title: Causes and outcomes of emergency presentation of rectal cancer.
abstract: Emergency presentation of rectal cancer carries a relatively poor prognosis, but the roles and interactions of causative factors remain unclear. We describe an innovative statistical approach which distinguishes between direct and indirect effects of a number of contextual, patient and tumour factors on emergency presentation and outcome of rectal cancer. All patients diagnosed with rectal cancer in Ireland 2004-2008 were included. Registry information, linked to hospital discharge data, provided data on patient demographics, comorbidity and health insurance; population density and deprivation of area of residence; tumour type, site, grade and stage; treatment type and optimality; and emergency presentation and hospital caseload. Data were modelled using a structural equation model with a discrete-time survival outcome, allowing us to estimate direct and mediated effects of the above factors on hazard, and their inter-relationships. Two thousand seven hundred and fifty patients were included in the analysis. Around 12% had emergency presentations, which increased hazard by 80%. Affluence, private patient status and being married reduced hazard indirectly by reducing emergency presentation. Older patients had more emergency presentations, while married patients, private patients or those living in less deprived areas had fewer than expected. Patients presenting as an emergency were less likely to receive optimal treatment or to have this in a high caseload hospital. Apart from stage, emergency admission was the strongest determinant of poor survival. The factors contributing to emergency admission in this study are similar to those associated with diagnostic delay. The socio-economic gradient found suggests that patient education and earlier access to endoscopic investigation for public patients could reduce emergency presentation.
authors.affiliation: National Cancer Registry, Cork, T12 CDF7, Ireland.
authors.forename: Harry
authors.initials: H
authors.lastname: Comber
authors.affiliation: Institute of Health & Society, Newcastle University, United Kingdom.
authors.forename: Linda
authors.initials: L
authors.lastname: Sharp
authors.affiliation: Division of Population Research, Brazilian National Cancer Institute, Rio De Janeiro, Brazil.
authors.forename: Marianna
authors.initials: M
authors.lastname: de Camargo Cancela
authors.affiliation: Social and Economic Consultant, Dublin, Ireland.
authors.forename: Trutz
authors.initials: T
authors.lastname: Haase
authors.affiliation: Health & Wellbeing Directorate Health, Intelligence Unit, Health Service Executive, Ireland.
authors.forename: Howard
authors.initials: H
authors.lastname: Johnson
authors.affiliation: Department of Economics and Statistics, University of Salerno, Salerno, Italy.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Pratschke
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004630:Emergencies; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D015994:Incidence; D007494:Ireland / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D063868:Patient Outcome Assessment; D011159:Population Surveillance; D016016:Proportional Hazards Models; D012004:Rectal Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology* / Q000628:therapy; D012042:Registries; D012307:Risk Factors
keywords: deprivation; emergency; insurance; rectal; survival