Here, we have identified a distressing issue in U.S. healthcare—that of delayed and transferred care for an important medical condition, namely CRC. In patients with CRC in a safety-net health system, we found that there was a striking delay in presentation (i.e., with advanced stage disease in a presumably preventable cancer) and a pervasive transfer of care to the safety-net facility; 75 % of patients with CRC at the PHHS were either transferred to this facility or presented through the ED, typically after being seen at an outside facility and being instructed to present to the PHHS for further care.
The cause of the shift of care to the PHHS is likely to be highly complicated, and could be due to a number of factors. For example, one possibility was that advanced CRC patients were referred to the Parkland Health System because it was in fact serving as a safety net system for uninsured individuals (Table ), and was thus functioning as intended. Whether appropriate or not, patients were transferred to Parkland. This process has some analogies to “dumping” of patients from one system to another for financial reasons. However, it is important to emphasize that it is virtually impossible to prove that “dumping” due to financial motives occurred. Secondly, what is considered dumping by one person, may be considered appropriate transfer of care by another. In its classic sense, dumping or unprincipled transfer of a patient from one hospital to another for financial reasons22
most often refers to transfer of an unstable patient from one emergency room to another. Its practice led to enactment of the Emergency Medical Treatment and Active Labor Act (EMTALA).23–25
Regardless of the motivation for the pervasive transfer of care depicted here, this practice appears to have many downstream effects, including confusion and disorganization on the part of the patient and family, likely resulting in fracture and splintering of care, and ultimately delay in care.
Our finding that 34 % of patients in PHHS had stage 4 CRC, compared to only 16 % of patients in the Presbyterian system (p
0.001) is consistent with previous literature indicating a differential burden of cancer in certain populations, including racial and ethnic minorities and the medically underserved.26–31
As might be predicted, PHHS patients were more likely to belong to an ethnic minority group and were more likely to be uninsured or have Medicaid when compared to patients at a community health system. The finding of far greater late stage disease in the Parkland cohort raises many issues about the cause for this disparity. On one hand, there may be socioeconomic factors at play (i.e., differences in education leading to differences in environmental risk). On the other hand, there may be inherence differences in the biology of CRC in different races. Indeed, since approximately one-half of those with late stage disease were black, we cannot exclude the possibility that blacks may possibly have biologically more aggressive CRC.
When examining transferred care, we found that 75 % of patients were diagnosed with CRC and/or established care for CRC treatment after referral from an outside facility to PHHS or a PHHS emergency room visit. In most instances, these patients were not established PHHS patients. In many safety net systems, including the local PHHS, there is no direct method for physicians in the community to directly set-up follow-up. This leaves patients without a reasonable approach to access the safety-net system. While some may argue that care for un- and under-insured individuals is the responsibility of the safety-net system, it is also likely that asking patients to transfer care (typically without good communication), poses a burden on the patient to independently navigate multiple health systems.
There are several opportunities to enhance transfer of care between patients seen in different health systems, some of which might have helped improve the care of patients in this study. For example, the PHHS could provide urgent clinic appointment slots for certain types of disorders (i.e. such as cancer), and publicize these within the region. Further, previous studies have demonstrated that awareness of a safety-net healthcare system improves care among minorities.32
Additionally, a nationalized healthcare system could improve care; other such systems have resulted in decreased mortality of socioeconomically disadvantaged persons.33
Finally, integrated health systems such as the Veteran’s Administration system may to lead to higher quality of care compared to community health systems.34
We recognize limitations of our study. First, we examined only one safety net system, and one comparison system. It is possible that these are not representative of other national entities. However, both are both large and situated in a major urban area, so we speculate that they are representative. Additionally, we lacked individual-level data on measures of socioeconomic status, specifically education and income. However, our cohort matches closely previously published studies examining Parkland in terms of demographics (i.e., age, gender, education level, etc…)35,36
and thus is likely reflective of the safety net. Additionally, education and income often correlate with lack of insurance.37–39
Since we collected race data based on self-report, we may have underestimated the number of Hispanic patients in both populations. As race did not appear to be a significant factor in outcomes at either hospital, it appears unlikely that the results were systematically biased by the self-reporting of race. Finally, there is potential for unmeasured confounding variables, perhaps related to local physician practices or patient behaviors.
In summary, we have identified several novel issues related to transfer of care and underutilization of primary care services in patients with CRC. Importantly, patients from outside of a safety-net hospital had care transferred when it became evident that they had cancer, possibly because they did not have funding with which to pay private physicians and hospitals, emphasizing a syndrome of “delayed care”. While not surprising, this phenomenon has been poorly documented previously. Thus, investments in access to care for at-risk populations, particularly Medicaid and uninsured patients may have substantial benefits in terms of morbidity, mortality, quality of life, and even healthcare costs.