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Patients with cancer are more likely to visit an emergency department (ED) than those without cancer, but data on the specific demographic and clinical features of these patients have been sparse.

A retrospective chart review of 658 patients diagnosed with pancreatic cancer between 2015 and 2021 showed that substance abuse (odds ratio 4.43) and Black race (HR 2.8) were the strongest predictors of recurrent ED visits. The analysis, presented at the , also found that 14% of the Black patients with pancreatic cancer had a history of substance abuse.

"Our analysis identified a striking and concerning association between high utilization of the ED and patients who are Black or who have a history of substance abuse," said Kristen M. John, a third-year medical student at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, and colleagues.

"Substance abuse may contribute to high ED utilization among Black Americans; however, 86% had no history of substance abuse, suggesting that other causal factors are at play," the researchers added. "These results compel further investigation into these casual factors to guide the development of health equity interventions to address these disparities."

Of the patients with pancreatic cancer seen across the Northwell Health system, 181 visited the ED more than three times, meeting the study criteria for high utilization. A total of 140 patients had no ED visits. Other predictors of high ED use included a median income of less than $125,000 (HR 1.43), having pancreatitis (HR 1.25), and age older than 80 (HR 1.12).

In the following interview, John, who led the study under the mentorship of Daniel King, MD, PhD, of the Institute of Cancer Research, Feinstein Institutes for Medical Research, Northwell Health, discussed the findings and ongoing research.

What does this study add to the literature?

John: Acute hospital care is one of the largest drivers of increased spending in advanced cancer care and is associated with a significant emotional and mental burden for patients and their families. Studies suggest that 30-60% of ED visits by cancer patients are preventable, but data are lacking on the factors that predispose some patients to recurrent ED use.

Our goal with this study was to better understand the characteristics of this population so that evidence-based interventional strategies can be developed to mitigate these unplanned hospital encounters.

Did any of your findings come as a surprise?

John: We weren't too surprised to find that drug abuse was a significant predictor of ED utilization as it may be associated with several other social determinants of health, may exacerbate disease progression, and lead to presentations requiring acute care.

However, while it is known that Black Americans disproportionately experience the highest incidence rates of pancreatic cancer across all ethnic and racial groups in the U.S., we did find it striking that Black patients with pancreatic cancer were 2.8 times more likely to have recurrent ED visits than their non-white counterparts. This disparity may reflect the larger disease burden experienced by Black patients with cancer in general, as they tend to be diagnosed at a later stage of disease and to have lower rates of surgical resection.

What is your main take-home message to clinicians?

John: We identified race and drug abuse as two independent factors associated with high ED utilization in patients with pancreatic cancer, but most patients presenting to the ED did not have any history of substance abuse. Our study highlights the need to further investigate and address additional causal factors.

The results of this study motivated a quality-improvement . We reached out to 14 Black patients with pancreatic cancer who had at least one ED visit over a 2-month period to get a better sense of the factors that may predispose them to higher rates of unplanned hospital care.

Of note, we found that half of the patients had already required a second ED visit during the span of this project, and through our analyses, we found various factors that highlight potential vulnerabilities in their social determinants of health.

What were these vulnerabilities?

John: Although 50% of these patients were unreachable at the phone number listed in their charts, 71% of those we were able to contact told us that their highest level of education was high school. In addition, 29% said they did not feel safe in their homes and communities; 14% reported not having any family support; and 57% said they were experiencing difficulty affording medical care.

Each of these factors could play a contributing role in the higher rates of recurrent ED visits we saw in this patient population.

Have there been any other developments?

John: We have since refined and expanded our pilot project. Currently, we are prospectively following Black patients with pancreatic cancer who visit the ED, using culturally tailored outreach to do so. After each ED visit, an African American oncology nurse practitioner phones the patient to evaluate healthcare vulnerabilities using questions based on the social determinants of health and the factors leading to the ED visit.

What's next?

John: We are continuing to apply for grants to fund this research. We would like to further clarify the most salient areas for evidence-based interventions that address the disparities predisposing this population to higher rates of unplanned hospital care.

Read the study here.