Emergency presentation worsens survival, complications, and reveals profound disparities in acute lymphoblastic leukemia: A national propensity-matched study

Abstract Background Acute lymphoblastic leukemia (ALL) can progress rapidly and often presents with nonspecific symptoms, leading to delays in diagnosis. Patients presenting through the emergency department (ED) may face systemic barriers to early care. This study assessed the impact of ED presentation on early mortality, complications, hospital length of stay (LOS), cost, and disparities among adult patients with ALL.Methods We queried the Nationwide Readmissions Database from 2016 to 2019 to identify adult patients hospitalized with newly diagnosed ALL, stratified by patients versus elective presentation. Propensity score matching was conducted using age, sex, insurance type, income quartile, hospital bed size, teaching status, and Elixhauser Comorbidity Index (ECI). Outcomes included 30 and 90-day in-hospital mortality, LOS, total cost, ICU use, mechanical ventilation, and renal replacement therapy. Logistic regression and Kaplan-Meier survival analyses were performed.Results After matching, 3,987 patients were included in each cohort. ED presentation was associated with a 30-day mortality rate of 10.9%, compared to 8.2% in non-ED admissions (aOR 1.34; 95% CI: 1.12–1.62; p = 0.001). Ninety-day mortality was also higher in the ED group at 16.7% versus 14.3% (aOR 1.18; 95% CI: 1.01–1.39; p = 0.039). Kaplan-Meier curves showed a persistent and significant survival disadvantage in ED-presenting patients (log-rank p = 0.002). Hospital LOS was significantly longer among ED admissions (median 10.2 vs. 7.9 days; p < 0.001), and mean hospitalization cost was more significant ($84,210 vs. $65,480; p < 0.001). ICU admission occurred in 41.7% of ED patients versus 27.5% in non-ED patients (p < 0.001). Mechanical ventilation was used in 16.3% of ED patients compared to 8.7% in others (p < 0.001), while dialysis was required in 7.6% vs. 4.3% (p < 0.001). These outcome differences are summarized in Table 1. Disparities were pronounced. Self-pay patients experienced significantly higher odds of early death compared to those with private insurance (aOR 2.06; 95% CI: 1.52–2.79; p < 0.001). Medicaid patients also had worse outcomes (aOR 1.43; 95% CI: 1.18–1.74; p < 0.001). Mortality was highest among patients from the lowest income quartile (aOR 1.29; 95% CI: 1.06–1.58; p = 0.012). In contrast, admission to teaching hospitals was protective (aOR 0.77; 95% CI: 0.65–0.91; p = 0.002), as was female sex (aOR 0.85; 95% CI: 0.74–0.97; p = 0.015). Higher ECI scores were associated with higher rates of mortality and all complications (p < 0.001).Conclusion Emergency presentation in adult ALL is independently linked to excess early mortality, increased life-threatening complications, prolonged hospitalization, and elevated costs. These consequences disproportionately burden uninsured, Medicaid, and low-income populations, highlighting critical inequities in care access and timeliness. ED presentation likely reflects diagnostic delays and fragmented outpatient access. Immediate health system reforms are needed including rapid-access leukemia pathways, early diagnostic triage protocols, and equity-driven policy initiatives to improve survival outcomes and dismantle the structural barriers contributing to leukemia disparities in the United States. Table 1. Outcomes of patients with ALL presenting to the emergency department (ED) vs electively Outcomes Adjusted OR 95% CI P-value 30-day mortality 1.34 1.12–1.62 0.001 90-day mortality 1.18 1.01–1.39 0.039 Self-pay insurance 2.06 1.52–2.79 <0.001 Medicaid insurance 1.43 1.18–1.74 <0.001 Lowest income quartile 1.31 1.10–1.57 0.003 Teaching hospital 0.77 0.65–0.91 0.002 Female sex 0.85 0.74–0.97 0.015