Transferred and Delayed Care of Patients with Colorectal Cancer in a Safety-Net Hospital System-Manifestations of a Distressed Healthcare System
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.
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.
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.
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ABSTRACT: Safety-net hospitals provide a disproportionately large share of the medical care to uninsured and vulnerable patients. For those who use these hospital systems merely as institutions of last resort, there would be little reason to believe that they could indeed be receiving the safest, highest quality health care because safety-net hospitals are a role model of health care reform and the high quality delivery of care. However, there is increasing evidence, albeit not yet conclusive, that these critically important hospitals do indeed provide high quality, safe and low-cost health care. Although America’s health care systems have not achieved the desired level of quality and safety as exhorted by the Institute of Medicine’s seminal writings in the late 1990s, Denver Health, an integrated public safety-net institution, has developed a multifaceted structured approach to patient safety and quality, which has garnered much national recognition for Denver Health during the last decade. Herein is described this safety-net hospital’s structured model for achieving patient safety and quality. The Denver Health experience demonstrates that care quality and patient safety can be advanced within America’s health care institutions, even in safety-net hospitals which, remain challenged by lack of resources and by socially disadvantaged patients.
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ABSTRACT: The authors review the history and motivations behind medical repatriation, the transfer of undocumented patients in need of subacute care to their country of origin. They argue that involuntary medical repatriation violates the ethical duties of health care providers.
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