title: 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.
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Jessica P
authors.initials: JP
authors.lastname: Shah
authors.forename: Marisa
authors.initials: M
authors.lastname: Valdes
authors.forename: Don C
authors.initials: DC
authors.lastname: Rockey
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003695:Delivery of Health Care / Q000191:economics / Q000379:methods*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D054625:Healthcare Disparities / Q000191:economics; D006747:Hospital Communication Systems / Q000191:economics; D006801:Humans; D019458:Insurance Coverage / Q000191:economics; D008297:Male; D008875:Middle Aged; D061214:Patient Safety / Q000191:economics; D010360:Patient Transfer / Q000191:economics / Q000379:methods*; D013997:Time Factors