Schwartz/Reisman Emergency Medicine Institute (Grewal), Sinai Health System; ICES (Grewal, Sutradhar, Krzyzanowska, Redelmeier, Atzema); University Health Network (Krzyzanowska); Sunnybrook Health Sciences Centre (Redelmeier, Atzema); Division of Emergency Medicine (Grewal, Atzema), Divisions of Medical Oncology and Hematology (Krzyzanowska), and Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto; Institute for Health Policy, Management & Evaluation (Sutradhar, Redelmeier, Atzema), University of Toronto, Toronto, Ont.
CMAJ. 2019 Apr 23;191(16):E436-E445. doi: 10.1503/cmaj.180962.
Patients with cancer have complex care requirements and frequently use the emergency department. The purpose of this study was to determine whether continuity of care, cancer expertise of an institution or both affect outcomes in patients with cancer in the emergency setting.
We conducted a retrospective cohort study using administrative databases from Ontario, Canada, involving records of patients aged 20 years and older who received chemotherapy or radiation in the 30 days before a cancer-related visit to the emergency department between 2006 and 2011. Patients seen in an emergency department at an alternative hospital (not the site where cancer treatment was given) were matched based on propensity score to patients who visited their original hospital (site where cancer treatment was given). Next, patients seen at an alternative emergency department that was in a general hospital (i.e., not a cancer centre) were matched to patients who visited their original hospital or a cancer centre. Outcomes were admission to hospital at the index visit to the emergency department, 30-day mortality, having imaging with computed tomography and return visits to the emergency department.
We found 42 820 patients who were eligible for our study. Patients seen in the emergency departments at alternative hospitals were less likely to be admitted to hospital (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.74-0.83) and had higher hazards of return visits to the emergency department than matched patients at original hospitals (hazard ratio [HR] 1.06, 95% CI 1.03-1.11). In comparison, patients at alternative general hospitals also had lower odds of admission to hospital (OR 0.83, 95% CI 0.79-0.88) and higher hazards of return visits to the emergency department (HR 1.07, 95% CI 1.03-1.11) compared with matched counterparts; however, these patients had higher 30-day mortality (OR 1.13, 95% CI 1.05-1.22) and lower odds of having CT imaging (OR 0.74, 95% CI 0.69-0.80).
Cancer expertise of an institution rather than continuity of care may be an important predictor of outcomes following emergency treatment of patients with cancer.
癌症患者的护理需求复杂，经常使用急诊部。本研究旨在确定在癌症相关急诊就诊前 30 天内接受化疗或放疗的患者中，连续性护理、机构的癌症专业知识或两者都对患者的结局有何影响。
我们使用来自加拿大安大略省的行政数据库进行了回顾性队列研究，涉及 2006 年至 2011 年间在癌症相关就诊前 30 天内接受化疗或放疗的 20 岁及以上患者的记录。在替代医院（非接受癌症治疗的医院）就诊的患者，根据倾向评分与在原医院（接受癌症治疗的医院）就诊的患者相匹配。接下来，在一般医院（即非癌症中心）就诊的替代急诊部的患者与在原医院或癌症中心就诊的患者相匹配。结果是在急诊就诊时住院、30 天死亡率、接受 CT 成像检查和急诊复诊。
我们发现了 42820 名符合研究条件的患者。在替代医院就诊的患者住院的可能性较低（优势比 [OR] 0.78，95%置信区间 [CI] 0.74-0.83），并且比在原医院就诊的匹配患者再次就诊急诊的风险更高（风险比 [HR] 1.06，95% CI 1.03-1.11）。相比之下，在替代综合医院就诊的患者住院的可能性也较低（OR 0.83，95% CI 0.79-0.88），再次就诊急诊的风险更高（HR 1.07，95% CI 1.03-1.11），但这些患者 30 天死亡率较高（OR 1.13，95% CI 1.05-1.22），CT 成像的可能性较低（OR 0.74，95% CI 0.69-0.80）。
机构的癌症专业知识而非连续性护理可能是癌症患者急诊治疗后结局的重要预测因素。
