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The association of continuity of care and cancer centre affiliation with outcomes among patients with cancer who require emergency department care

Grewal K, Sutradhar R, Krzyzanowska MK, Redelmeier DA, Atzema CL. CMAJ. 2019; 191(16):E436-45. Epub 2019 Apr 23.


Background — 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.

Methods — 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.

Results — 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).

Interpretation — Cancer expertise of an institution rather than continuity of care may be an important predictor of outcomes following emergency treatment of patients with cancer. Cancer is one of the leading causes of mortality worldwide, and patients with cancer frequently use the emergency department. Previous studies have shown the importance of continuity of medical care to patient outcomes in certain patient populations. This may be particularly relevant for patients who are undergoing active treatment for cancer, because these patients have complex care requirements. Poor continuity of care, as a result of a visit to an emergency department at an alternative hospital (i.e., not the hospital where cancer treatment is received), could be associated with worse outcomes secondary to lack of familiarity with the patient’s course of illness. Information gaps owing to poor continuity of care may lead to treatment delays or receipt of duplicate or unnecessary investigations and treatment. Lack of subspecialized expertise could also be a factor in emergency department care: cancer expertise has been associated with better outcomes among patients who receive surgical and medical cancer care. Emergency departments without access to subspecialized cancer expertise may not be able to offer the same level of care. We aimed to determine whether continuity of care, cancer care expertise of the institution or both are associated with outcomes in patients with cancer in the emergency department setting.

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