Focusing on the Obvious,the Elephant: Livingood and Colleagues Respond

The editorial, ¹ “An Elephant—But not Just in the Emergency Room,” has a title that could reflect the underlying problems of excessive late-stage cancers being detected during emergency department (ED) visits, but the conclusions miss the point. The ED is only where the problem becomes obvious, the resulting symptom of broader systemic issues. This elephant ² that seems to be overlooked in the US health care system and shows up as symptoms in the ED is the poor outcomes related to the lack of early diagnosis and treatment for cancer, until an ED visit. Initial ED cancer diagnosis portends poor outcomes regardless of insurance status as our data suggest. However, the lack of access to early diagnosis, staging, and treatment of cancer for low-income patients without insurance is a plausible, if not obvious, explanation for the observed poor outcomes and gross disparities associated with ED-related initial cancer diagnosis. That is not to preclude many other factors from contributing to the observed disparities.

Mr. Duncan ¹ points to the high rate (49.1%) of patients with Medicare obtaining initial diagnosis through the ED as proof that insurance is not the problem, seeming to ignore the problem that low-income people without insurance may not try to get care until they are old enough or disabled enough to qualify for Medicare. Waiting until age 65 to obtain health care does not obviate the impact of lack of health insurance on low rates of early cancer diagnosis and treatment. As cancer becomes more prevalent with the aging process, and diagnosis and treatment can be expensive, if not prohibitive for low-income people without health insurance, high rates of initial ED-related cancer diagnoses might even be expected for Medicare clients served by a safety net hospital.

Our retrospective study simply pointed to a major problem that should be addressed but is relatively ignored—ED-associated initial cancer diagnosis. The problem may not even exist in other safety net hospitals serving low-income clients if the ED only treats the acute condition. Non-safety net hospital EDs, particularly those that do not accept Medicaid, may only treat legally required acute conditions without any follow-up diagnosis of suspected tumors. Providing non-ED-related cancer screenings without providing follow-up diagnosis and treatment would not alleviate the problem.

A multisite study would be required to establish generalizability of our findings to other safety net hospitals or hospitals in general, and a more prospective study would be needed to definitively clarify causality such as lack of access to early diagnosis and treatment because of lack of insurance. However, lack of access to early diagnosis and treatment should not be dismissed as a plausible cause of the observed phenomena (an elephant or obvious problem) in the ED because Medicare clients served by a safety net hospital also experience the problems of late-stage initial diagnosis through ED use. Given the importance of early diagnosis and treatment for controlling many forms of cancer, health systems would appear to be ignoring the obvious when trying to address disparities without addressing obvious barriers.