Pancreatic Cancer Surgery Following Emergency Department Admission: Understanding Poor Outcomes and Disparities in Care

Background: The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes. Study Design: The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008–2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status. Results: A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all p <.0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%, p <.0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%, p <.0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%, p <.0001) and had higher mortality (7.4% vs. 3.5%, p <.0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43–0.70)). Conclusion: Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.