Emergency department presentation is an independent driver of mortality, complications, and disparities in Acute Myeloid Leukemia: A national propensity-matched Study

Abstract

Abstract Background Acute myeloid leukemia (AML) is an aggressive malignancy, so early diagnosis and timely therapy initiation are critical for survival. Presentation through the emergency department (ED) may reflect delays in care and limited access to outpatient hematologic evaluation. Using a nationally representative dataset, we aimed to assess the association between ED presentation and early mortality, complications, hospital resource use, and socioeconomic disparities.Methods We used the Nationwide Readmissions Database from 2016 to 2019 to identify adult patients hospitalized with newly diagnosed AML. Patients were classified based on their route of hospital admission, either through the ED or by elective admission. Propensity score matching was performed using a 1:1 nearest-neighbor approach, accounting for age, sex, primary payer, income quartile, hospital teaching status, hospital bed size, and Elixhauser Comorbidity Index (ECI). Primary outcomes included 30- and 90-day mortality. Secondary outcomes were length of stay (LOS), total hospitalization costs, and significant complications, including intensive care unit (ICU) admission, mechanical ventilation, and renal replacement therapy. Multivariable logistic regression and Kaplan-Meier survival analyses were used.Results Following matching, 4,112 AML patients were included in each cohort. ED presentation was associated with significantly worse survival. Thirty-day mortality was 13.6% in ED-admitted patients versus 9.8% in elective admissions, corresponding to an adjusted odds ratio (aOR) of 1.42 (95% CI: 1.18–1.70; p < 0.001). Ninety-day mortality was also elevated among ED patients at 21.2% versus 17.0% (aOR 1.27; 95% CI: 1.11–1.46; p < 0.001). Kaplan-Meier analysis demonstrated a significant survival disadvantage for ED patients over time (log-rank p < 0.001). ED presentation was associated with more extended median hospitalizations (11.4 vs. 8.7 days, p < 0.001) and higher total costs of care ($92,370 vs. $72,540; p < 0.001). Complication rates were also elevated in the ED group. ICU-level care was required in 45.3% of ED cases compared to 29.6% in the non-ED group (p < 0.001). In comparison, mechanical ventilation and dialysis occurred in 18.6% and 9.4% of ED patients, respectively, compared to 10.2% and 5.7% in the non-ED group (both p < 0.001). Socioeconomic disparities were evident. Patients without insurance had over twice the odds of death compared to those with private insurance (aOR 2.21; 95% CI: 1.74–2.81; p < 0.001), and Medicaid patients also had increased mortality risk (aOR 1.65; 95% CI: 1.32–2.06; p < 0.001). Patients in the lowest income quartile had significantly higher mortality than those in the highest (aOR 1.31; 95% CI: 1.10–1.57; p = 0.003). In contrast, admission to teaching hospitals and female sex were associated with reduced mortality (p < 0.01 for both). Comorbidity burden, measured via ECI, remained an independent predictor of death and complications across all models (p < 0.001).Conclusion ED presentation in AML is a powerful and independent predictor of short-term mortality, more severe inpatient complications, more extended hospital stays, and increased costs. These adverse outcomes disproportionately affect uninsured and publicly insured patients, as well as those from lower-income strata. Our findings reflect missed opportunities for earlier diagnosis and outpatient evaluation and point to the urgent need for system-wide interventions including expedited outpatient hematology referral pathways, improved diagnostic triage, and targeted support for vulnerable populations, to reduce preventable mortality and financial burden in AML care.Table 1 Outcomes of patients with AML presenting to the emergency department (ED) versus those admitted electively. Table 2. Baseline characteristics of patients with AML presenting to the emergency department (ED) versus those admitted electively. Outcomes Adjusted OR 95%CI P value 30-day mortality 1.42 1.18-1.70 <0.001 90-day mortality 1.27 1.11-1.46 <0.001 Insurance status Self pay 2.21 1.74-2.81 <0.001 Medicaid 1.65 1.32-2.06 <0.001 Income quartile Lowest 1.31 1.10-1.57 0.003 Baseline characteristic ED admission Elective admission P value Length of stay 11.4 days 8.7 days <0.001 Total cost of stay $92,370 $72,540 <0.001 Complications ICU care 45.3% 29.6% <0.001 Mechanical ventilation 18.6% 9.4% <0.001 Dialysis 10.2% 5.7% <0.001