Transferred and delayed care of patients with colorectal cancer in a safety-net hospital system--manifestations of a distressed healthcare system

Abstract

Background: 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.

Results: 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.

Conclusions: 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.

Figure 1.

Overview of the Parkland and Presbyterian health systems. The numbers provided are estimates based on 2007 information. Numbers provided have been rounded for ease of reporting.

Figure 2.

Distribution of patients with CRC at PHHS (a) and Presbyterian (b) by age group. Bars represent the total number of patients in each age group. Lines represent the number of patients within each age group with early and late stage CRC. The total number of patients with early and late stage CRC within each age group are provided in the tables below each graph. The sum of early and late stage CRCs does not equal the total because some patients had unknown staged CRC.