uninsured patients (25 % vs. 68 %, p < 0.001). Insurance status and physician encounter resulting in diagnosis were independent predictors of disease stage at diagnosis.
A large proportion of patients seen in the safety-net health system were transferred from outside systems after diagnosis, thus leading to delayed care. This delay in care drove advanced stage at diagnosis. The data point to a pervasive and systematic issue in patients with CRC and have fundamental health policy implications for population-based CRC screening.
- Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008: CA.2007.0018.
- Ransohoff, DF, Sandler, RS (2002) Clinical practice. Screening for colorectal cancer. N Engl J Med 346: pp. 40-4 CrossRef
- Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008; 149(9): 627–37.
- CDC: Behavioral Risk Factor Surveillance System Survey Data. In: (CDC) CfDCaP, ed. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2007.
- Seeff, LC, Nadel, MR, Klabunde, CN (2004) Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 100: pp. 2093-103 CrossRef
- Meissner, HI, Breen, N, Klabunde, CN, Vernon, SW (2006) Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev 15: pp. 389-394 CrossRef
- Wardle, J, McCaffery, K, Nadel, M, Atkin, W (2004) Socioeconomic differences in cancer screening participation: comparing cognitive and psychosocial explanations. Soc Sci Med 59: pp. 249-61 CrossRef
- Cairns, CP, Viswanath, K (2006) Communication and colorectal cancer screening among the uninsured: data from the Health Information National Trends Survey (United States). Cancer Causes Control 17: pp. 1115-25 CrossRef
- Denberg, TD, Melhado, TV, Coombes, JM (2005) Predictors of nonadherence to screening colonoscopy. J Gen Intern Med 20: pp. 989-95 CrossRef
- Farmer MM, Bastani R, Kwan L, Belman M, Ganz PA. Predictors of colorectal cancer screening from patients enrolled in a managed care health plan. Cancer 2008; 112(6):1230–8.
- Fernandez, ME, Wippold, R, Torres-Vigil, I (2008) Colorectal cancer screening among Latinos from U.S. cities along the Texas–Mexico border. Cancer Causes Control 19: pp. 195-206 CrossRef
- Geiger TM, Miedema BW, Geana MV, Thaler K, Rangnekar NJ, Cameron GT. Improving rates for screening colonoscopy: Analysis of the health information national trends survey (HINTS I) data. Surg Endosc 22(2):527–33.
- Ko, CW, Kreuter, W, Baldwin, LM (2005) Persistent demographic differences in colorectal cancer screening utilization despite Medicare reimbursement. BMC Gastroenterol 5: pp. 10 CrossRef
- Lewin M, Altman S, eds. America's Health Care Safety Net: Intact but Endangered: Washington, DC: Institute of Medicine, National Acadamies Press, 2000.
- Goodman, MJ, Ogdie, A, Kanamori, MJ, Canar, J, O'Malley, AS (2006) Barriers and facilitators of colorectal cancer screening among Mid-Atlantic Latinos: focus group findings. Ethn Dis 16: pp. 255-61
- Devoe, JE, Baez, A, Angier, H, Krois, L, Edlund, C, Carney, PA (2007) Insurance + access not equal to health care: typology of barriers to health care access for low-income families. Ann Fam Med 5: pp. 511-8 CrossRef
- Fiscella, K, Holt, K (2007) Impact of primary care patient visits on racial and ethnic disparities in preventive care in the United States. J Am Board Fam Med 20: pp. 587-97 CrossRef
- Powell-Griner, E, Bolen, J, Bland, S (1999) Health care coverage and use of preventive services among the near elderly in the United States. Am J Public Health 89: pp. 882-6 CrossRef
- Sambamoorthi, U, McAlpine, DD (2003) Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women. Prev Med 37: pp. 475-84 CrossRef
- Sudano, JJ (2003) Baker DW: Intermittent lack of health insurance coverage and use of preventive services. Am J Public Health 93: pp. 130-7 CrossRef
- The Uninsured in Texas. 5/5/2008 ed: Texas Medical Association, 2008.
- Examination and treatment for emergency medical conditions and women in active labor. 131: S13902-S13904. Congressional Record: Congressional Record, 1985.
- Ansell, DA, Schiff, RL (1987) Patient dumping. Status, implications, and policy recommendations. JAMA 257: pp. 1500-2 CrossRef
- Schiff, RL, Ansell, D (1996) Federal anti-patient-dumping provisions: the first decade. Ann Emerg Med 28: pp. 77-9
- Schiff, RL, Ansell, DA, Schlosser, JE, Idris, AH, Morrison, A, Whitman, S (1986) Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med 314: pp. 552-7 CrossRef
- Sloane, D (2009) Cancer epidemiology in the United States: racial, social, and economic factors. Methods Mol Biol 471: pp. 65-83 CrossRef
- Halpern MT, Pavluck AL, Ko CY, Ward EM. Factors Associated with Colon Cancer Stage at Diagnosis. Dig Dis Sci 2009; 54: 2680–93.
- Halpern, MT, Ward, EM, Pavluck, AL, Schrag, NM, Bian, J, Chen, AY (2008) Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol 9: pp. 222-31 CrossRef
- Ward, E, Jemal, A, Cokkinides, V (2004) Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 54: pp. 78-93 CrossRef
- Rapid Response Surveillance Studies. National Cancer Institute.
- American Community Survey: Accuracy of the Data. In: Bureau USC, ed.
- Carrasquillo, O, Pati, S (2004) The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States. Prev Med 39: pp. 943-50 CrossRef
- Korda RJ, Butler JRG, Clements MS, Kunitz SJ. Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality. Int J Epidemiol 2007; 36(1):157–65.
- Asch, SM, McGlynn, EA, Hogan, MM (2004) Comparison of quality of care for patients in the veterans health administration and patients in a national sample. Ann Intern Med 141: pp. 938-945
- Parkland Hospital. Parkland Hospital at a Glance: Who We Are. http://www.parklandhospital.com/whoweare/at_a_glance/. Accessed April 4, 2012.
- Pestonjee S et al. The Reading Level Determination Study: Parkland Health & Hospital System. Parkland Health & Hospital System, 1998. http://www.parklandhospital.com/patients_visitors/health_information/pdf/Rdg%20Stdy%20Abstr.pdf. Accessed April 12, 2012.
- DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2007. U.S. Census Bureau, Current Population Reports. Washington, DC: U.S. Government Printing Office, 2008; 60–235.
- Bundorf, MK, Pauly, MV (2006) Is health insurance affordable for the uninsured?. J Health Econ 25: pp. 650-73 CrossRef
- Healthy people 2010: understanding and improving health. US Government Printing Office, Washington, DC
- Transferred and Delayed Care of Patients with Colorectal Cancer in a Safety-Net Hospital System—Manifestations of a Distressed Healthcare System
Journal of General Internal Medicine
Volume 27, Issue 9 , pp 1142-1149
- Cover Date
- Print ISSN
- Online ISSN
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- heath disparity
- health policy
- populations at risk
- Industry Sectors
- Author Affiliations
- 1. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-8887, USA
- 2. Performance Improvement and Patient Safety, Parkland Health and Hospital System, Dallas, TX, USA