a b s t r a c t

Background: 11% of new cancer diagnoses occur in the emergency department. Historically, these diagnoses disproportionately affect underserved patient populations and are associated with poor outcomes. This is an ob- servational study of the Rapid Assessment Service (RAS) program, which aims to provide timely outpatient follow-up and facilitate a diagnosis for patients discharged from the emergency department with suspected malignancies.

Methods: We performed a retrospective chart review of 176 patients who were discharged from the emergency department with RAS clinic follow up between February 2020 and March 2022. We manually chart reviewed 176 records in order to determine the average time to RAS clinic appointment, average time to diagnosis, and the final diagnosis based on biopsy.

Results: 163 of 176 patients (93%) discharged to RAS received reliable follow-up care. 62 of the 176 patients (35%) followed up in the RAS clinic with a mean of 4.6 days. 46 of the 62 patients (74%) who followed up in the RAS clinic were ultimately diagnosed with a new cancer, with a mean time to diagnosis of 13.5 days. The leading new cancer diagnoses included: lung, ovarian, hematologic, head and neck, and renal cancers.

Conclusions: Creating a Rapid Assessment Service facilitated an expedited oncologic work-up and diagnosis in an Outpatient setting.

(C) 2023

1. Introduction

Emergency Department (ED) patients often undergo a variety of tests, including diagnostic imaging and blood tests, enabling emergency physicians to make new diagnoses in a single ED visit. As a result, 11% of new cancer diagnoses in the United States occur in the ED [1]. patients with cancer diagnosed in the ED disproportionately tend to be minori- ties, from Lower socioeconomic status, and have multiple medical co- morbidities when compared to patients with cancer diagnosed elsewhere [3,7]. Furthermore, cancer diagnosed in the ED tends to be more advanced than cancers diagnosed through routine screening or in a Primary care setting and are often associated with higher Disease burdens [2].

Managing the disposition of patients with a suspected underlying malignancy can be a nuanced and challenging process. Even though lab- oratory and radiology tests performed during a patient’s ED stay may be

* Corresponding author at: Department of Emergency Medicine, 965 48^th St. Brooklyn, NY 11219, USA.

E-mail address: [email protected] (J. Drapkin).

concerning for a malignancy, most of these patients are stable and safe for Discharge home and further outPatient evaluation. The emergency physician must convey the Clinical concern for the potential cancer diag- nosis to patients and coordinate follow-up care to facilitate rapid diag- nosis and treatment. Without a predefined and easily accessible outpatient pathway, patients with suspected new cancer diagnoses may have difficulty arranging follow up for various reasons, including being underinsured, language barriers, appointment availability, or medical literacy. Thus, they may be admitted with the goal of providing more rapid diagnostic care and treatment even though they may be stable enough for discharge.

While there are no broadly used guidelines for timing of referral to a specialist in the US, it is generally accepted that patients should follow up as soon as possible. In the UK, providers request a “two week wait” referral for patients to ensure rapid follow-up with a cancer specialist [3]. A study from the Netherlands found that time to specialist referral ranged from 0 days for breast cancer to 14 days for Lung cancer [4]. A similar study of clinics in Australia, Canada, and several northern European countries found referral times from 1 day for breast cancer to 14 days for prostate cancer [5]. Patients can be lost to follow up

https://doi.org/10.1016/j.ajem.2023.04.048

0735-6757/(C) 2023

immediately following their diagnosis of a potential malignancy. One cancer fast-track program in Spain found that 6.5% of the 4493 patients referred to a cancer specialist did not attend the specialty appointment [6].

To our knowledge, there are no studies on programs in the US de- signed to facilitate quick follow up for cancer care. There is also little data on the current mean times to outpatient follow up for cancer evaluation after ED referral.

This program aimed to describe a newly created Rapid Assessment Service and its performance for our patients.

1. Methods
   1. Study setting

The objective of the Rapid Assessment Service (RAS) is to arrange timely follow up, diagnosis, and treatment for ED patients with suspected malignancies. Prior to the initiation of the RAS clinic, patients with a new potential malignancy were either referred to their primary care physicians upon discharge from the ED or admitted for diagnostic evaluation.

Through a partnership through the departments of Emergency Medicine and Oncology, Maimonides Health started the RAS clinic in February 2020. Patients with suspected malignancies who do not meet admission criteria are discharged by the ED provider with follow-up to the RAS clinic. Once the referral is placed in the system, ad- ministrators from the clinic contact patients by phone to schedule ap- pointments, targeting a follow up visit within two business days after ED presentation. If unable to reach patients by phone, the RAS team subsequently sends a letter by mail, restating the need for urgent follow up. The team also contacts the patient’s primary care when possible to coordinate follow up. If this also fails, patients are flagged as “lost to follow up.”

The RAS is a multidisciplinary clinic including oncologists and Family Medicine providers, offering comprehensive screening, diagnostic, and treatment services for: brain and spinal tumors, breast cancer, Colorectal cancer, gastrointestinal cancer, gynecological cancers, head and neck cancers, leukemia and lymphoma, lung and thoracic cancers, melanoma and other dermatologic cancers, sarcomas and other orthopedic can- cers, pediatric cancers, and prostate and other urologic cancers. The clinic facilitates all aspects of a patient’s malignancy work-up, including: arranging additional imaging or laboratory testing, coordination of bi- opsies, and referral to an appropriate surgical or oncologic subspecialist.

• 1. Study design

This is a retrospective observational study of patients discharged from the ED with follow up at the RAS clinic from February 2020 to March 2022.

• 1. Selection of participants

Patients older than 18 years of age who had suspected malignancies based on ED evaluation, were medically stable at the time of ED dis- charge, and received a RAS referral were included in the study. Patients with suspected Underlying malignancies who met criteria for medical admissions or known cancer diagnoses were not included in the study.

• 1. Methods of measurement

Since clinic inception in February 2020, the RAS clinic administrators have maintained a list of all patients referred to the clinic via the emer- gency department and Primary care clinics. The reviewers used this dataset to identify all the patients eligible for the retrospective study. In the list, the RAS team kept records of final diagnoses and biopsy re- sults, along with descriptions of where each patient followed up if

they received care outside of the Maimonides Health system. Further- more, some patients who were referred were already aware of the on- cologic diagnoses and had previously established care outside of Maimonides. Some patients with new diagnoses opted to seek care at another institution. Lastly, clinic administrators also recorded important dates for each referral, including the referral date, appointment date, and the final diagnosis date. All patient information was de-identified in the dataset.

Three independent reviewers performed the quantitative data anal- ysis using the RAS dataset. The RAS clinic administrators were not involved in the data analysis. Reviewers were not blinded to the fact that patients were referred to the RAS clinic.

The reviewers met in advance to standardize the outcome metrics. We looked at the following parameters: mean time to follow-up ap- pointment, mean time to diagnosis, type of follow-up, and final diagno- ses. The type of follow-up looked at the location, broken down by lost to follow-up, declined to follow-up, and reliable follow-up outside of Maimonides Health, and RAS clinic follow-up.

“Lost to follow-up” was defined as being unable to reach the patient by telephone or mail after multiple attempts made by the RAS clinic. “Declined follow-up” was defined as when the patient was successfully reached by telephone and made aware of concerning findings but de- clined to further work up the case after the initial referral by the emer- gency department. Reliable follow-up outside of RAS was if a RAS clinic coordinator directly spoke to the patient and confirmed that the patient was meeting with an oncologist outside of the Maimonides system.

We used Excel to calculate the mean time to follow-up and time to diagnosis for the patients referred through the ED. The reviewers also had met to establish a Coding system for the “type of follow-up care” pa- rameter. This information was captured in the dataset in text. In cases of uncertainty, the reviewer correlated the MRN with the EMR to confirm follow-up location by looking at chart notes.

The dataset listed “yes or no” for the final diagnosis section by pa- tient. This column was used to calculate the incidence of cancer from the dataset through Excel. Furthermore, the dataset included the type of cancer. To verify the final cancer type, the reviewers manually corre- lated the positive cases with the laboratory, imaging, and pathology results through chart review.

Ultimately, a final reviewer grouped the types of cancers by ana- tomic region to perform the final abstraction. Gastrointestinal included colon, stomach, and liver cancers. Genitourinary cancers included renal, prostate, and bladder. Gynecologic cancers included ovarian and uterine.

• 1. Outcomes

Data obtained included the date of ED visit, follow up provider, date of outpatient follow up, time and nature of initial diagnostic tests, and final diagnosis. The number of patients lost to follow up was also obtained.

• 1. Primary analysis

Data was organized on Microsoft Excel. Calculations such as the days to follow up and to Cancer diagnosis were made within the software.

Some data was missing for patients who were lost to follow up. For those who did not follow up at the RAS clinic, it is possible that some of them followed up with their own primary medical doctor or special- ist. Other patients who verbalized that they would seek specialist care elsewhere were not followed up on and could not have been confirmed to have made their appointments.

1. Results

Between February 2020 and March 2022, 176 patients received RAS referrals from the emergency department (See Table 1).

Table 1

Follow up rates, diagnoses, and types of new cancers.

Type of follow-up care Total patients referred to RAS

n = 176

Percent %

these high risk patients, ultimately providing a benefit to both patients and their physicians. Rapid follow up reassures patients.

The RAS program ensured that 163 of the 176 (93%) patients re- ferred to the RAS clinic had reliable follow-up. Ultimately, 46 of the 62

Lost to follow-up 11 6%

Reliable follow-up outside of RAS 103 59%

Followed up at RAS clinic 62 35%

Declined follow-up 2 1%

(74%) patients who followed up at the RAS clinic were given a new cancer diagnosis. The mean time to the RAS appointment was

4.6 days, resulting in an mean time to diagnosis of 13.5 days. These numbers do not factor weekends or holidays, so we suspect the mean

Final diagnosis Total patients seen in RAS clinic

n = 62

Percent %

time to follow-up in business days is lower. In addition to coordination of medical care, the RAS team also provided social services to ensure all

Not Cancer 14 23%

Cancer 46 74%

Known cancer diagnosis 2 3%

Types of new cancers Cancers diagnosed through RAS Percent %

n = 46

Lung	9	20%
Gynecologic	9	20%
Gastrointestinal tract	9	20%

Genitourinary 8 17%

Hematologic 5 11%

Head & neck 3 7%

Breast 2 4%

Dermatologic 1 2%

• 1. RAS referral follow-ups

We determined that 163 of the 176 (93%) patients referred to RAS had reliable follow-up appointments. 11 of 176 (6%) patients were lost to follow-up after the RAS referral since the RAS was unable to reach them, and 2 of the 176 patients (1%) declined follow-up appoint- ments since they did not wish to pursue work-ups given their ages and goals of care.

62 of the 176 (35%) patients discharged with RAS follow-up chose to go to the RAS clinic. 103 of the 176 patients (59%) chose not to follow-up at the RAS clinic. These patients already had established care with oncol- ogists or chose to follow up with their primary care physicians to go through another hospital system.

• 1. Time to-follow-up

Overall, the mean time to follow up with the RAS was 4.6 days, with a 95% confidence interval [0, 14.5 days.] 26 of the 62 patients (42%) were evaluated within two days. This number includes weekends and holidays.

• 1. Time to diagnosis

The mean time to diagnosis through RAS clinic was 13.5 days with a 95% confidence interval [0, 41.7 days]. This number includes weekends and holidays.

• 1. New cancer diagnoses through RAS

Of the 62 patients who followed up at the RAS clinic, 46 (74%) were determined to have new cancer diagnoses based on the pathology re- sults. 2 of the 62 patients (3%) already had known cancer diagnoses. 14 of the 62 (23%) patients were determined to not have cancer after their workups. Some of these diagnoses were consistent with benign growths.

1. Discussion

A potentially new diagnosis of cancer is unfortunate and all too fre- quent result from an emergency department visit. Through thoughtful design and close collaboration, emergency and oncology departments can develop programs to ensure timely and appropriate follow-up for

patients had appropriate insurance coverage. 2 of the 62 (3%) patients who had known cancers diagnoses and were already following up outside of the Maimonides Health system.

11 of the 176 patients (6%) were lost to follow up and were unable to be reached. Some of the reasons behind the “lost to follow-up” status in- clude incorrect contact information and patients not picking up the phone. The RAS team called these patients, left voicemails, sent letters to their home addresses, and reached out to the patient’s primary care physician when available. Efforts to reduce the number of patients lost to follow up could include verifying contact prior to discharge and in- creasing the availability of interpretation services for phone calls made from the RAS program.

Past research about ED-mediated cancer treatment has focused on the morbidity and mortality of these diagnoses and the median survival times for patients who present with cancer-related complications or symptoms to ED.

However, there are limited data about the average time to follow-up, time to diagnosis, and time to treatment initiation of ED-mediated cancer diagnoses. Future studies can look at patient outcomes after the initiation of this program and follow them through cancer diagnosis and treatment, tracking Morbidity and mortality rates. In addition, fu- ture studies can analyze demographic differences, the severity of initial disease and clinical outcomes for this cohort of cancer patients who receive initial diagnoses in the ED when compared to a cohort that presents through primary care offices.

Further research could also explore patient outcomes when given

expedited care through the Emergency Department as well as looking at patient satisfaction data about this program. We also hope to do a subsequent qualitative analysis looking at patients’ attitudes of the pro- gram. Continued efforts are under way to promote greater awareness of the RAS program among ED staff and ensure all suspected cancer patients have appropriate follow-up.

1. Conclusions

Creating a RAS facilitates oncologic work-up while prioritizing pa- tient comfort in an outpatient setting. This allows for a more compas- sionate clinical care model. This service allows providers to safely discharge vulnerable patients, and it reassures patients that they will re- ceive timely care after being given potentially life-changing news in the emergency department.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Sabena Vaswani: Writing – review & editing, Writing – original draft, Resources, Methodology, Investigation, Data curation, Conceptu- alization. Christopher Kuhner: Writing – review & editing, Resources, Methodology, Investigation. Jason Xu: Writing – review & editing, Re- sources, Methodology, Investigation, Data curation. Eitan Dickman: Writing – review & editing, Supervision, Project administration, Methodology, Investigation. Kevin Becker: Writing – review & editing,

Resources, Methodology, Investigation, Data curation. Jefferson Drapkin: Writing – review & editing, Resources, Project administration. Michael Turchiano: Writing – review & editing, Writing – original draft, Supervision, Resources, Methodology, Investigation, Conceptualization.

Declaration of Competing Interest

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors have no independent disclosures or conflicts of interest.

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